Every finding on record at Alden Valley Ridge Rehab & HCC

Based on observation, interview, and record review the facility failed to ensure air-conditioning units in residents' room were maintained in proper working condition with control knobs. This applies to 3 of 5 residents (R1, R2, and R4) reviewed for comfortable and homelike environment. The findings include:1. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including atrial fibrillation, hypertension, peripheral vascular disease, Alzheimer's, bipolar disorder, history of malignant neoplasm of breast. R1's MDS (Minimum Data Set) dated July 21, 2026, showed R1 was cognitively impaired. On August 17, 2026, at 11:53 AM, V14 (Family Member) stated that R1's room was hot and humid on one of her visits. V14 stated the air-conditioning unit could not be turned on because a toenail clipper had been placed in the location where the control knob should have been. 2. R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE], with multiple diagnoses including congestive heart failure, chronic obstructive pulmonary disease, asthma, and hypertension. R2's MDS dated [DATE] showed R2 had moderate cognitive impairment. R2's care plan dated May 29, 2026, showed potential for respiratory difficulty secondary to active diagnosis of Asthma, and active diagnosis of chronic obstructive pulmonary disease (COPD). On August 17, 2026, at 10:16 AM, R2 stated the air conditioning unit in her room was not functioning and had been out of service for several days. R2 shared a room with R7 and R8. R2 also stated the air conditioning knob had been missing for some time (unsure of the exact time). R2 stated when the temperature is hot outside, the room becomes very hot. 3. R4's EMR (Electronic Medical Record) showed R4 was admitted to the facility on [DATE], with multiple diagnoses including difficulty in walking, hypertension, hearing loss and syncope and collapse. R4's MDS dated [DATE], showed R4 was cognitively intact. On August 17, 2026, at 1:13 PM, R4 stated his room gets hot on very hot days and the air-conditioning unit is not working, it has no knobs to turn on or off, he was unsure how long the knobs have been missing. R4 stated he was not sure why the toenail clipper was on there. On August 17, 2026, and August 18, 2026, during random observations of R1, R2, and R7's rooms, air conditioning units were observed without functional control knobs, toenail clippers were observed being used in place of the missing air conditioning knobs. On August 18, 2026, at 9:53 AM, V13 (Maintenance Director) stated he had observed toenail clippers being used in place of an air conditioning control knob, he said removed them and instructed staff not to use them for safety reasons. V13 stated he was aware some resident rooms were missing air conditioning control knobs, and he had ordered replacement knobs but was unsure how long the knobs had been missing or when the replacement knobs would be delivered. V13 stated he believed staff were using the toenail clippers because the air-conditioning knobs were missing. On August 18, 2026, at 11:56 AM, V1 (Administrator) stated he was not aware staff were using toenail clippers in place of missing control knobs on the air conditioning units. V1 stated it was his expectation for staff not to use toenail clippers on the air conditioning units and to contact maintenance if knobs were missing. The facility's policy titled Heat Emergencies/Lack of Cooling dated October 2020, under the subheading Procedure shows the building manager will monitor air conditioning equipment and ensure that equipment was working at peak performance.

Based on observation, interview, and record review, facility failed to follow up with a Wound Consult ordered on 5/27/25 which resulted in the resident not being seen until 6/5/25. This failure resulted in a delay in Wound consult, assessment and implementation of new interventions for a pressure wound that deteriorated to an unstageable pressure injury.The findings include:R95's most recent pressure ulcer risk assessment (dated 04/22/25) showed R95 is at Mild Risk for developing pressure ulcers.On 06/03/25 at 9:51 AM, R95 was sleeping in bed. At 9:53 AM, V38 (CNA-Certified Nursing Assistant) said R95 had some redness on her backside. V38 said she was unsure if R95 had any wounds because she only cleans the skin around a dressing when providing incontinence care. At 10:07 AM, V32 (R95's POA-Power of Attorney) said that the facility had not mentioned anything about R95 having any pressure sores or open skin.On 06/04/25 at 2:10 PM, V16 (ADON-Assistant Director of Nursing/IP-Infection Preventionist) reviewed the EBP (Enhanced Barrier Precautions) list and said that R95 was not on the list since she does not have any wounds. V16 stated R95 has only exhibited some rash-like redness and was receiving treatment for Moisture-Associated Skin Damage (MASD).On 06/05/25 at 9:49 AM, V14 (RN-Registered Nurse) said that she had already changed R95's dressing earlier that morning. V14 stated that R95 did not have any pressure-related wounds and only had redness with some open skin. Per V14, R95's current wound treatment orders were only for the prevention of pressure injury. At 10:00 AM, V14 and V34 (CNA-Certified Nursing Assistant) turned R95 to her left side and V14 removed R95's undated dressing from her sacrum. The dressing was saturated with red and yellow fluid. R95's sacral area had a round, open area, and the wound bed was covered with thick, yellow, stringy slough adhered to it. The wound had a dark gray perimeter around the slough. V14 measured the wound and stated R95's wound was a pressure sore. At 10:15 AM, V14 stated that the last time she saw R95's wound was on 06/03/25 (2 days earlier) and she described it as a little open with little slough.V14's 6/5/25 1:24 PM wound assessment showed R95 has a sacral unstageable pressure ulcer with 90% slough and moderate serosanguinous discharge, with peri-wound measuring [in cm- centimeters] 6.2 cm x 4.2 cm with a pressure ulcer in the center that measured 3.2 cm x 3 cm with an undetermined depth. R95's EMR (Electronic Medical Record) did not include any previous wound assessments for R95's pressure ulcer.R95's POS (Physician Order Sheet) showed a 5/27/2025 order from V33 (PA- Physician Assistant) for a foam dressing and Medi-honey to R95's sacrum every day and evening for skin condition. The POS also included another order for in-house Wound Consult. No other new orders or interventions were included in R95's POS to address the unstageable pressure ulcer.On 06/06/25 at 11:03 AM, V33 (PA-Physician Assistant) said that on 05/27/25, facility staff notified her regarding a skin issue with R95's and she did not examine R95's skin herself and based her order for Medi-honey on the staff's description of R95's skin. V33 confirmed that Medi-honey is for pressure-related wounds and stated that she would have ordered a different topical treatment if R95 only had redness.On 06/05/25 at 12:30 PM, V31 (Wound Doctor) said that he had been in the facility on 06/03/25 and was not notified of R95's Wound Consult order and he did not see R95. V31 confirmed that Medi-honey is not an appropriate treatment for redness or MASD as it is typically used as a debridement agent for pressure-related wounds.R95's 12/14/23 care plan showed R95 with a potential alteration in skin integrity .previously with MASD to upper inner buttock/gluteal cleft area. R95's care plan had not been updated to include her actual pressure ulcer until 6/5/25, during the survey, and nine days after the Medi-honey order.The facility's policy on Prevention and Treatment of Pressure Injury and other Skin Alterations includes identifying residents at risk for developing pressure injuries, identifying the presence of pressure injuries and/or other skin alterations, and implementing preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through an individualized resident care plan. The policy also states that at least daily, staff should remain alert for potential changes in the skin condition during resident care .

Based on observation, interview, and record review, the facility failed to practice safe food preparation, and properly label/date/seal/store food items in the facility kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 6/3/25 documents that the total census was 162 residents. On 6/3/25 at 10:29 AM, V20 (Dietary Manager) said they only have 1 NPO (Nothing By Mouth) resident. On 6/3/25 starting at 9:30 AM, the facility kitchen was toured independently and the following was found: In Main Kitchen Area: 1.4 different prescription pills were found sitting on a plate on the food preparation counter. V25 (Dietary Aide) said the pills were hers. 2. The robo-coup blender and large plastic storage container of thickener with the lid off were located within splash distance of the handwashing sink. In the walk-in cooler: 3. There was no room to walk in the cooler, there were four different carts on wheels stored in the cooler, one of the two tall rolling carts only had two small food items on it. The over-crowding of the cooler noted for potential to prevent proper air circulation and cooling of food items. 4. Small silver bin dated 5/19/25 with what appeared to be either tuna or chicken salad. Bin unlabeled. 5. A large silver bin or facility prepared egg salad dated 5/28/25. Salad looked wet and watery. At 10:26 AM V20 (Dietary Manager) said prepared salads are only good in the refrigerator for 1-2 days. 6. A half of a deli ham was dated 5/27/25. At 10:27 AM V20 said the ham is safe in the refrigerator for 4-5 days. 7. A white paper bag with unlabeled and undated plastic container of what appears to be a salsa like food item. Appears to be a personal staff or resident food item. 8. A plastic grocery store bag with 2 small plastic containers of liquid food items. Appears to be resident or staff personal food items inside. Food is unlabeled. In the Dry Storage: 9. 4 large plastic bins on wheels labeled: Sugar, Rice, Oatmeal, and Flour, not dated. 10. 2-3lb (pound) 14 ounce cans of mushroom pieces and stems on circulation rack with large dents in the side of both cans. 11. 50lb bag of long grain white rice opened, not sealed, with a Styrofoam cup stored inside bag. 12. 1lb bag of jumbo marshmallows with a hole ripped in the side of the bag, not sealed or wrapped. After the kitchen tour was completed independently on 6/3/25, around 10:15 AM, the tour was re-walked with V20 (Dietary Manager) and he was shown all of the above concerns found. On 6/4/25 at 2:40 PM, V20 said the food in the walk-in cooler was not staff food, it was resident food brought in by family. V20 and V26 (Corporate Chef) said the facility does not have any policies that talk about storing scoops/cups in dry food items, storage of resident food brought in by family, storage of food/carts in walk-in cooler to allow for proper air circulation, any policies specific to how long prepared salads and/or deli meats are good for in the refrigerator, or labeling and dating of dry foods. V20 and V26 said all time/temperature controlled for safety foods are good in the refrigerator for 3-7 days. On 6/5/25 at 10:38 AM, V20 said kitchen staff should not have their personal prescription pills out on the food preparation counter because of the risk of the pills getting mixed into resident foods. V20 said if a resident consumes a pill that is not their prescription it can harm the resident. V20 said the robo-coup and uncovered thickener container should not be stored within splash distance of the handwashing sink because of the risk of cross-contamination that can lead to resident illness. V20 said the sugar, rice, oatmeal, and flour bins should be dated for food safety and dented cans should be taken out of circulation because of the risk of botulism and resident death. V20 said a Styrofoam cup should not be stored inside of the rice bag because of the risk of cross-contamination and all opened food items should be resealed/wrapped to prevent contamination from dust, flies, or any kind of bacteria in the air. V20 said overcrowding in the walk-in cooler could affect the air circulation and food quality. V20 said all food items in the kitchen should be labeled and dated for food safety and quality. V20 said food brought in by resident families should not be stored in the walk-in cooler with other resident food because they don't know what is in the food and it can cause cross contamination. The facility policy titled, Cleaning and Storing of Dishwares last revised 3/22 states, Policy: Dishwares will be cleaned and stored in a manner to decrease the risk of cross contamination. Purpose: To reduce the risk of cross contamination. Procedure: . 4.dishwares will be stored .in such a location as to prevent splash . The facility policy titled, Food Storage Guidelines last revised 8/18 states, Policy: Food will be stored and used in an acceptable amount of time. Purpose: To reduce the risk of food borne illness. Procedure: . 3. Refrigerated TCS (Time/Temperature Controlled for Safety) food may be kept 3-7 days . The facility's policy titled, Dented Cans last revised 3/24 states, Policy: Cans will be rejected if compromised. Purpose: To reduce the risk of food borne illness. Procedure: .2. Compromised cans will be stored on a shelf marked - do not use . The facility's policy titled, Visitor Procured Food last revised 8/18 states, .Procedure: .2. Food & Nutrition Services will provide visitors a tip sheet on safe food handling. The tip sheet will highlight proper food handling practices .3. Food & Nutrition Services when assisting visitors with reheating or other preparation activities will use safe food handling practices . The facility's undated tip sheet titled, Food Safety Information for Families and Visitors Tips to Keep Food Safe states, .Holding Foods: . Resident food should be in a tight container labeled with name, food item, and date it was prepared .Each facility has specialty designated area(s) where resident food .may be stored .

2. On 6/3/25 at 10:33 AM, R87 was in bed. Her hair was not combed and greasy. R87 stated, It's been a while since they shampooed my hair. I would like my hair washed and combed. R87's MDS dated [DATE] shows she is moderately impaired in cognition. R87's care plan dated (5/12/25) shows she has an ADL functional performance deficit due to diagnosis of major depressive disorder, hypokalemia, iron deficiency anemia, hyperlipidemia, CHF (Congestive Heart Failure), GERD (Gastro-esophageal reflux disorder), and Osteoarthritis of hip. Intervention: Assist with ADL tasks as needed. 3. On 6/3/25 at 11:14 AM, R2 was in bed. She had hair on her chin and upper lip. R2 stated, I wanna be shaved. It doesn't look good. R2's MDS dated [DATE] shows she is cognitively intact. R2's care plan dated (7/24/24) shows she has an ADL Self Care Performance deficit due to diagnosis of encounter for surgical aftercare following surgery. Intervention: Assist with ADL tasks as needed. 4. On 6/3/25 at 11:20 AM, R121 was in bed. Her hair was not combed and it was greasy. R121 stated, I didn't get a shower one day last week. They said they are short of CNA's (Certified Nursing Assistants). They don't wash my hair. I want it washed and combed. R121's MDS dated [DATE] shows she is cognitively intact. R121's care plan dated (7/26/24) shows she has an ADL Self Care Performance Deficit due to muscle weakness; decrease mobility related to diagnosis of rhabdomyolysis, lower back pain, abnormalities of gait, and radiculopathy/lumbar region. Intervention: Assist with personal hygiene as needed. Allow enough time for completion of ADL tasks. Do not rush the resident. 5. On 6/3/35 at 11:27 AM, R149 was in his room in bed. His nails on both hands were long and had a black substance underneath his nail tips. He stated he wanted his nails cut. He had a beard and he stated he wanted to be shaved. R149's MDS dated [DATE] shows he is cognitively intact. R149's care plan dated (5/27/25) shows he has an ADL functional performance deficit due to spondylosis, major depressive disorder, COPD, anemia, mild neurocognitive disorder, and essential tremor. Interventions: Assist with ADL tasks as needed. On 6/4/25 at 2:09 PM, V16 (ADON-Assistant Director of Nursing/IP-Infection Preventionist) stated, Typically CNA's are responsible for shaving, providing nail care and washing/combing residents' hair. Facility's policy titled Bath, Tub, or Shower (9/2020) shows: Policy: 1. To provide cleanliness and comfort to the resident. Facility's policy titled Shaving The Resident (9/2020) shows: Purpose: To remove facial hair and improve the resident's appearance and morale. Facility's policy titled Hair and Scalp Care (9/2020) shows: Purpose: 1. To clean hair and scalp. 3. To provide the resident with an attractive appearance and improve morale. Facility's policy titled Nails (Care Of) (9/2020) shows: Policy: All residents will have clean, well-trimmed nails. Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care to residents who require assistance with their ADLs. This applies to 5 of 5 residents (R2, R21, R87, R121, R149) reviewed for ADL's in a sample of 32. The findings include: 1. On 06/03/25 at 3:25 PM, R21 was in the dining room reclined and slouched in a high-back wheelchair. On the table in front of R21 was a brown semi-liquid substance with some dried areas that smelled like a bowel movement. R21 was playing with the brown substance using her left fingers like finger painting on the table. V4 (Activity Aide) told V3 (Registered Nurse/RN) that R21 needed to be cleaned up, showing V3 the brown substance. R21 was sitting in the wheelchair with a visible dried brown substance on the front of her pants and the side of the right armrest. On 06/03/25 at 3:47 PM, V6 (Certified Nursing Assistant/CNA) and V7 (CNA) brought R21 to her room. The mechanical lift sling under R21 was soaked and soiled. After removing R21's soiled and wet pants, R21 was positioned lying on her right side while V6 was performing incontinence care with disposable personal wipes to clean a significantly soft, loose bowel movement. A line of dried stool was noted on R21's left buttock, lower hip, and upper outer thigh. V6 continued to clean the buttocks and placed her left gloved hand on the area of the dried stool. R21 had a small soft splint on her right hand. V6 and V8 said R21's hands were both cleaned. After removing the soft splint in R21's right hand, the soft splint was noted to be soiled with a brown substance. When R21's hands were wiped again with the personal disposable wipes, the wipes had shown brown soiling. As V6 and V8 prepared to transfer R21 from the bed to the wheelchair, this it was noteds that the wheelchair had a dried brown substance on the inside of its right armrest. V8 propelled R21 to the bathroom, and V6 carried the garbage in her bare hands to the soiled utility room. While cleaning R21's hands with a washcloth at the sink in the bathroom, the washcloths were visibly soiled. V6 and V8 threw the soiled washcloths into the sink when they were done. R21's EMR (Electronic Medical Record) showed R1 has diagnoses including hemiplegia and hemiparesis affecting the right side, dementia, contracture of the right elbow, aphasia, and tinea unguium (nail fungus). The MDS (Minimum Data Set) dated 04/02/2025 showed R21's cognition was severely impaired. R21 had impairment of both the upper and lower extremities on one side. The MDS shows R21 was dependent on staff for toileting, bathing, dressing, and personal hygiene. R21 was always incontinent of bowel and bladder. The Care Plan indicated that R21 had an Activities of Daily Living (ADL) self-care deficit, requiring assistance with ADLs for hygiene, toileting, and bathing, with interventions that included two persons to perform these tasks. R21 required the use of a mechanical lift for transfers. The care plan showed R21 had bowel and bladder incontinence with a goal to be socially continent, clean, dry, and odor-free, with interventions including checking and changing R21 after incontinence episodes. R21 has impaired cognition and a deficit in the ability to self-understand due to a past cerebrovascular accident. On 06/05/2025 at 2:52 PM, V2 (DON) stated that the facility doesn't have a policy on how often a resident needs to be checked or when the incontinence brief should be changed, but it should usually be done every two hours and as needed. If the resident is soiled or wet, they should be changed.

Based on observation, interview and record review, the facility failed to safely secure an oxygen cylinder. to prevent from tipping over and potentially causing a fire or explosion. This applies to 1 out of 3 residents (R143) reviewed for oxygen tanks in a sample size of 32. The findings include: On 6/3/2025 at 10:11 AM, 6/4/2025 at 9:05 AM and 6/4/2025 at 9:21 AM, a portable oxygen cylinder was unsecured on the floor. The oxygen cylinder was located on the head part on the right side of R143's bed and was half full. R143 said he does not use oxygen. On 6/5/2025 at 8:35 AM , V2 (DON-Director of Nursing) said portable oxygen cylinders should be secured in a container to keep from tipping over. She said oxygen is flammable and if it tips over, may cause a fire or explosion. R143's POS (Physician Order Sheet) showed no order for oxygen and his MDS (Minimum Data Sheet) dated 5/15/2025 documents that R143 has intact cognitive functions. Facility's undated Policy and Procedure on Oxygen storage documents the following: Policy Oxygen will be stored in accordance with applicable regulations. Procedure: 1. All oxygen containers (compressed tanks and liquid cylinders) will be restrained while in storage.

Based on observation, interview, and record review, the facility failed to treat a resident with respect and dignity during a meal. This applies to 2 of 3 residents (R46 and R73) who were reviewed for feeding assistance in a sample of 32. Findings included: During an observation of the lunch meal at 12:27 PM on 06/04/2025, V37 (Certified Nursing Assistant), after completing assisting R73, without changing her sitting arrangement, overstretching to reach R46 to feed her by passing over R73. On 06/05/2025 at 10:00 AM, V37 said she should have sat between V46 and V73, or changed R73 to a different table after feeding her. V37 stated that she understands her residents should be treated with respect and dignity. The review of R46's EMR (Electronic Medical Records) showed that R46's diagnoses included Alzheimer's disease, dysphagia, psychosis, anemia, gastroesophageal reflux disease, and anxiety disorder. Minimum Data Set (MDS) dated [DATE] indicated R46's cognition is severely impaired, is not interviewable, and needs assistance for eating. R46's care plan dated 03/032025 indicated R46 pockets her food and eats slowly. R73's EMR ) showed that R46's diagnoses included Alzheimer's disease, psychosis, and anxiety disorder. MDS dated [DATE] indicated R73's cognition is severely impaired, is not interviewable, and needs assistance for eating. 06/0520/25 10:12 AM V2 (Director of Nursing) said all staff received services on residents' rights, and V37 should not be feeding any residents by passing over R73 to reach R43 to feed. V2 said all residents should be treated with respect and dignity. The facility policy titled Dignity, dated 06/2023, in part, showed all residents should be treated with dignity and respect. The facility will promote care for residents that promotes and enhances their sense of well-being, level of life satisfaction, and feelings of self-worth and self-esteem .

Based on observation, interview, and record review, the facility failed to ensure infection control practices. This applies to 2 of 2 residents (R11 and R21) observed for infection control in a sample of 32. Findings include: 1. On 06/03/25 at 3:25 PM, R21 was in the dining room reclined and slouched in a highback wheelchair. On the table in front of R21 was a brown semi-liquid substance with some dried areas that had the odor of excrement. R21 was playing with the brown substance using her left fingers, like finger painting on the table. V4 (Activity Aide) brought R21 to the nurse's station and, without donning gloves, used a dry paper towel to wipe the right armrest and R21's right arm, which was covered in the brown substance. After wiping R21's arm and armrest, V4 threw away the soiled paper towel and, without performing hand hygiene, punched in the code to access the clean utility room. Without performing hand hygiene, V4 donned gloves to clean off the table in the dining room. On 06/03/25 at 3:47 PM, V6 (Certified Nursing Assistant/CNA) and V7 (CNA) brought R21 to her room. Using her dry, soiled left hand, R21 was touching V7's bare right upper arm. V7 was unaware R21's hand was soiled. V8 (CNA) assisted V6 (CNA) in lifting R21 in the total body mechanical lift. V8 instructed R21 to hold the bar on the total body mechanical lift with her left hand. R21 held the bar briefly with her left hand. The mechanical lift sling under R21 was soaked and soiled. After removing R21's soiled pants and without removing her soiled gloves, V8 opened the closet door and removed clean pants. While V6 and V8 remained in the room, V7 (CNA) removed and disposed of her gloves, put hand sanitizer into her right hand and then opened the bedroom door before using the hand sanitizer. R21 was positioned lying on her right side while V6 was performing incontinence care with disposable personal wipes to clean a significant amount of soft, loose bowel movement. A line of dried stool was noted on R21's left buttock, lower hip, and upper outer thigh. V6 continued to clean the buttocks and placed her left gloved hand on the area of the dried stool. When V6 needed to change gloves, she reported that she did not have more gloves in the room and was required to obtain some. V6 removed the soiled gloves and left the room, touching the door handle with bare hands without washing her hands or performing hand hygiene. During this time, V8 continued to clean R21's left thigh. V6 returned, and both V6 and V8 continued providing incontinence care for R21. After completing incontinence care and without removing their soiled gloves, V6 and V8 applied a clean incontinence brief to R21. V8 then removed R21's soiled shirt and assisted in donning a clean shirt R21 without changing gloves. V8 removed her soiled gloves and without performing hand hygiene, grabbed the door handle, opened the door, walked to the shower room, punched in the code, opened the door, went into another room, punched in the code of the soiled utility room, opened that door, then got on the elevator saying she needed to go to the second floor to find a clean mechanical lift sling for R21. At 4:06 PM, as V6 and V8 prepared to transfer R21 from the bed to the wheelchair, R21's wheelchair had a dried, brown substance on the inside of its right armrest. Once R21 was in the wheelchair, V6 and V8 (CNAs) separated the soiled linens into a separate bag from the garbage, then placed both the garbage and the soiled linen bag onto the bedside table before closing each bag. V6 and V8 each removed their gloves but did not perform hand hygiene. V8 held the handrest of the highback wheelchair to propel R21 to the bathroom, and V6 carried the garbage in her bare hands to the soiled utility room. While cleaning R21's hands with a washcloth at the sink in the bathroom, V6 and V8 threw the soiled washcloths into the sink when they were done. R21's EMR (Electronic Medical Records) showed R21 has diagnoses including hemiplegia and hemiparesis affecting the right side, dementia, contracture of the right elbow, aphasia, and tinea unguium (nail fungus). R21's Minimum Data Set (MDS) dated [DATE] showed R21's cognition was severely impaired. R21's care plan showed R21 had bowel and bladder incontinence with interventions including checking and changing R21 after incontinence episodes. The facility's Hand Hygiene policy dated 10/2024 showed hand hygiene should be performed by washing hands with soap and water or using hand sanitizer to reduce the potential spread of pathogens. The policy includes performing hand hygiene prior to touching a resident when moving from a soiled body site to a clean body site of the same resident, after touching a resident or their immediate environment, and immediately upon removing gloves. Hand hygiene with soap and water should be performed when hands are visibly soiled or after any contact with blood, body fluids, or contaminated surfaces. Gloves or the use of perineal wipes are not substitutes for hand hygiene. 2. R11's EMR (Electronic Medical Records) showed R11 had diagnoses including vascular dementia, neuropathy, morbid obesity, tinea unguium, peripheral vascular disease, and contracture of the right and left knees. The MDS dated [DATE] showed R11's cognition was moderately impaired and was dependent on staff for toilet hygiene and bathing. R11 was always incontinent of bowel and bladder. On 06/03/25 at 3:26 PM, At the other table, R11 was sitting in a wheelchair asking for help, saying he p***ed himself and needs to be changed. Underneath R11's wheelchair was a large puddle of liquid. The front of R11's pants was saturated with water. V4 and V5 (Activity Aides) were present in the room by the water cart. On 06/03/2025 at 3:32 PM, V5 (Activity Aide) donned gloves and used a thin cloth to wipe up the liquid on the floor, but more liquid remained on the floor. At 3:33 PM, V4 (Activity Aide) walked through the wet trail of liquid/urine to clean up the dining room table. At 3:34 PM, R141 walked through the wet trail of urine in the dining room. R133 was in a wheelchair and propelled herself using her feet through the trail of urine. R133 was wearing socks only, no shoes. V5 then placed a towel over the area and left it. On 06/03/2025 at 3:36 PM, V6 (Certified Nursing Assistant/CNA) wiped the urine off the floor with a towel only. On 06/04/2025 at 3:32 PM, V4 (Activity Aide) stated that when a resident experiences an incontinence episode, they will notify the CNAs or nurses. V4 said they would clean up what they could and should wear gloves when cleaning it up. V4 said he should have had gloves on when cleaning R21 at the nurses' station, but there weren't any gloves available at the time. He cleaned the table with the purple top wipes but did not notify housekeeping to clean or disinfect the table or the floor on 06/03/2025, following R11 and R21's incontinence episodes. On 06/04/2025 at 4:07 PM, V3 (RN, MDS Coordinator) said the activity aide should put on gloves, then clean R21's hands and wheelchair with disposable cleaning wipes and paper towel. On 06/04/2025 at 4:07 PM, V3 (RN, MDS Coordinator) said the staff needed to call housekeeping if there were body fluids, such as urine or stool, on the table or the floor. During incontinence care, the nursing staff should use hand sanitizer, don gloves, remove the resident's soiled incontinence brief, clean the resident, then remove gloves, perform hand hygiene, and don new clean gloves before placing a new incontinence brief on the resident. If staff members need to exit the room to retrieve any items, they should remove their gloves and perform hand hygiene before touching anything else. V3 stated that staff should not place garbage bags or soiled linen bags on the bedside table or any other surface. On 06/04/2025 at 3:36 PM, V5 (Activity Aide) stated that if a resident had an incontinent episode that spilled onto any surfaces, they should call housekeeping to mop and clean the area. V5 stated on 06/03/2025 that they had only cleaned the floor with a towel and did not call housekeeping. On 06/05/2025 at 11:05 AM, V9 (Housekeeping Supervisor) stated that if body fluids, such as a bowel movement or urine, were present on the floor or table, staff should call housekeeping to disinfect the area. The staff can clean up the area to remove the body fluids, but we would be the last ones to come in to disinfect the areas. Housekeeping uses Oxivir Five 16 to clean the table surfaces and Prominence to clean the floors. On 06/05/2025 at 12:02 AM, V2 (Director of Nursing/DON), with V1 (Administrator) present, stated that if body fluids, such as stool or urine, were present on a table or floor, the staff should contact housekeeping to clean and disinfect the area. V1 (Administrator) said that, in theory, the staff can clean up the area as best they can, but they should still have housekeeping come in to clean up. V2 said hand hygiene should be performed after removing gloves, before touching another surface, and when going from a dirty to a clean area. If the gloves are visibly soiled, the staff should wash their hands with soap and water after removing them, or they can use hand sanitizer if the gloves are not visibly soiled. V2 said the staff should not place a garbage bag or a soiled linen bag on the floor or bedside table.

Based on record review and interviews the facility failed to submit an initial resident abuse allegation to the Illinois Department of Public Health (IDPH) for an allegation of sexual abuse. This applies to 1 of 2 residents (R2) reviewed for abuse reporting. The findings include: Review of the facility's Abuse Policy, dated 09/20, stated in part, Initial Reporting of Allegations shall be completed immediately upon notification of the allegation. The written report shall be sent to the Department of Public Health. The EMR (Electronic Medical Record) shows R2 was admitted to the facility on [DATE] with multiple diagnoses, including dementia, cardiac disorders with a pacemaker, venous thrombosis, type 2 dialysis, and chronic kidney disease, R3's MDS (Minimum Data Set) dated 09/11/2024 shows R3 is cognitively severely impaired requires two staff assistance for mobility and transfer. The facility investigation report dated 11/04/2024 showed R3 (R2's family member), who is on the second floor, reported to V4 (Director of Memory Care) that some man came to R2's room with his hot dog hanging in between his leg and showed it to her. V1 (Administrator) and V4 met with R2 and investigated the allegation. The allegation was unfounded. On 12/09/2024 at approximately 11:00 AM, V4 said she reported to V1 when R3 reported the allegation and they investigated the incident. V4 said R2 could not converse in person or over the phone, and there was no contact between R2 and R3 due to the infection control lockdown. V4 said the allegation was not substantiated, so they did not report the allegations to the State Agency. On 12/06/2024 at 3:00 PM, V3 (Director of Nursing) said R2 was in memory care, and R3 was on the second floor. V1 and V3 said R2 is unable to hold any conversation, and R3 is delusional and paranoid with multiple psychiatric problems. V3 said there was no contact between R3 and R2 during the allegation time since R3 was isolated due to COVID-19 and the second floor was on lockdown. V2 said that after a week, R3 reported the allegation to the police and the police investigated with no findings. V1 and V3 said it had slipped from their mind to report to IDPH and acknowledged that they should have reported it.

Based on observation, interview, and record review, the facility failed to ensure residents were transferred and/or repositioned in a safe manner for 4 of 33 residents (R69, R66, R114, and R130) reviewed for safety and supervision in the sample of 33. The findings include: 1. On 8/19/24 at 10:50 AM, V10 (Certified Nursing Assistant/CNA) and V11 (CNA) finished changing R69. V10 was on one side of R69's bed and V11 was on the other side. V10 and V11 each hooked their respective arms under R69's underarms and pulled R69 up in bed. Then, V10 and V11 proceeded to pull R69 forward by R69's underarms using the same method described above to reposition R69's pillow. On 8/19/24 at 11:24 AM, V16 (CNA) said when boosting a resident in bed there should be a person on each side of the bed and they should use the bed pad or flat sheet to pull the resident up in bed. V16 said it is not safe to pull a resident up by their arms. R69's Admission Record shows she is a [AGE] year old female. R69's current care plan provided by the facility shows R69 has limitation in range of motion and is to receive passive range of motion to both upper and lower extremities. R69's current care plan provided by the facility shows R69 has the potential for hemorrhage or bruising and impaired skin integrity due to use of anticoagulant therapy and a history of decreased mobility. Staff are to instruct R69 to put her arms into a self-hugging position when being boosted up in bed and an assistive device is to be used to decrease friction to lift (do not slide) R69 for bed mobility. 2. On 8/19/24 at 11:02 AM, V16 was in the bathroom with R66. V16 assisted R66 off the commode and pulled up R66's pants and transferred R66 to her wheelchair without using a gait belt. R66's Admission Record dated 8/21/24 shows R66's diagnoses include, but are not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R66's Minimum Data Set, dated dated dated [DATE] shows R66 has limitation that interfered with daily functions or placed resident at risk of injury to an upper extremity and a lower extremity, is dependent on staff for toileting hygiene, and requires substantial/maximal assistance with lower body dressing, sit to stand, and toilet transfers. The facility's Incidents by Incident Type list dated 8/20/24 shows R66 fell on [DATE] and again on 8/7/24. The facility's Transfer Techniques Policy dated 2/2022 shows the purpose is to safely transfer the resident from one location to another and staff are to place a gait belt around the resident's waist during the transfer. 34506 3. R114's Admission Record shows he was admitted to the facility on [DATE] with diagnoses including legal blindness, major depressive disorder, and depression. R114's Care Plan revised January 8, 2024 shows, [R114] has potential for alteration in skin integrity related to frequent falls, syncope and collapse, muscle weakness, unsteadiness on feet, cognitive communication deficit and bowel and bladder incontinence. On August 19, 2024 at 9:56 AM, R114 was asleep in someone else bed. V4 (CNA) transferred R114 from the bed to his wheel chair with no gait belt. R114 was unsteady on his feet and was hunched over during the transfer. V4 held R114 by the back of his pants while transferring him. 4. R130's Admission Record shows she was admitted to the facility on [DATE] with diagnoses including dementia, anxiety disorder, abnormalities of gait and mobility, and muscle weakness. R130's Care Plan revised on August 1, 2024 shows R130 is at risk for falls due to diagnoses of dementia, high blood pressure, depression, and benign paroxysmal vertigo. On August 19, 2024 at 11:42 AM, R130 let V3 (CNA) know that R130 had to go to the bathroom. V3 wheeled R130 to the bathroom via her wheel chair. V3 pulled R130 up via the back of R130's pants. V3 had a transfer belt around V3's waist. V3 sat R130 onto the toilet. When R130 was done using the bathroom, V3 stood R130 up and wiped R130's peri area. V3 pulled R130's incontinence brief and pants up and then transferred R130 back into her wheel chair. R130 was unsteady on her feet. On August 20, 2024 at 1:32 PM, V14 (CNA) said staff should use a gait belt when transferring resident for the resident and staff safety. The facility's Transfer Techniques dated February 2022 shows, Purpose: To safely transfer the resident from bed to chair or from one location to another. Transfer from bed to wheel chair: Have resident sit on the edge of the bed with feet uncrossed and resting on the floor. He/she may use this as an opportunity to practice sitting balance. Put on gait belt and shoes.

Based on observation, interview, and record review the facility failed to ensure a COVID-19 positive resident remained in isolation, failed to ensure a resident identified as a close contact with COVID-19 symptoms was wearing a mask, failed to ensure staff donned personal protective equipment (PPE) when providing care for a resident on enhanced barrier precautions (EBP), failed to ensure residents with feeding tubes were placed on EBP, and failed to perform hand hygiene and change gloves during pericare to prevent cross contamination. These failures apply to 8 of 33 residents (R44, R91, R9, R60, R57, R33, R17, R19) reviewed for infection control in the sample of 33. The findings include: 1. R44's Facesheet printed on 8/21/24 showed R44 to be a [AGE] year old female resident readmitted to the facility on [DATE]. This document showed a new diagnosis of COVID-19 on 8/12/24. R44's COVID-19 Results Worksheet showed R44 being COVID-19 positive on 8/12/24. R44's Order Summary printed on 8/21/24 showed an order for Isolation: contact and droplet precautions due to positive COVID-19 times 10 days ending on 8/22/24. On 8/19/24 at 11:45 AM, R44's room doorway had a contact/droplet isolation sign on it and a PPE cart next to the doorway. R44's room is near the opposite end of the hallway from the nurses station. On 8/19/24 at 1:30 PM, R44 was in her wheelchair near the nurses station area raising her voice to the staff, she was looking for her ranch dressing. R44 had several staff members pass her while she was in the hallway waiting. None of the staff members attempted to redirect R44 back down the hall toward her room until they had found the salad dressing bottle. On 8/19/24 at 2:00 PM, R44 was in her room. During the interview, R44 had a repeated cough and congestion symptoms. On 8/20/24 at 1:40 PM, V2 (Director of Nursing) stated if a COVID-19 positive resident is out of their room the staff should attempt to redirect the resident back to their room as soon as possible. The first positive resident we had was on 7/21/24, and we had the 3 new positives on 8/4/24. The facility's undated COVID-19 policy showed residents COVID-19 transmission based precautions should have transport and movement outside their room limited to medically essential purposes. 35541 2. A facility roster dated 8/19/24 showed R40 and R91 resided in the same room in the facility. R40's Communication Form and physician orders dated 8/20/24 showed R40 was placed on strict contact/droplet isolation for possible COVID exposure as R40 had developed COVID-like symptoms of a congested, productive cough. The form showed R40 refused to be tested for COVID. On 8/20/24 at 9:11 AM, a droplet/contact isolation sign hung on the door of R40 and R91's room. V9 (Registered Nurse/RN) entered the room to administer medications to R91 but R91 was not in his room. R40 was in bed, actively coughing. When V9 was asked about R40's cough, V9 stated R40 had developed a cough and COVID-like symptoms overnight so was placed on droplet/contact isolation. V9 stated R40 had refused any COVID testing. At 9:14 AM, V9 (RN) found R91 seated in the second floor dining room, eating breakfast with thirteen other residents noted in the room. R91 wore no protective mask. V9 administered medications to R91. On 8/21/24 at 9:52 AM, V2 (Director of Nursing) stated, (R91) should be wearing a mask when he is out of his room. Any resident that has had close contact with someone exhibiting COVID symptoms are tested but don't need to be isolated if negative with no symptoms. They do need to wear a mask when out of their room for ten days post-exposure. The facility's COVID-19 policy (undated) showed residents who are not symptomatic but have had close contact with someone who has COVID-19 do not need to be isolated but do need to wear source control (masks) when out of their rooms for ten days post-exposure. 3. R9's physician order dated 8/22/23 showed R9 was on Enhanced Barrier Precautions (EBP) do to the placement of her urinary catheter. On 8/20/24 at 8:47 AM, an EBP isolation sign hung on the door to R9's room. V10 (Certified Nursing Assistant/CNA) and V11 (CNA) entered R9's room without donning protective gowns, only masks and gloves. V10 and V11 provided incontinence care to R9 which included cleansing R9's left buttock pressure injury and the handling of R9's urinary catheter. On 8/21/24 at 11:01 AM, V2 (Director of Nursing) stated any resident with a urinary catheter, gastrostomy tube, or wounds are to be placed on Enhanced Barrier Precautions (EBP). V2 stated staff are to wear gowns, gloves, and masks when providing cares to residents on EBP. 40798 4. R57's Order Summary Report dated 8/19/24 shows an active order for EBP for device care or use of feeding tube. On 8/19/24 at 9:43 AM, R57 was lying in his bed with tube feeding infusing. There were no signs on his door or in his room regarding enhanced barrier precautions and no PPE was located outside of his room. R60's Order Summary Report dated 8/19/24 shows an active order for EBP for device care or use of feeding tube. On 8/19/24 at 9:53 AM, R60 was lying in her bed with tube feeding infusing. There were no signs on her door or in her room regarding enhanced barrier precautions and no PPE was located outside of her room. On 8/21/24 at 10:50 AM, V2, Director of Nursing, said they follow the CDC guidelines for infection prevention/isolation precautions. According to the CDC (Centers for Disease Control and Prevention) website dated 6/28/24 https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html?CDC_AAref_Val=https://www.cdc.gov/hai/containment/faqs.html Signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the resident. To do this effectively, the sign must contain information about the type of Precautions and the recommended PPE to be worn when caring for the resident. Generic signs that instruct individuals to speak to the nurse are not adequate to ensure Precautions are followed. According to the CDC website (updated 7/12/22) https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html, residents with an indwelling medical device (including a feeding tube) are to be placed on EBP, regardless of MDRO colonization status. 34506 5. R33's Admission Record shows she was admitted to the facility on [DATE] with diagnoses including malnutrition, palliative care, morbid obesity, depression, anxiety disorder, and dementia. R33's Order Summary Report dated August 19, 2024 shows an order for indwelling urinary catheter and EBP (Enhanced Barrier Precautions) for device care or use of urinary catheter. R33's Care Plan initiated March 5, 2024 shows, Enhanced barrier Precautions will be implemented during high contact resident care activities. On August 19, 2024 at 10:11 AM, there was a sign outside of R33's door that showed, Enhanced Barrier Precautions Everyone Must: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, changing linens, providing hygiene, and changing briefs or assisting with toileting. V4 (Certified Nursing Assistant/CNA) provided incontinence care to R33. V4 did not wear a gown while she changed R33's linens or changing her incontinence brief. The facility's Enhanced Barrier Precautions dated December 14, 2023 shows, Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) in nursing homes. As well as to prevent multi-drug resistant organism acquisition of those with an increased risk of acquiring MDROs including resident with a chronic wound or an indwelling medical device. 6. R17's Admission Record shows he was admitted to the facility on [DATE] with diagnoses including dementia, non pressure chronic ulcer of skin, depressive episodes, and kidney disease. On August 19, 2024 at 9:56 AM, V4 (CNA) and V5 (CNA) provided incontinence care for R17. There was a large amount of urine and stool in R17's incontinence brief. V5 wiped R17's front peri area, then turned R17 onto his side. V5 then wiped R17's buttocks, applied cream to R17's buttocks. V5 turned R17 back onto his back and then touched R17's pillow under his head. V5 did not change her gloves or perform hand hygiene. 7. R19's Admission Record shows she was admitted to the facility on [DATE] with diagnoses including hemiplegia, dementia, anxiety disorder, and heart failure. R19's Care Plan revised on July 8, 2024 shows R19 experiences bowel and bladder incontinence due to dementia, chronic kidney disease stage three, diabetes, atrial fibrillation, and anxiety. On August 19, 2024 at 10:56 AM, V6 (CNA) and V4 (CNA) provided incontinence care on R19. V6 folded down R19's incontinence brief in between R19's legs while she was laying on her back. V6 then helped R19 turn onto her left side. V6 wiped the stool from R19's buttocks, placed a new incontinence brief underneath R19, then turned R19 back onto her back. V6 then wiped the stool from R19's front peri area, removed R19's gown, placed clean pants and a clean blouse onto R19. V6 did not change her gloves or perform hand hygiene. On August 20, 2024 at 1:32 PM, V14 (CNA) said gloves should be changed after touching dirty items and before touching clean items to prevent infection. The facility's Hand Washing and Hand Hygiene policy dated June 4, 2020 shows, Appropriate hand hygiene is essential in preventing the spread of infectious organisms in healthcare settings. Hand hygiene must be performed after touching blood, body fluids, secretions, excretions, and contaminated items.

Based on observation, interview, and record review, the facility failed to provide a resident with privacy during activities of daily living (ADL) care for 1 of 33 residents (R17) reviewed for privacy in the sample of 33. The findings include: R17's Admission Record shows he was admitted tot he facility on September 7, 2007 with diagnoses including dementia, non pressure chronic ulcer of skin, depressive episodes, and kidney disease. R17's Care Plan initiated on June 10, 2024 shows R17 is incontinent of bowel and bladder. On August 19, 2024 at 9:56 AM, V4 and V5 (Certified Nursing Assistants/CNA) were preparing to provide incontinence care for R17. V5 CNA folded R17's incontinence brief downward in between in legs while he was laying on his back. R17's curtain was not closed and R17's roommate was in his bed, facing R17, and talking with V4 and V5. R17's front peri area was exposed. On August 20, 2024 at 1:32 PM, V14 CNA said resident's curtains should be closed during incontinence care so the resident has privacy. The State of Illinois Residents' Rights revised November 2018 shows, You have a right to privacy and confidentiality of your personal and medical records. Your medical and personal care are private. Facility staff must respect your privacy when you are being examined or given care.

Based on observation, interview and record review the facility failed to ensure staff-dependent residents were provided incontinence care for 2 of 33 residents (R34, R51) reviewed for activities of daily living (ADL's) in the sample of 33. The findings include: 1. R34's current care plan showed R34 was dependent on staff for incontinence care and toileting. R34 was cognitively intact. On 8/19/24 at 9:32 AM, R34 was in bed, eating breakfast. R34 stated, They really treat me good here but, lately it seems like it's taking longer for someone to come change me. There have been times that I have waited over five hours for someone to come. I wear a brief. This last time someone changed me today was around 4 AM. At 9:38 AM, V12 (Certified Nursing Assistant/CNA) entered R34's room to provide cares. V12 stated this was her first time providing incontinence care to R34 for the day. V12 removed R34's brief which was saturated with urine. Urine had leaked out of R34's brief, onto R34's sheet and mattress. 2. R51's current care plan showed R51 was dependent on staff for incontinence care and incontinent of bowel and bladder related to his diagnoses of dementia, impaired cognition, and cerebral infarction (stroke) with left arm and leg hemiplegia (paralysis). The plan showed, Provide incontinence care after each incontinent episode. On 8/19/24 at 9:53 AM, R51 was in bed. A strong foul odor of urine and stool was noted in the room. At 9:55 AM, V13 (CNA) entered R51's room. V13 (CNA) was asked about the odor in R51's room, V13 stated, I don't know what that is. I last changed him at 7 AM. V13 repositioned R51 to check his incontinence brief. R51's brief was saturated with urine and stool. Urine and stool had leaked out of R51's brief, onto R51's bedding. R51's buttocks appeared bright pink. V13 stated incontinence care should be provided every two hours to resident's that require staff assistance or are dependent on staff for incontinence care.

Based on observation, interview, and record review, the facility failed to have a physician ordered treatment in place for a resident with open areas to his buttocks for 1 of 33 residents (R17) reviewed for quality of care in the sample of 33. The findings include: R17's Admission Record shows he was admitted to the facility on [DATE] with diagnoses including dementia, non pressure chronic ulcer of skin, depressive episodes, and kidney disease. R17's Care Plan that was provided by the facility did not include any skin issues on R17. On August 19, 2024 at 9:56 AM, V4 (Certified Nursing Assistant/CNA) and V5 (CNA) provided incontinence care to R17. When R17 was turned onto his side, there was multiple open areas noted to R17's buttocks. There was spots of dried blood on R17 incontinence brief. R17 said Ow! each time V5 wiped R17's buttocks. V5 said she was going to tell the nurse about R17's buttocks. There was no dressing or treatment in place to R17's buttocks. On August 20, 2024 at 1:07 PM, V14 (CNA) and V3 (CNA) transferred R17 back into his bed from his chair to perform incontinence care on him. R17's penis was raw and bright red. R17 said OW! as V3 wiped the tip of R17's penis. V3 turned R17 onto his side. There was no dressing to R17's buttocks. R17's buttocks area still had open areas. V3 got R17's nurse, V15 (Registered Nurse/RN). V15 came into R17's room and placed zinc to R17's buttocks. V3 showed V15 R17's penis. V15 said, Oh . V15 was not aware of the sores to R17's penis. V15 said she was going to contact the hospice nurse. On August 20, 2024 at 1:39 PM, V15 said she did not know that R17 had an order for a dressing to his buttocks. V15 said that night shift places the dressing onto R17's buttocks. V15 said a foam dressing is used for extra protection. R17's Order Summary Report dated August 19, 2024 shows an order dated August 5, 2024 for optifoam dressing apply to right buttocks every evening shift for skin condition and apply to left buttocks every evening shift for skin condition. There's an order dated May 30, 2024 optifoam adhesive island apply to left buttock topically as needed. R17's skin/wound progress note dated August 19, 2024 shows, right buttocks slightly red. R17's skin/wound progress note dated August 21, 2024 shows R17 has excoriation to his buttocks. The facility's Prevention and Treatment of Pressure Injury and Other Skin Alterations dated March 2, 2021 shows, Implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan. Revise Care Plan approaches as needed based on resident's response and outcomes.

Based on observation, interview and record review the facility failed to ensure pressure injury treatments and pressure relieving interventions were in place for 1 of 7 residents (R9) reviewed for pressure injuries in the sample of 33. The findings include: R9's care plan dated 10/19/2018 showed R9 was at risk for developing pressure injuries due to her history of a previous pressure injury to her left buttock, inability to reposition herself, and history of bowel incontinence. The care plan showed R9 had diagnoses of multiple sclerosis, spinal stenosis, and quadriplegia. The plan showed R9 was cognitively intact. R9's wound note dated 2/21/23 showed a Stage III pressure injury to R9's left buttock had resolved and was completely healed. R9's progress note dated 6/5/24 showed an open area and redness was identified to R9's left buttock. R9's wound note dated 6/11/24 showed R9 was seen by the facility's wound physician for a re-opened Stage III pressure injury, to her left buttock, that measured 9 centimeters (cm) x 9.5 cm x 0.2 cm. R9's wound note dated 8/6/24 showed R9's left buttock Stage III pressure injury measured 5.7 cm x 7 cm x 0.2 cm. The note showed to monitor R9 for incontinence and change after each episode. The note showed staff were to reposition R9 every two hours and offload R9's heels with a pillow or heel boots while in bed. The note showed facility staff were to apply treatment ointments and a foam dressing to R9's pressure injury once a day and as needed. On 8/19/24 at 10:03 AM, R9 was in bed, lying on her right side. R9's heels rested directly on mattress of her bed. R9 was alert and cognitively intact. R9 stated she could not lay on her left side in bed due to a wound on her left buttock. When asked about her wound, R9 stated, I got the wound here because they didn't reposition me. I can't move myself because I have MS (multiple sclerosis). On 8/20/24 at 8:45 AM, R9 was lying in bed. R9's heels rested directly on the mattress of her bed. R9 stated she was seen by the facility's wound physician around 7 AM that morning. R9 stated, I don't have a dressing on my wound. They never put one back on after the doctor looked at it. At 8:47 AM, V10 (Certified Nursing Assistant/CNA) and V11 (CNA) entered R9's room to provide cares. V10 removed R9's incontinence brief as R9 was incontinent of stool. No dressing was noted to the large, circular, open wound to R9's left buttock. Stool was noted in and around the wound. As V10 cleansed R9's buttocks, R9 complained of pain when V10 wiped R9's left buttock wound. V10 and V11 placed a clean incontinence brief on R9 with no dressing in place to her buttock wound. A scant amount of bleeding was noted from the wound. As R9 was repositioned in bed, she complained of pain to her left buttock. R9 stated, It just hurts because there is no dressing on there. V10 and V11 exited R9's room. On 8/20/24 at 8:54 AM, V9 (Registered Nurse/RN) stated if staff observe that a resident's wound does not have a dressing in place, staff are to report it to a nurse immediately to have a dressing put in place. On 8/20/24 at 10:47 AM, V8 (previous Wound Nurse/RN) stated R9 was at risk for developing pressure injuries due to her history of previous pressure injuries and her diagnosis of multiple sclerosis. V8 stated, (R9) can't reposition herself. She has very limited movement. She can only move her left hand to pick up a cup. She had Stage III pressure injury to her left buttock before. She has no wounds to her heels, but they should be offloaded with a pillow. When V8 was asked what caused R9's left buttock pressure injury to reopen, V8 stated, Her skin is fragile, but I would say it was also likely because of infrequent repositioning and not making sure peri-care isn't done right away. On 8/20/24 at 12:46 PM, R9 was in bed, being fed by staff. R9 stated staff placed a dressing on R9's left buttock pressure injury sometime after 10 AM that morning. When R9 was asked if she ever refused to allow staff to apply a dressing to her wound on the morning of 8/20/24, R9 stated, No I didn't. The facility's Prevention and Treatment of Pressure Injury and other Skin Alterations policy dated 3/2/21 showed it was the facility's policy to identify the presence of pressure injuries . implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan .

Based on observation, interview, and record review, the facility failed to perform peri care in a manner to prevent urinary tract infection and failed to maintain the catheter bag below the level of the bladder to prevent infection for three of three residents (R33, R19, R9) reviewed for incontinence care and catheter care in the sample of 33. The findings include: 1. R19's Admission Record shows she was admitted to the facility on [DATE] with diagnoses including hemiplegia, dementia, anxiety disorder, and heart failure. R19's Care Plan revised on July 8, 2024 shows R19 experiences bowel and bladder incontinence due to dementia, chronic kidney disease stage three, diabetes, atrial fibrillation, and anxiety. R19's Medication Administration Record shows she has been treated for a urinary tract infection in the past. On August 19, 2024 at 10:56 AM, V6 (Certified Nursing Assistant/CNA) and V4 (CNA) provided incontinence care on R19. R19 had a large amount of stool in her incontinence brief. R19 was turned on her side and V6 wiped the stool from R19's buttocks. R19 was then laid back onto her back. There was a moderate amount of stool noted to R19's front peri area. V6 wiped the stool from R19's peri area from back to front multiple times. 2. R33's Admission Record shows she was admitted to the facility on [DATE] with diagnoses including malnutrition, palliative care, morbid obesity, depression, anxiety disorder, and dementia. R33's Medication Administration Record shows she has been treated with antibiotics for a urinary tract infection in the past. On August 19, 2024 at 10:11 AM, V4 (CNA) performed incontinence care on R33. There was stool noted in R33's buttocks. V4 wiped R33's buttocks then laid her onto her back to perform peri care to R33's front. There was a large amount of stool noted to R33 front peri area. R33 had an urinary catheter in place. V4 wiped the stool in R33's front peri area from back to front multiple times, using the same wet wipe. On August 20, 2024 at 1:32 PM, V14 (CNA) said stool should be wiped from front to back on residents to prevent infection. The facility's Perineal Care policy dated September 2020 shows, Purpose: To prevent infection and odor. Female Perineal Care: Separate the labia. Clean downward from front to back with one stroke. 35541 3. R9's current care plan showed R9 required the use of a supra-pubic urinary catheter due to her diagnosis of obstructive and reflux uropathy. The plan showed, keep (catheter) tubing free of kinks and monitor (tubing) for patency . On 8/20/24 at 8:45 AM, R9 was lying in bed, covered with a blanket. No urinary catheter collection bag was noted hanging off either side of R9's bed. At 8:47 AM, V10 (CNA) and V11 (CNA) entered R9's room to provide cares. As V10 (CNA) removed the blanket off R9, R9's urinary catheter collection bag lay next to R9's left leg, on the bed. Urine was noted in the tubing of R9's catheter tubing. As V10 and V11 repositioned R9 in bed, a back-flow of urine was noted in the tubing of R9's catheter. Once cares were completed on R9, V10 (CNA) hung R9's urinary catheter collection bag off the side of R9's bed, allowing the urine in the catheter tubing to drain into the collection bag. On 8/20/24 at 8:54 AM, V9 (Registered Nurse) stated a resident's urinary catheter collection bag should be hanging below the level of the resident's bladder to make sure the urine is able to drain out. If the urine can't drain out, it can cause pain or infection.

Based on observation and interview, the facility failed to ensure a resident's tube feeding bag was labeled with the time it was initiated for 1 of 4 residents (R60) reviewed for tube feeding in the sample of 33. The findings include: On 8/19/24 at 9:49 AM, R60 was lying in bed with her tube feeding infusing. R60's tube feeding formula bag was dated 8/18/24, however, no time was documented. On 8/20/24 at 10:56 AM, V17, (Registered Nurse), said the G-tube bags should be labeled with the formula, dose, date and time since the bag and the tubing are good for 24 hours before they need to be changed. On 8/21/24 at 11:07 AM, V2, (Director of Nursing), said the tube feeding bag is good for 24 hours once hung; it needs to be labeled with the date and time it was started. R60's Order Summary Report dated 8/19/24 shows an order to infuse tube feeding at 60 ml (milliliters)/hour for 24 hours.

Based on observation, interview and record review the facility failed to ensure medications were dispensed according to standards of practice. The facility failed to ensure residents were assessed to self-administer medications. These failures apply to 3 of 33 residents (R9, R65, R158) reviewed for medication administration in the sample of 33. The findings include: 1 .On 8/20/24 at 8:45 AM, R9 was lying in bed. A medication cup, containing sixteen different pills of size and color, was on the table directly in front of R9. When R9 was asked about the pills, R9 stated, I think those are my morning medications. No nursing staff were noted in R9's room. On 8/20/24 at 8:54 AM, V9 (Registered Nurse/RN) stated, No residents on the second floor (R9's floor) can self-administer their medications or have meds in their room. We must watch them take their medications to make sure they take them or don't choke. We would need a physician order to let a resident administer their own medications. On 8/20/24 at 1:38 PM, V1 (Administrator) stated, R9 had never been assessed to self-administer her medications. R9's August 2024 Order Summary Report showed no physician order to allow R9 to self-administer her medications or to keep medications in her room. The facility's Medication Administration: General Guidelines policy dated 1/2022 showed, All medications shall be administered as prescribed by licensed personnel authorized to do so in accordance with standard nursing practice and current regulations. Residents are permitted to self-administer medications when specifically authorized by the physician and if determined able in accordance with policies and procedures for self-administration of medication. 35174 2. R65's Facesheet printed on 8/21/24 showed R65 to be an [AGE] year old male resident readmitted to the facility on [DATE] with diagnoses which include: acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation, and pneumonitis due to inhalation of food and vomit. On 8/19/24 at 11:00 AM, R65 was in his room completing a nebulizer treatment. R65 had a mediation package with 2 DuoNeb doses, 1 dose of Budesonide suspension, and 1 Fluticasone aerosol dispenser which R65 placed in the middle drawer of his nightstand. R65 stated he had made a deal to take the medications himself since he takes 4 DuoNeb and 2 Budesonide treatments a day. R65 stated the nurse will sometimes listen to my lungs in the morning, but they don't do it with every treatment. I have been doing these myself just after I was in the hospital with pneumonia. R65's Order Summary printed on 8/21/24 showed an order for Budesonide Inhalation Suspension 1 milligram/milliliter (mg/ml) inhale orally two times daily, DuoNeb Solution 0.5-2.5 (3) mg/3ml inhale orally via nebulizer four times daily (and as needed), and Fluticasone Furoate Aerosol Powder Breath Activated 200 micrograms per activation inhaled orally one time a day. On 8/20/24 at 9:35 AM, V21 (RN) stated if a resident is able to give themselves medications they need to be assessed. R65 has been doing his own nebulizer treatments for a while. R65's medical record showed no Self Administration Assessments prior to 8/20/24, and no Care Plan entries for Self administration of medications prior to 8/21/24. 3. R158's Facility assessment dated [DATE] showed R158 is a cognitive [AGE] year old female who was readmitted to the facility on [DATE] with diagnoses which included: chronic obstructive pulmonary disease with acute exacerbation and acute and chronic respiratory failure with hypoxia. On 8/19/24 at 11:20 AM, R158 was sitting on her bed self administering a nebulizer treatment. R158 had 3 unopened nebulizer medication vials (Albuterol) on the night stand. R158 stated I am very independent. It is just easier to have a few of these (treatments) in my room to just do them instead of tracking down a nurse to get one. Since restarting them I usually need 3 or 4 treatments a day. I knew how to use a nebulizer from before, but no one has ever came to teach me how to use it or had me sign anything saying I knew how. R158's Order Summary printed on 8/21/24 showed R158 has an order for Albuterol Sulfate Inhalation Nebulization Solution 2.5mg/3ml. Inhale orally every 4 hours as needed for wheezing or shortness of breath. R158's medical record showed no Self Administration Assessments prior to 8/20/24, and no Care Plan entries for Self administration of medications prior to 8/21/24. On 8/21/24 at 1:20 PM, V2 (Director of Nursing) stated a resident needs to be assessed to be able to self administer medications. The facility's Self-Administration of Medications Policy dated 9/2020 showed a resident will not be permitted to administer or retain medications in their rooms unless so ordered by the attending physician, assessed for their cognitive, physical, and visual ability to self-medicate, and approved by the care planning team. This Policy also showed a resident able to self-administer medications will be placed on a training program which includes: Self-medication assessments completed initially and quarterly, a plan of care with quarterly documentation, and the completion of a Self-Medication Daily Flow Sheet.

Based on observation, interview and record review the facility failed to ensure Activities of Daily Living (ADL) cares including showers and shaving were being completed for 4 of 31 residents (R123, R125, R52 and R35) reviewed for ADL's in the sample of 31. The findings include: 1.) On 9/11/23 at 10:43 AM, R123 said his biggest complaint about the facility is the fact he is not getting showered regularly, and also has not been shaved in 2-3 weeks. He said he is supposed to receive showers on Tuesday and Friday evenings. R123 had scruffy facial hair and a partial beard growing. He said, When I ask about a shower or shaving I get told they are too busy or short staffed and cannot do it but look at me I have never had a beard. R123's facility assessment completed on 7/3/23 shows his cognition is intact. R123's ADL care plan initiated on 9/13/22 shows he requires extensive staff assistance with his ADL's including grooming and showering. The facility shower schedule reviewed on 9/12/23, shows R123 should receive showers on Tuesday and Friday evenings. The shower book was also reviewed by this surveyor on 9/12/23 and it had 1 shower sheet in it for R123 dated 7/18/23. On 9/13/23 the facility provided shower sheets for R123. Those sheets dated between 8/17/23 and 9/11/23 show he had a shower on 8/17/23 and again on 8/31/23. The sheets indicate he either refused a shower, or was given bed baths on 8/21, 8/24, 8/28, 9/4, 9/7 and 9/11. On 9/12/23 at 1:34 PM, R123 was in his room visiting with V12 (R123's family member). V12 said she went out and bought R123 a electric razor and a hair trimmer in hopes that would help get someone to shave him and clip his hair. V12 said it is a big problem here, with R123 not being showered regularly. This surveyor asked R123 if he had in fact received a bed bath on Monday 9/11/23 (as the shower sheets indicated) and R123 said he did not receive a bed bath, and his shower days are Tuesdays and Fridays. On 9/12/23 at 1:51 PM, V11 (Certified Nursing Assistant/CNA) said R123 does complain a lot about not getting showered on the evening shift. She said they cannot do all of the showers on day shift but she tries to help out and do extra when she can. R123 said she did in fact shave R123 but it has been 2-3 weeks since she did. On 9/13/23 at 9:47 AM, V10 (Agency CNA) said residents can be shaved when they are showered but they also have shaving days where staff go around and shave residents. 2.) On 9/11/23 at 11:28 AM, V9 (R125's family member) was in the bathroom with R125 shaving him. V9 said there is a problem at the facility with showers and shaving. He said R125 is not getting showered or shaved regularly by the facility. V9 said he has mentioned it many times to staff when R125 does not receive his shower. V9 also said R125 is alert and with it and he knows if he had a shower or not. He said, today is supposed to be his (R125's) shower day but watch he won't end up getting one. On 9/12/23 at 1:49 PM, both V9 and R125 said that R125 did not receive his shower on 9/11/23. V9 said I reminded several staff before I left yesterday (9/11/23) that he (R125) still needed his shower. V9 said the only reason R125's hair is not greasy is because he took him down for a hair cut and they washed it. On 9/12/23 at 1:42 PM, V8 (CNA) said residents should be showered 2 times a week, and they document it is done on shower sheets that are then placed in the shower book and also in the computer in residents medical record. V8 was asked by the surveyor if R125 had received his shower on 9/11/23 and she confirmed he did not receive one due to time constraints. The facility shower sheets in the shower book shows R125 is scheduled for showers on Monday and Thursdays on day shift. The facility provided shower sheets to the surveyors on 9/13/23 (that were not in the book on 9/12/23). Those shower sheets have documented and signed off that R125 not only received a shower on 9/11/23 but also on 9/14/23, 9/18/23, and 9/21/23. The sheets appear to be already filled out and signed for his upcoming showers. R125's electronic medical record (EMR) task charting for showers show his last documented shower was 8/31/23. 3.) On 9/11/23 at 9:32 AM, R52 said he had a spinal cord injury and now requires a lift to transfer out of bed. He said when asks about getting a shower he is told that they have to use a lift to transfer him to the shower chair and don't have enough people to do that. R52 said he has been at the facility since February and has probably had 2-3 showers and 6 bed baths in total. He said he has refused a bed bath on one occasion due to them coming to his room very late in the evening. R52 said he is supposed to receive his showers on Tuesday and Friday evenings. On 9/12/23 at 1:51 PM, V11 (CNA) said R52 does complain that he is not receiving his showers on the evening shift. R52's 8/22/23 facility assessment show his cognition is intact and he requires extensive staff assistance with his ADL's including bathing and grooming. The facility shower book shows R52 should receive his showers on Tuesday and Friday evenings. On 9/12/23 the shower book had no shower sheets for R52 inside. The facility provided shower sheets to the surveyors on 9/13/23 that had documented R52 received bed baths on 8/22/23, 8/25/23, and 9/5/23. Those sheets also document that R52 refused showers on 9/1/23 and 9/8/23 and the sheet for 9/12/23 is pre-signed but not indicated if he had a shower or not. R52's (EMR) task charting for showers show his last documented shower was 9/9/23 and that shower documentation says he receives showers on Wednesdays and Saturdays. The dates in the computer and the documented bed baths/showers for R52 do not correspond with the sheets provided by the facility. On 9/13/23 at 9:51 AM, R52 said he did not receive his scheduled shower on 9/12/23. He said he even reminded several staff it was his shower day but still didn't get one. R52 said he has not recently refused any showers or bed baths and he last received a bed bath 3 weeks ago. R52's active care plan does not show any refusals of care documented. 4.) On 9/12/23 at 11:27 AM, R35 was in bed. Her hair appeared very messy and to have not been brushed in awhile. She had some dried food on her chin and gown. R35 said she has not been getting baths recently. She said when she asks about one the staff tell her the shower bed is broken. R35's facility assessment dated [DATE] shows her cognition is intact and she requires extensive staff assistance with her ADL's including bathing and grooming. The facility shower book shows that R35 should receive showers on Tuesday and Friday evenings. The shower book reviewed on 9/12/23 had 1 documented shower on 8/10/23 for R35. R35's EMR shower task charting shows 1 documented shower for R35 on 8/25/23. That charting has no documented refusals of showers. The facility provided shower sheets on 9/12/23 show R35 refused showers on 8/15/23, 8/18/23, 8/22/23, 8/29/23, 9/1/23 and 9/12/23. The sheets have documented that R35 received a bed bath on 8/18/23, 8/22/23, 9/5/23 and 9/8/23. On 9/13/23 at 9:45 AM, R35 said, I have not refused a shower. I want a shower but they tell me the shower bed is broken. It has been a month since I had a shower. R35's active care plan does not show any refusals of care documented. The facility provided ADL policy dated 9/20 for Bath,Tub or Shower, and Shaving the Resident says the purpose is to bring comfort and cleanliness to the resident. The policies do not address time frames that showers should be given or the required documentation. The policy does list shaving should also be completed for the residents.

Based on observation, interview, and record review, the facility failed to ensure pureed rice was prepared and served in a smooth, palatable consistency for 4 of 14 (R105, R154, R68, and R64) residents reviewed for food palatability in the sample of 31. The findings include: The facility's Diet Type Report dated 9/11/23 shows R105, R68, R64, and R154 are all on a pureed diet. During the initial kitchen tour on 9/11/23 at 9:21 AM, V13, Cook, said they are having chicken, broccoli and rice for the lunch meal. On 9/11/23 at 10:58 AM, V13 said when making pureed foods he wants to make it to a smooth, pudding like consistency. V13 said he tastes the pureed foods to make sure they are very smooth. On 9/11/23 at 12:53 PM, a sample tray of the pureed lunch meal was obtained and tasted by the survey team. The pureed rice had an unappetizing, chunky texture which required chewing. The facility's Puree Prep Policy (revised 8/18) shows puree food will be palatable, attractive and prepared in a safe manner and will be puree to mashed potato or applesauce consistency.

Based on observation, interview and record review the facility failed to ensure symptomatic residents were immediately isolated and tested for COVID-19 to prevent to spread of infection and failed to ensure appropriate personal protective equipment was used when entering a contact/droplet isolation room for 5 of 31 residents (R10, R83, R100, R115 and R121) reviewed for infection control in the sample of 31. The findings include: 1. On 9/11/23 at 9:30 AM, R100 was laying in bed coughing and had a hoarse voice. R100 said that he had been coughing since yesterday (9/10/23). V17 (Certified Nursing Assistant) provided incontinence care and a transfer for R100. R100 was not on isolation. On 9/12/23 at 1:23 PM, there was a sign outside of R100's room that showed that he was on contact droplet isolation. The sign showed, Droplet Precautions-Everyone must: .Make sure their eyes, nose and mouth are fully covered before room entry [picture of a person with a faceshield on and a picture of a person with goggles on] .Remove face protection before room exit. There was an isolation cart outside of R100's room. This cart did not contain any faceshields or goggles. V17 donned a surgical mask, gloves and gown before entering the room. V17 did not apply any eye protection. On 9/12/23 at 9:20 AM, V17 stated that she started getting sick last night with a cough and congestion. V17 stated, Everyone is sick. On 9/12/23 at 1:09 PM, V18 (CNA) said that when entering a contact/droplet isolation room staff should put on gloves, gown and a surgical mask. R100's Nursing Notes dated 9/7/23 at 7:13 AM shows, Resident w/ (with) on and off cough, runny nose .DON (Director of Nursing) updated. Will monitor. R100's Nursing Notes dated 9/11/23 at 1:45 PM shows, Resident noted with hoarse voice and occasional dry cough .Rapid COVID 19 test negative, place on contact/droplet isolation due to COVID-19 symptoms . On 9/12/23 at 11:53 AM, V5 (Infection Prevention Nurse) said that symptoms of COVID 19 include: sore throat, cough, runny nose, increased weakness, confusion, muscle aches and fever. V5 said that a resident should be immediately place on contact/droplet isolation if they have any COVID-19 symptoms. V5 said that the resident should then be tested for COVID-19. V5 said that the facility is only currently using rapid COVID tests and not doing PCR testing. V5 said that staff should wear a surgical mask, faceshield, gloves and gown when entering a contact/droplet isolation room. V5 said that it should be documented in the nursing notes if a COVID test was performed. On 9/13/23 at 12:48 PM, V5 said that in the evening of 9/12/23 (5 days after R100's documented symptoms) when he was working the floor, he tested R100 for COVID-19 and placed him on isolation. The only COVID-19 testing that was provided as being done for R100 was a rapid test that was performed on 9/12/23. 2. On 9/11/23 at 10:25 AM, R121 was walking down the hallway and coughing. R121 sat in a chair near the nurse's station. Two other residents were sitting in chairs on each side of R121. The residents were not 6 feet apart and did not have masks on. The other two residents were cough. On 9/12/23 at 9:00 AM, R121 was in his room. R121 said that he has been coughing and short of breath since Friday. R121 was not on isolation and R121 had a roommate. R121's Nursing Notes dated 9/11/23 at 1:23 PM shows, Resident complaining about coughing. [Nurse Practitioner] made aware, per NP received new order chest x-ray, and mucinex 600 mg twice a day R121's Electronic Medical Record from 9/8/23-9/12/23 does not document that the resident was placed on isolation or COVID-19 tested . On 9/13/23 at 12:48 PM, V5 (Infection Control Nurse) said that in the evening of 9/12/23 when he was working the floor, he tested R121 for COVID-19 and placed him on isolation. 3. On 9/12/23 at 9:09 AM, R83 was heard from the hallway coughing. R83 said, I wish I could quit hacking. R83 was not on isolation and had a roommate present in her room. R83 said that she has had a cough and sore throat for about 3 days. R83's Electronic Medical Record from 9/8/23 to 9/12/23 does not document that she has a cough or sore throat or that she was COVID-19 tested . On 9/12/23 at 1:38 PM, V20 (Licensed Practical Nurse) said that she was not aware that R83 had a cough or sore throat. On 9/13/23 at 12:48 PM, V5 (Infection Control Nurse) said that he is not aware that R83 has a cough or sore throat. V5 said that he is not sure how often the nurse's assess the resident for signs and symptoms of COVID-19 but he thinks it might be once a shift. The facility's Managing of Residents with Confirmed or Suspected COVID-19 Infection or Identified as a Close Contact Policy dated 7/2023 shows, Residents Suspected to have COVID-19-Test symptomatic residents regardless of vaccination status .Resident placement: Single room with door closed if safe to do so .If limited single rooms are available or if numerous resident are simultaneously identified to have COVID-19 exposure or symptoms draw a privacy curtain between the beds, and wait for test results Isolate empirically using Transmission-Based Precautions until results of tests are known .Monitor resident at least daily screen for signs and symptoms of COVID-19 Staff must wear full PPE (N95 respiratory, gown, gloves, eye protection) when providing care The decision to discontinue empiric Transmission-Based Precautions by excluding the diagnosis of current COVID-19 infection for a resident with symptoms of COVID-19 can be made based on having negative results from one PCR test. 45540 4. On 9/11/2023 at 10:48 AM, 12:22 PM, and 1:41 PM no isolation signs of any kind were observed outside of R10's room. No isolation cart or Personal Protective Equipment (PPE) was observed outside of R10's room either. On 9/11/2023 at 12:36 PM, V5 Infection Control Preventionist (ICP) said R10 developed a cough on 9/9/2023. V5 said R10 was swabbed for COVID-19 and was placed on contract/droplet isolation. V5 said the testing used was a rapid test and no PCR tests were completed for any residents tested for COVID-19. V5 said R10 should have still been on isolation on 9/11/2023. V5 said staff members caring for residents with COVID-19 symptoms but negative test results should wear mask, gloves, gown, and face shield while caring for the resident. V5 said an isolation cart with PPE should be placed outside of the room for any resident on isolation. R10's Order Summary Report dated 9/11/2023 shows an order for isolation contact and droplet precautions with a start date of 9/9/2023 and end date of 9/19/2023. 5. On 9/11/2023 at 9:40 AM, R115's room was observed to have an enhanced barrier precautions (EBP) sign on the door, but no isolation supply cart or PPE outside of the door. On 9/11/2023 at 9:42 AM, R115 said he had a stuffed-up nose and was swabbed for COVID-19 last week but was never placed on the correct isolation. R115 said facility staff had not been wearing masks when coming into his room since he was swabbed. R115 said he had some medic training in the military and understands some level of infection control practices. On 9/11/2023 at 12:24 PM, R115's room was observed to have an EBP sign but no other isolation sings and no isolation cart outside of the resident's room. On 9/11/2023 at 12:30 PM, V24 Registered Nurse (RN) said she was assigned to R115's room. V24 said R115 should be on contact/droplet isolation for COVID-19 exposure or symptoms. On 9/13/2023 at 12:36 PM, V5 said R115 was swabbed using a rapid test for COVID-19 on 9/7/2023 due to occasional coughing and complaints of body aches. V5 said R115 should have remained on isolation until 9/12/2023, pending three negative COVID-19 testing results. R115's Physician Order's show an order for contact droplet isolation with a start date of 9/7/2023 and end date of 9/17/2023. R115's Minimum Data Set (MDS) section C dated 8/18/2023 shows a BIMs score of 15, cognitively intact. The facility provided COVID-19 testing plan policy states rapid antigen testing should be performed for staff and/or residents who develop symptoms consistent with COVID-19 (even mild symptoms), regardless of their vaccination status. Should an individual with symptoms consistent with COVID-19 have negative results from a rapid antigen test, they should remain excluded from work and/or isolated pending the results of confirmatory PCR testing. The facility provided Management of Resident with Confirmed or Suspected COVID-19 Infection or Identified as a Close Contact policy states the decision to discontinue empiric Transmission-Based Precautions by excluding the diagnosis of current COVID-19 infection for a resident with symptoms of COVID-19 can be made based upon having negative results from one PCR test.

Based on observation, interview, and record review, the facility failed to ensure residents were free from physical and verbal abuse. This failure resulted in R1 experiencing a corneal abrasion following physical abuse by R2. This applies to 2 of 3 residents (R1 and R2) reviewed for abuse in the sample of 8. The findings include: 1. On May 8, 2023, at 3:37 PM, R1 was in his wheelchair in the dining room. R1 had an eyepatch over his right eye. R1 said, [R2] punched me and hurt my eye. R1's EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE], with multiple diagnoses including: chronic obstructive pulmonary disease, Crohn's disease, heart failure, dementia, and anxiety. R1's MDS (Minimum Data Set) dated April 12, 2023, shows R1 has moderate cognitive impairment. The MDS continues to show R1 requires limited assistance from facility staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and walking in room. R1's abuse care plan revised on May 12, 2022, shows, [R1] is at risk for abuse related to: has a history of dementia. The facility's final report to the State Agency dated May 5, 2023, shows, On 04/29/23 at approximately 6:00 PM, the nurse witnessed both resident's (R1 and R2) arguing and had physical contact . On April 30, 2023, at 9:58 AM, V12 (emergency room Physician) documented, Presenting status post being physically assaulted by another member of his nursing facility. Patient states that a gentleman came up and punched him in the face breaking his glasses yesterday, says he was also struck several times in the right shoulder. Denies any other injuries during the assault, denies fall, denies head strike loss of consciousness other than where he was punched. Primary reason for presenting today is that he has some mild pain in the right eye and says that his vision is slightly blurry. Says he had difficulty sleeping last night because the pain. The documentation continues to show R1 was diagnosed with a corneal abrasion on his right eye in the emergency room . On May 9, 2023, at 2:25 PM, V7 (RN/Registered Nurse) said, I was the nurse on April 29, 2023. I was in the dining room and I heard a commotion by the washroom, and I went over there. [R1] was in the doorway in the washroom, and the scene that I saw was [R2] hitting [R1]. [R1] was covering his face like a boxer and waving his head side to side. I saw [R2] hitting [R1]'s arms. [R2] was making contact with [R1]. It was really scary. On May 8, 2023, at 2:13 PM, R2 said, I have a problem with another resident, [R1]. He has yelled at me and called me an [expletive]. I had enough. I tried to talk to staff about it, but no one ever talked to me. [R1] and I got in an argument on Friday, I couldn't sleep all night because of it. The next day, [R1] was coming out of the bathroom and said, '[Expletive], you're going to jail.' So, I slapped him a few times. It hasn't gotten better since we changed rooms. On May 9, 2023, at 3:49 PM, V2 (DON/Director of Nursing) said physical abuse was substantiated for the incident on April 29, 2023. On May 9, 2023, at 3:18 PM, V11 (Physician) said R1's corneal abrasion happened due to the physical altercation when R2 hit R1. V11 continues to say his expectation is residents should be free from abuse. 2. R2's EMR shows R2 was admitted to the facility on [DATE] with multiple diagnoses including: chronic obstructive pulmonary disease, heart failure, chronic kidney disease, depression, and dementia. R2's MDS dated [DATE], shows R2 is cognitively intact. The MDS continues to show R2 requires supervision of facility staff for locomotion on and off the unit, toilet use, and eating. R2's abuse care plan revised on February 22, 2023, shows, [R2] is at risk for abuse related to: diagnosis of dementia, major depression, history of yelling at staff, making threatening statements and history of verbal abuse from another resident. On May 9, 2023, at 3:49 PM, V2 (DON/Director of Nursing) said, [R1] said, '[expletive] you, you are going to jail,' to [R2]. [R2] went to slap [R1] and [R1] covered his face. Verbal abuse was substantiated in this incident. There is not a separate reportable for [R1]'s verbal abuse to [R2]. On May 8, 2023, at 2:13 PM, R2 said, I have a problem with another resident, [R1]. He has yelled at me and called me an [expletive]. I had enough. I tried to talk to staff about it, but no one ever talked to me. [R1] and I got in an argument on Friday, I couldn't sleep all night because of it. The next day, [R1] was coming out of the bathroom and said, '[Expletive], you're going to jail.' So, I slapped him a few times. It hasn't gotten better since we changed rooms. On May 9, 2023, at 2:11 PM, V13 (Psychiatric Nurse Practitioner) said, [R1] is bullying [R2] and swearing at [R2] without provocation and [R2] gets agitated. [R2] told me yesterday, that [R1] came to [R2]'s floor and was bullying [R2]. I think [R1] is verbally aggressive and bullying [R2] and that is provoking [R2]. On May 8, 2023, at 1:59 PM, V10 (Social Services Director) said, I have seen [R1] stick his middle finger up at [R2], and I have seen [R1] be verbally aggressive towards [R2]. The facility's policy titled, Abuse Policy, dated 09/20, shows, Policy: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility will report reasonable suspicion of a crime. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done by: . 3. Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; 4. Identifying occurrences and patterns of potential mistreatment; 5. Immediately protecting residents involved in identifying reports of possible abuse; 6. Implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences; 7. Filing accurate and timely investigative reports; This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals who have been convicted of abusing, neglecting, or mistreating individuals. Definitions: . Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful means the individual acted deliberately, not that the individual must have intended the injury or harm . Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment . Verbal abuse is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of their age, ability to comprehend or disability .

Based on observation, interview and record review the facility neglected to provide sufficient numbers of nursing staff to meet the physical and psychosocial needs of residents in the facility. The facility failed to ensure facility residents were free of neglect resulting in the actual or potential physical and/or psychosocial harm to 18 of 18 residents in a sample of 23. This failure resulted in physical harm to R1 who was observed to have two re-opened, previously healed pressure ulcers and scratch marks on her skin from skin irritation, psychosocial harm to R1 after not receiving showering assistance from staff which caused her to become more depressed, physical harm to R16 after R16's previously healed pressure injury reopened, physical harm to R4 after development of a new pressure injury, as well as psychosocial harm to R3 and R10, as well as putting R2, R5-R9, R11, R12, R14, R15, R17, R19 and R20 at serious risk of physical/psychosocial harm. These failures resulted in Immediate Jeopardy. The Immediate Jeopardy began on 2/1/23 when a severe lack of facility staff caused the neglect of facility residents requiring assistance from facility staff. V1 (Administrator) was notified of the Immediate Jeopardy on 2/7/23 at 1:49 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 2/9/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the staffing interventions. The findings include: On 2/1/23 at 12:45 PM, V6 (C.N.A.-Certified Nursing Assistant) stated the third floor AM shift usually has only two CNAs scheduled on the floor for the 54 total residents. V6 stated each CNA was responsible for 27 residents on 2/1/23. V6 stated six of her residents require two staff to assist with mechanical lifts for transfers and four of her residents require two staff because of behaviors during care. At 12:55 PM, V6 stated when the CNAs have time, they toilet residents before and after breakfast and again before lunch. V6 stated when there are only two CNAs working on the third floor, they are unable to toilet residents after breakfast or before lunch because they need to get residents out of bed that remain in bed for breakfast. V6 stated she had five residents that remained in bed during breakfast. V6 stated the CNAs are unable to give residents showers/bed baths when only two CNAs are scheduled on the third floor. V6 stated they document in the computer when they perform resident showers. V6 stated if there are three CNAs on the floor and a Resident Assistant (RA), the RA helps transport residents and they are sometimes able to give showers. On 2/1/23 at 12:48 PM, V5 (CNA) stated he was caring for 24 residents - six of which required two staff for mechanical lift transfers. On 2/6/23 at 9:40 AM, V12 (Scheduler/CNA) stated there were only 2 CNAs working for a total of 62 residents residing on the second floor. Resident Council Minutes, dated 12/26/232, show, Staffing issues are still working progress and is getting better Resident Council minutes, dated 11/21/22, show, .CNA staffing is still being worked on On 2/1/23 at 1:43 PM with V16 (RN), V12 (CNA/Scheduler) stated the facility census had remained fairly stable for the last couple months and any census changes that did occur did not change staffing needs on the facility floors. V12 stated if she had sufficient staff, she would schedule 5 CNAs on the 2nd floor and 5 CNAs on the 3rd floor during both the AM and PM shifts. V12 stated those 5 CNAs scheduled would be in addition to any restorative staff working in the facility. V12 stated restorative staff only get pulled to help on the second or third floor if only 1 CNA shows up for a shift on a floor. V12 stated she was currently working as one of the two CNAs on the second floor and she alone was caring for 31 residents. V12 stated V10 (CNA) was the only other CNA working on the second floor during the AM shift on 2/1/23 and V12 alone was caring for 32 residents. V12 stated the second-floor census is higher than usual and is almost at capacity as they have 63/68 beds filled. V12 stated there were 24 residents requiring mechanical lifts for transfers in addition to several other residents requiring two staff's assistance for ADLs. V12 stated 2 CNAs on the floor of approximately 63 residents had been typical at the facility for a long time. V12 stated she is only allowed to call staff employed by the facility. V12 stated, We just do not have the staff to call. V12 stated she has been requesting for the use of agency staff to help fill in the schedule for some time. Facility Roster, dated 2/1/23, shows the facility census was 160 residents. The roster shows there were 43 residents residing on the first floor, 63 residents residing on the second floor, and 54 residents residing on the third floor. Review of schedules, dated 1/30/23 to 2/6/23, show on the AM or PM shifts on either the second or third floors of the facility: 1. 13/36 shifts had only 2 CNAs working on the entire floor. 2. 4/36 shifts had three CNAs but one CNA only worked part of the shift 3. 17/36 shifts had only three CNAs working on the entire floor Review of Facility Nurses and CNAs list, provided 2/8/23, shows the facility only employed 15 full time CNAs, 4 part time CNAs, and 7 casual CNAs. Facility Assessment, reviewed 11/22/22, shows the facility average census was 153 residents. The assessment shows the total number of CNA full time equivalents required at the facility were 34-37. The assessment shows, .Facility budgets are established to act as a general guideline for facilities to follow when determining staffing levels needed to provide care to residents being serviced. These budgets are established based on the average resident census along with their projected needs for care and support. Facility budgets are maintained by the Administrator and are flexible based on the actual acuity and unique individual care needs of the residents. To promote continuity of care, and consistent practices, we avoid the use of contract staff and agency staff for direct care positions Individual staffing assignments are determined at the facility level and take into consideration the current support/care needs of the residents that include, but are not limited to medical/physical conditions, acuity, physician orders, therapeutic needs, infection prevention and control needs, behavioral support as well as any other special care needs as identified, Consultation with [NAME] Management Services in customizing and revising individual staffing assignment is obtained, if necessary. On 2/1/23 at 3:03 PM, V1 (Administrator) stated she was aware of the schedule being short staffed and stated the facility was offering financial incentives for staff to work longer or extra shifts. V1 stated the facility was only able to rely on the staff on the facility payroll and the facility recently lost two CNAs to another facility. V1 stated she was not given permission to utilize agency nursing staff by her corporate supervisors. 1. Face sheet, printed 2/1/23, shows R1's diagnoses included multiple sclerosis, quadriplegia, spinal stenosis, overactive bladder, anxiety, and depression. MDS (Minimum Data Set), dated 1/30/23, shows R1 was cognitively intact, was totally dependent on staff for transfers, personal hygiene, eating and dressing, and required extensive assistance from two staff for bed mobility, R1 was always incontinent of bowel and bladder, and R1 had an indwelling urinary catheter. Braden scale, dated 1/28/23, shows R1 was at moderate risk for development of a pressure ulcer and R1 was not able to make even slight changes in body or extremity position without staff assistance. ADL Care Plan, initiated 8/7/22, shows R1 required a mechanical lift for transfers and requires staff assistance for bathing, toileting, and personal hygiene. Interventions include R1 refuses to take showers on non-scheduled dates. Skin integrity care plan, revised on 2/17/22, shows R1 had a history of skin injuries to her sacrum, had a reopened injury to sacrum and impaired mobility. Interventions include inspect skin with showers and as needed and turn and reposition every two hours and as needed. Depression care plan, revised 1/29/23, shows R1 had a diagnosis of depression and was observed of feeling down and tearful. Incontinence care plan, dated 10/18/21, shows R1 was incontinent of bowel related to multiple sclerosis and quadriplegia and interventions included offering toileting opportunities based on R1's pattern of elimination. Bed mobility care plan, revised 4/19/18, shows R1 was unable to turn and reposition herself in bed without assistance with staff. On 2/1/23 at 2:00 PM with V14 (Sister) on speaker phone, R1 stated the facility did not have enough staff to care for residents including providing showers, repositioning, and checking/changing incontinence briefs. R1 stated she had not received a shower for two weeks. R1 stated had not received her showers twice a week for a few months and that was when R1 began having skin irritation. R1 stated not having showers twice weekly caused her to itch and scratch her skin until she bled. R1 had visible, scabbed, scratch marks on her left upper thigh, right upper arm near her shoulder, and bright red scabs on her right breast. R1 stated, Once I start scratching, I can't stop! It started a couple months ago when it began to be one shower a week. I started itching more as it declined. R1 also stated, I feel terrible, wouldn't you!? Sometimes I can smell myself! V14 (Sister) stated, I have called her and she has been so depressed and feels so bad about herself. She has told me it is depressing. R1 also stated, They're not turning me. The other day I was not moved for 13 hours. R1 stated she had pressure ulcers and her repositioning schedule is never followed by staff. R1 stated, When I am left sitting in one position for so long my pressure ulcer starts burning and I call my sister and she calls and talks to nurses and gets them in here. R1 stated she has waited two hours for staff to answer her call light for ADL assistance. R1 had a repositioning schedule over her bed that showed R1 was to be turned every two hours on the even hours. On 2/6/23 at 3:35 PM, R1 was observed with V8 (Assistant Director of Nursing) and two open areas were noted during the observation - one area on the sacrum and one area on the left buttock. Per V8, these areas had been healed, were previously closed, and now were newly open. Facility's wound report, dated 2/2/23, shows R1's wounds were healed. On 2/7/23 V17 (Wound Physician) stated that he would expect that R1 be repositioned at least every two hours and that R1 has a history of skin breakdown. On 2/9/23 at 8:08 AM, V2 (Director of Nursing) stated R1 could not move her body and would not be able to scratch herself. At 9:20 AM, V2 stated she visited R1 and asked R1 to show her if she could reach the areas that were observed to have scratch marks on 2/1/23. V2 stated she bathed R1 on 2/3/23 and saw no scratch marks red marks, or skin irritation on R1. V2 stated the night nurse on 2/8/23-2/9/23 stated R1 was scratching all night and the nurse called the physician for cream the AM of 2/9/23. V2 stated she was unaware of any creams R1 was provided prior to 2/9/23 for her itching. At 10:09 AM, V2 stated R1 told V2 she could reach those areas R1 stated she had been scratching and had caused scratch marks. On 2/9/23 at 9:34 AM, V14 (Sister) stated she previously provided R1 with a back scratcher and creams because R1 became so itchy recently. V14 stated the staff previously gave her a tube of cream to put on her skin when she started itching. V14 stated I was just talking to her about the back scratcher. She just told me V2, and a nurse came in asking her about her scratch marks. You can't tell them anything because they deny it or downplay it. I told them not to do that to me. [R1] told them she could reach as far as the scratches are. Progress notes, dated 2/9/23, show, Prior to resident scratching no skin issues noted. Resident noted to scratch skin at times this shift with dry brownish scratch marks noted to both anterior thigh, right chest and pinkish discoloration noted to right arm, with complaint of itching and per resident she scratches her skin. Review of Bath/Shower Follow Up Question Report, printed 2/6/23, shows R1 received only 5 showers from 1/1/23 to 1/31/23 (showered on 1/6/23, 1/10/23, 1/13/23, 1/16/23, 1/20/23). The shower sheet shows R1 refused showers on 1/4/23, 1/25/23, and 2/1/23 all of which were documented as late entries by V9 (Restorative Nurse) on 2/2/23. On 2/6/34 at 3:50 PM, V9 (Restorative Nurse) stated the documentation entered on 2/2/23 on the Bath/Shower Follow Up Question report was not accurate and then provided hand-written shower sheets for R1 showing she provided R1 a shower on 1/16/23. V9 stated the hand-written shower sheets she provided were accurate documentation of showers she provided R1. V9 stated she filled out the shower sheet dated 1/20/23 for V12 (CNA/Scheduler) when V12 gave R1 a shower. V9 stated on 1/4/23 and 1/25/23 she offered R1 PM showers which she knew R1 did not prefer and R1 subsequently refused. V9 stated she only provided R1 one shower during January 2023 despite the documentation she recorded on 2/2/23 on the Bath/Shower Follow Up Question Report. On 2/6/23 at 9:40 AM, V12 (Scheduler/CNA) stated R1 only preferred her showers in the morning and all staff are aware of her preferences. V12 stated if you try to offer R1 showers in the afternoon/evening, she normally refuses. V12 stated the prior week was the second week in a row R1 had not received showers. V12 stated the last time she gave R1 a shower was on 1/20/23. V12 stated she was able to give R1 showers on 1/6/23, 1/10/23, 1/13/23, and 1/16/23 because they had more CNA staff. V12 stated the CNAs choose Not Applicable in the electronic record as a response when a resident's shower task appears during a day/shift that R1 was not scheduled for a shower. V12 stated residents are not offered showers when the response in the computer was marked Not Applicable. Second floor facility shower list, dated 11/22/22, shows all residents are scheduled to receive two showers each week. Third floor facility shower list, dated 6/20/19, show all residents are scheduled to receive two showers each week. On 2/1/23 at 2:14 PM, V2 (Director of Nursing) stated staff were expected to check resident's incontinence briefs in their rooms every two hours if the residents were incontinent. 2. On 2/6/23 at 10:18 AM on the third floor, there was a strong smell of concentrated urine throughout each of the two hallways. R16 was a [AGE] year-old resident with multiple diagnosis including: Diabetes, Heart Failure, Hypertension, Protein Calorie Malnutrition, Gout, Dysphagia, and Muscle Weakness. Per R16's MDS (Minimum Data Assessment) dated December 27, 2022, R16 was dependent on staff for personal hygiene, transfers, position change, and is always incontinent of bowel and bladder. R16's care plan dated January 11, 2023, shows R16 required a two-person mechanical lift to transfer and R16's interventions included turning and repositioning R16 every two hours and as needed. R16 was assessed as cognitively impaired per the MDS assessment. Facility wound list, dated 2/2/23, shows R16 as having a healed wound to the left buttock and open Stage III wound to right buttock. R16 also has a previous Stage III pressure injury to the right heel that was documented as closed on October 25, 2022. R16's wound to the left buttock was noted as healed on January 24, 2023. Braden Scale, dated 2/1/23, shows R16 was at mild risk for development of a pressure injury. On 2/6/23, V13 (CNA) stated between 7:30 AM and 8:30 AM on 2/6/23, there was only one CNA working on the floor providing direct care for all 54 residents. At 8:30, a second CNA began working on the floor. On 2/6/23, R16 was observed on the third floor in the dining room or directly outside the dining room near the nursing station from 9:10 AM until 1:40 PM. R16 was noted sitting directly on the sling for the mechanical lift in an adult reclining chair. During this time, R16 was not checked for incontinence nor was she repositioned. At 3:20 PM, R16's wounds were observed with V2 (Director of Nursing RN) and V8 (Assistant Director of Nursing RN) and the area on the left buttocks was noted to be open. Both V2 and V8 confirmed that this area was now reopened and V8 stated he would notify the wound doctor. V17 (Wound Physician) was notified about the re-opened wound, was interviewed on February 7, 2023, at 1:15 PM, and stated that R16 should be repositioned at least every two hours to remove pressure. V17 also stated that since he is not in the facility all of the time that he assumed the staff would change R16's position at least every two hours. V17 stated that not providing position changes leads to new skin issues. 3. Face sheet, printed 2/1/23, shows R3's diagnoses included hemiplegia and hemiparesis following cerebral infarction, chronic respiratory failure with hypoxia, morbid obesity, and depression. MDS, dated [DATE], shows R3 was cognitively intact, required total assistance from staff for transfers, required the extensive assistance from two staff for bed mobility, dressing, toilet use, bathing and personal hygiene, and was always incontinent of bowel and bladder. Braden scale, dated 12/5/22, shows R3 was at mild risk for the development of a pressure ulcer. On 2/1/23 at 2:29 PM, R3 stated during the day shifts she usually waits approximately 45 minutes for staff to answer her call light. R3 stated staff fail to turn her every two hours and fail to provide R3 showers. R3 stated she had not had a shower for weeks. R3 stated, It makes me feel horrible. R3 stated front office staff had to help last time she was bathed because she needed so much cleaning. On 2/6/23 at 9:40 AM, V12 (CNA) stated in early December 2022, R3 was seen by her Nurse Practitioner who told the facility to give R3 a shower because R3 was unclean, had foul odor, and R3's hair was matted. V12 stated she showered R3 at that time and had not given her a shower since. On 2/6/23 at 11:48 AM, V20 (Nurse Practitioner) stated she did ask staff to give R3 a shower because R3's hair was not able to be combed out, R3 had an odor, and R3 had a denuded area under her breasts. Review of facility Bath/Shower Follow Up Question report, printed 2/6/23, shows R3 received only 3 showers between 1/1/23 and 1/31/23 (showered on 1/20/23, 1/27/23, and 1/31/23). The report shows the staff marked Not Applicable on 1/3/23, 1/10/23, 1/17/23 and 1/24/23 indicating no shower was offered. Hand-written shower sheets provided by V9 (Restorative Nurse), showed she provided R3 showers on 1/20/23, 1/27/23, and 1/31/23. On 2/6/34 at 3:50 PM, V9 (Restorative Nurse) stated the documentation she entered on 2/2/23 on the Bath/Shower Follow Up Question report showing R3 was provided multiple showers by V9 (1/6/23, 1/13/23) was not accurate and provided hand-written shower sheets which accurately showed the showers she provided for R3. The shower sheets showed V9 only provided R3 showers on 1/20/23, 1/27/23, 1/27/23, and 1/31/23. On 2/6/23 at 9:40 AM, V12 (Scheduler/CNA) stated R3 did not receive showers on 1/6/23, 1/13/23, 1/17/23, 1/20/23 and 1/21/23. V12 stated the CNAs responded, Not Applicable in the computer when the task comes up in the computer and it is not the resident's shower/bath day. V12 stated no baths were provided to R3 on those days. ADL care plan, revised 2/6/23, shows R3 required two staff assistance with bed mobility, transfers, toileting, grooming and bathing. The revision shows, Often declines ADL cares - showers, repositioning then says she was not offered care. Intervention, revised 2/6/23, shows, Provide resident with a sponge bath when a full bath cannot be tolerated. If [R3] declines cares offer her a different time. Re-approach- re-attempt task. Alteration in skin integrity care plan, revised 1/6/22, shows R3 was at risk for an alteration in skin integrity and refuses to allow staff to provide incontinence care in a timely manner and to turn and reposition off a skin tear to thighs. Interventions include staff to provide toileting and incontinence care with care rounds and as needed as well as turn and reposition every two hours as needed. Transfer care plan, dated 12/13/22, shows R3 requires the use of a mechanical lift for transfers. On 2/8/23 at 2:43 PM, V12 stated the care plan for R3 was inaccurate that R3 declined ADL cares including repositioning, incontinence care and showers. V12 stated she had worked with R3 every day for a couple of years and R3 never refused her offers of showers, incontinence care, or turning/repositioning. On 2/8/23 at 12:24 PM, V1 (Administrator) stated V21 (Corporate Consultant) altered R3's care plan on 2/6/23. Attempts to reach V21 were unsuccessful. 4. Face sheet, printed 2/2/23, shows R10's diagnoses included pressure ulcer right heel, dementia, Alzheimer's disease, adult failure to thrive, restlessness and agitation, and legally blind. MDS, dated [DATE], shows R10 was severely cognitively impaired, was totally dependent on staff for bed mobility, transfers, dressing, toileting, required extensive assist from staff for bathing, eating, and personal hygiene, and was always incontinent of bowel and bladder. Braden scale, dated 12/26/22, shows R10 was at only mild risk for the development of pressure ulcers. Impaired skin integrity care plan, revised on 2/21/22, shows R10 was admitted with an alteration in skin integrity / pressure injury and interventions included R10 was to receive incontinence care with care rounds and as needed. Transfer care plan, initiated 12/29/22, shows R10 required the use of a mechanical lift for transfers and interventions included providing two staff assistance for transferring. Incontinence care plan, revised 12/29/22, shows R10 was incontinent related to dementia and interventions included provide assistance for toileting. On 2/1/23 at 9:30 AM, R10 was sitting reclined in her reclining wheelchair just outside the third floor dining room doorway. R10 yelled, I have to pee! What am I gonna do!? V7 (RN-Registered Nurse) responded to R10 and stated, Go ahead and pee. They will change your brief in a little bit. R10 responded to V7 and stated, That's embarrassing! Oh Lord! V7 then looked away from R10 and stated, She's a [mechanical] lift. R10 continued to ask to go to the bathroom and V7 left R10's vicinity. At 9:33 AM, V7 stated R10 was very demented and incontinent. R10 was observed sitting in her wheelchair on 2/6/23 from 9:47 AM-1:30 PM without being repositioned or having her incontinence brief checked/changed. R10 was noted with large amounts of facial hair, uncombed and matted hair, and strong body odor. R10's clothing was soiled with food and debris along with her chair. 5. Care plan, initiated 9/27/22, shows R4's diagnoses included dementia, cerebral infarction without residual deficits, muscle weakness, chronic obstructive pulmonary disease, non-pressure chronic ulcer of skin, chronic kidney disease, and diabetes. The ADL care plan, revised 9/27/22, shows R4 required assistance with transfer, bed mobility, hygiene, toileting and bathing. The care plan interventions included assisting R4 with ADLs and utilizing a mechanical lift for transfers. Skin integrity care plan, revised 9/27/22, shows R4 was at risk for alterations in skin integrity related to poor skin turgor, dementia, poor hygiene, dermatitis to scalp and feet, incontinence of bowels and bladders, and noncompliant with ADL care including turning, positioning, and incontinence care. The care plan shows R4 had chronic on and off redness to buttock and scrotum and a non-pressure wound to the right great toe and left second toe. Interventions included incontinence care with care rounds and as needed and turn and reposition as per schedule and as needed. Transfer care plan shows R4 required the use of a mechanical lift and two staff assisting R4 for transfers. Incontinence care plan shows R4 experienced bowel/bladder incontinence due to prostate enlargement and an inability to delay voiding. Interventions included checking R4 for incontinence. Repositioning care plan, revised 9/27/22, shows R4 required assistance from staff for bed mobility and was unable to turn/reposition himself in bed without physical assistance. Interventions included providing R4 weight bearing assistance as needed while sitting up, laying down, or turning side to side in bed. MDS, dated [DATE], shows R4 was severely cognitively impaired, required total assistance from staff for bathing, transfers and toileting, required extensive assistance from two staff for bed mobility, dressing, and required the extensive assistance of one staff for personal hygiene. The MDS shows R4 was always incontinent of bowel and bladder. Braden scale, dated 12/13/22, shows R4 was at mild risk for pressure ulcer development On 2/1/23 at 9:19 AM, R4 was sitting in the third-floor dining room slightly reclined in his wheelchair and finishing breakfast. On 2/1/23 during continuous observation between 9:19 AM and 12:19 AM, R4 sat in the same reclined position with no staff repositioning R4 and no staff checking/changing R4's incontinence brief. At 12:19 PM, R4 was taken to his room to have his incontinence brief checked/changed. On 2/6/23 R4 was again observed in his wheelchair from 9:15 AM until 1:36 PM and R4was not repositioned or checked for incontinence. R4 was noted with long jagged fingernails with a brownish substance underneath. R4 had food crumbs and debris on his clothing and face. R4 had dirty greasy hair, long facial hair, and strong body odor. At 1:36 PM, V13 (CNA) proceeded to provide personal care to R4. R4 was noted with saturated brief and hard dried fecal matter. R4's right buttock area was noted to be red and inflamed. V13 needed numerous wipes to clean the dried fecal matter from R4's buttock and anal area since the stool was dried. V13 stated that R4 will scratch his buttock and that is why R4 has fecal matter under his nails. V13 stated that this was the first time he had to change R4 since they only had 2 nurse aides on the floor. R4's skin assessment sheet dated February 7, 2023, documents that R4 has a pressure injury on the left buttock measuring 5.5 by 0.5 by 0.1 centimeters and another injury on the sacrum measuring 5.0 by 0.5 by 0.1 centimeters. 6. Face sheet, printed 2/1/23, shows R2's diagnoses included incontinence without sensory awareness, dementia, depression, and cervicalgia. MDS, dated [DATE], shows R2 was cognitively intact, was totally dependent on staff for transfers, required the extensive assistance of two staff for bed mobility and toileting, required the extensive assistance of one staff for bathing, dressing and personal hygiene, and was always incontinent of bowel and bladder. Braden scale, dated 11/11/22, shows R2 was at mild risk for development of a pressure ulcer. On 2/1/23 at 2:39 PM, R2 stated there were often only two CNA staff for the whole second floor of residents. R2 stated she sometimes waited 12-15 hours for her soiled briefs to be changed. R2 stated her last bed bath was 1/20/23 and before that she had not had a shower in a long time because there were not enough staff at the facility. R2 stated at times there is only one CNA working the entire second floor on a AM or PM shift. R2 stated the staff only reposition her when they change her incontinence brief. R2 stated the staff typically change her incontinence brief approximately three times a day - usually at 4:00 AM during the PM shift, at 10:00 AM after breakfast, and then at approximately 9:30 PM before she goes to sleep. On 2/8/23 at 2:43 PM, V12 (CNA/Scheduler) stated R2 preferred her showers on the AM shift per her shower schedule which had been followed for years. Review of Bath/Shower Follow Up Question Report, printed 2/6/23, shows R2 received only 4 showers from 1/1/23 to 1/31/23 (showered on 1/17/23, 1/24/23, 1/27/23, 1/31/23). The report shows on 1/6/23, 1/13/23, 1/20/23 and 1/21/23 the CNA responded, Not Applicable in the computer. Review of hand -written shower sheets, provided by V9 (Restorative Nurse), shows R2 received showers by V9 only on 1/17/23, 1/24/23, 1/27/23, and 1/31/23. No hand-written shower sheets were provided for 1/3/23 and 1/10/23. On 2/6/34 at 3:50 PM, V9 (Restorative Nurse) stated the documentation entered on 2/2/23 on the Bath/Shower Follow Up Question report showing R2 was provided multiple showers by V9 (1/3/23, 1/10/23) was not accurate and provided hand-written shower sheets which accurately showed the showers she provided for R2. The shower sheets showed V9 provided R2 showers on 1/17/23, 1/24/23, 1/27/23, and 1/31/23. On 2/6/23 at 9:40 AM, V12 (Scheduler/CNA) stated R2 did not receive showers on 1/6/23, 1/13/23, 1/20/23 and 1/21/23 because the CNAs responded, Not Applicable in the computer. V12 stated facility CNAs mark Not Applicable on the bath/shower task when the task comes up in the computer and it is not the resident's shower/bath day. ADL Care Plan, revised 11/18/22, shows R2 required staff assistance with ADLs related to weakness and pain. Interventions included one staff assistance for bed baths, assist with ADLs as needed, check for skin changes during bathing, Intervention, revised 7/24/18, shows R2 prefers bathing after dinner between 8:00 PM and 9:00 PM. On 2/8/23 at 2:31 PM, V12 (Scheduler/CNA) stated R2 prefers showers in the AM which had been her shower schedule for years. 7. Care plan, revised 9/22/21, shows R7's diagnoses included dementia, bipolar disorder, psychotic disorder, depression, and anxiety. Care plan, revised 9/21/21, shows R7 had a potential for impaired skin integrity and interventions included turning and repositioning every two hours as needed. MDS, dated [DATE], shows R7 was severely cognitively impaired, required the extensive assistance of staff for bathing, bed mobility, transfers, dressing, toileting, and personal hygiene, and was always incontinent of bowel and bladder. Braden scale, dated 9/30/22, shows R7 was at mild risk for the development of pressure ulcers. On 2/1/23 at 9:19 AM, R7 was sitting in her wheelchair finishing her breakfast in the third-floor main dining room. On 2/1/23, during continuous observation between 9:10 AM and 12:05 PM, R7 sat in her wheelchair without staff repositioning R7 or checking/changing R7's incontinence brief. At 2:05 PM, R7 was toileted by V5 (CNA). V5 stated he got R7 up from bed at approximately 8:00 AM and checked/changed R7's incontinence brief at that time. R7's incontinence brief had a very strong smell of urine. 8. Face sheet, printed 2/1/23, shows R9's diagnoses included dementia, anxiety, and depressive disorder. MDS, dated [DATE], shows R9 was severely cognitively impaired, was totally dependent on staff for bathing, required the extensive assistance of two staff for bed mobility and transfers, required the extensive assistance of one staff for dressing, eating, toileting and personal hygiene, and was always incontinent of bowel and bladder. Braden scale, dated 12/2/22, shows R9 was at mild risk for development of a pressure ulcer. On 2/1/23 at 9:24 AM, R9 was laying in her bed in her room on her back sleeping with a thick blanket covering her body from her toes to her neck. The room temperature was very warm. During continuous observation, R9 was laying in the same position without incontinence check/change or repositioning from 9:24 AM to 12:29 PM. As R9 laid in bed, R9's cheeks became more red and at 12:08 PM R9 pulled the blanket down from her chin to her chest. On 2/1/23 at 12:16 PM, V18 (Assistant Administrator) stated R9 required assistan [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure facility residents received ADL (Activities of Daily Living) assistance per their plan of care. This failure resulted in the physical harm to R1 who was observed to have two re-opened, previously healed pressure ulcers and scratch marks on her skin from skin irritation. In addition, R1 also experienced psychosocial harm after not receiving showering assistance from staff which caused her to become more depressed. The failure also resulted in the development of a reopening of a previously healed pressure injuries on R16, development of a new pressure injury on R4, as well as psychosocial harm to R3 and R10. This applies to 18 of 18 residents (R1-R12, R14-R17, R19 and R20) reviewed for ADLS in a sample of 23. The findings include: 1. Face sheet, printed 2/1/23, shows R1's diagnoses included multiple sclerosis, quadriplegia, spinal stenosis, overactive bladder, anxiety, and depression. MDS (Minimum Data Set), dated 1/30/23, shows R1 was cognitively intact, was totally dependent on staff for transfers, personal hygiene, eating and dressing, and required extensive assistance from two staff for bed mobility, R1 was always incontinent of bowel and bladder, and R1 had an indwelling urinary catheter. Braden scale, dated 1/28/23, shows R1 was at moderate risk for development of a pressure ulcer and R1 was not able to make even slight changes in body or extremity position without staff assistance. ADL Care Plan, initiated 8/7/22, shows R1 required a mechanical lift for transfers and requires staff assistance for bathing, toileting, and personal hygiene. Interventions include R1 refuses to take showers on non-scheduled dates. Skin integrity care plan, revised on 2/17/22, shows R1 had a history of skin injuries to her sacrum, had a reopened injury to sacrum and impaired mobility. Interventions include inspect skin with showers and as needed and turn and reposition every two hours and as needed. Depression care plan, revised 1/29/23, shows R1 had a diagnosis of depression and was observed of feeling down and tearful. Incontinence care plan, dated 10/18/21, shows R1 was incontinent of bowel related to multiple sclerosis and quadriplegia and interventions included offering toileting opportunities based on R1's pattern of elimination. Bed mobility care plan, revised 4/19/18, shows R1 was unable to turn and reposition herself in bed without assistance with staff. On 2/1/23 at 2:00 PM with V14 (Sister) on speaker phone, R1 stated the facility did not have enough staff to care for residents including providing showers, repositioning, and checking/changing incontinence briefs. R1 stated she had not received a shower for two weeks. R1 stated had not received her showers twice a week for a few months and that was when R1 began having skin irritation. R1 stated not having showers twice weekly caused her to itch and scratch her skin until she bled. R1 had visible, scabbed, scratch marks on her left upper thigh, right upper arm near her shoulder, and bright red scabs on her right breast. R1 stated, Once I start scratching, I can't stop! It started a couple months ago when it began to be one shower a week. I started itching more as it declined. R1 also stated, I feel terrible, wouldn't you!? Sometimes I can smell myself! V14 (Sister) stated, I have called her and she has been so depressed and feels so bad about herself. She has told me it is depressing. R1 also stated, They're not turning me. The other day I was not moved for 13 hours. R1 stated she had pressure ulcers and her repositioning schedule is never followed by staff. R1 stated, When I am left sitting in one position for so long my pressure ulcer starts burning and I call my sister and she calls and talks to nurses and gets them in here. R1 stated she has waited two hours for staff to answer her call light for ADL assistance. R1 had a repositioning schedule over her bed that showed R1 was to be turned every two hours on the even hours. On 2/6/23 at 3:35 PM, R1 was observed with V8 (Assistant Director of Nursing RN) and two open areas were noted during the observation - one area on the sacrum and one area on the left buttock. Per V8, these areas had been healed and were previously closed. Facility's wound report, dated 2/2/23, shows R1's wounds were healed. On 2/7/23 V17 (Wound Physician) stated that he would expect that R1 be repositioned at least every two hours and that R1 has a history of skin breakdown. On 2/9/23 at 8:08 AM, V2 (Director of Nursing) stated R1 could not move her body and would not be able to scratch herself. At 9:20 AM, V2 stated she visited R1 and asked R1 to show her if she could reach the areas that were observed to have scratch marks on 2/1/23. V2 stated she bathed R1 on 2/3/23 and saw no scratch marks red marks, or skin irritation on R1. V2 stated the night nurse on 2/8/23-2/9/23 stated R1 was scratching all night and the nurse called the physician for cream the AM of 2/9/23. V2 stated she was unaware of any creams R1 was provided prior to 2/9/23 for her itching. At 10:09 AM, V2 stated R1 told V2 she could reach those areas R1 stated she had been scratching and had caused scratch marks. On 2/9/23 at 9:34 AM, V14 (Sister) stated she previously provided R1 with a back scratchier and creams because R1 became so itchy recently. V14 stated the staff gave her a tube of cream to put on her skin when she started itching. V14 stated I was just talking to her about the back scratchier. She just told me V2 and a nurse came in asking her about her scratch marks You can't tell them anything because they deny it or downplay it. I told them not to do that to me [R1] told them she could reach as far as the scratches are. Progress notes, dated 2/9/23, show, Prior to resident scratching no skin issues noted. Resident noted to scratch skin at times this shift with dry brownish scratch marks noted to both anterior thigh, right chest and pinkish discoloration noted to right arm, with complaint of itching and per resident she scratches her skin Review of Bath/Shower Follow Up Question Report, printed 2/6/23, shows R1 received only 5 showers from 1/1/23 to 1/31/23 (showered on 1/6/23, 1/10/23, 1/13/23, 1/16/23,1/20/23). The shower sheet shows R1 refused showers on 1/4/23, 1/25/23, and 2/1/23 all of which were documented by V9 (Restorative Nurse) on 2/2/23. On 2/6/34 at 3:50 PM, V9 (Restorative Nurse) stated the documentation entered on 2/2/23 on the Bath/Shower Follow Up Question report was not accurate and provided hand-written shower sheets for R1 showing she provided R1 a shower on 1/16/23. V9 stated the hand-written shower sheets were accurate documentation of showers she provided R1. V9 stated she filled out the shower sheet dated 1/20/23 for V12 (CNA/Scheduler) when V12 gave R1 a shower. V9 stated on 1/4/23 and 1/25/23 she offered R1 PM showers which she knew R1 did not prefer and R1 subsequently refused. V9 stated she only provided R1 one shower during January 2023 in spite of the documentation recorded on 2/2/23 on the Bath/Shower Follow Up Question Report. On 2/6/23 at 9:40 AM, V12 (Scheduler/CNA) stated R1 only preferred her showers in the morning and all staff are aware of her preferences. V12 stated if you try to offer R1 showers in the afternoon/evening, she normally refuses. V12 stated the prior week was the second week in a row R1 had not received showers. V12 stated the last time she gave R1 a shower was on 1/20/23. V12 stated she was able to give R1 showers on 1/6/23, 1/10/23, 1/13/23, and 1/16/23 because they had more CNA staff. V12 stated the CNAs choose Not Applicable as a response in the computer when a resident's shower task appears during a day/shift that R1 was not scheduled for a shower. V12 stated residents are not offered showers when the response in the computer was marked Not Applicable. Second floor facility shower list, dated 11/22/22, shows all residents are scheduled to receive two showers each week. Third floor facility shower list, dated 6/20/19, show all residents are scheduled to receive two showers each week. On 2/1/23 at 2:14 PM, V2 (Director of Nursing) stated staff were expected to check resident's incontinence briefs in their rooms every two hours if the residents were incontinent. 2. On 2/6/23 at 10:18 AM on the third floor, there was a strong smell of concentrated urine throughout each of the two hallways. R16 was a [AGE] year-old resident with multiple diagnosis including: Diabetes, Heart Failure, Hypertension, Protein Calorie Malnutrition, Gout, Dysphagia, and Muscle Weakness. Per R16's MDS (Minimum Data Assessment) dated December 27, 2022, R16 was dependent on staff for personal hygiene, transfers, position change, and is always incontinent of bowel and bladder. R16's care plan dated January 11, 2023, shows R16 required a two-person mechanical lift to transfer and R16's interventions included turning and repositioning R16 every two hours and as needed. R16 was assessed as cognitively impaired per the MDS assessment. The facility wound list of 2/2/23 shows R16 as having a healed wound to the left buttock and open Stage III wound to right buttock. R16 also has a previous Stage III pressure injury to the right heel that was documented as closed on October 25, 2022. R16's wound to the left buttock was noted as healed on January 24, 2023. Braden Scale, dated 2/1/23, shows R16 was at mild risk for development of a pressure injury. On 2/6/23, R16 was observed on the third floor in the dining room or directly outside the dining room near the nursing station from 9:10 AM until 1:40 PM. R16 was noted sitting directly on the sling for the mechanical lift in an adult reclining chair. During this time, R16 was not checked for incontinence nor was her position altered or changed. At 3:20 PM, R16's wounds were observed with V2 (Director of Nursing RN) and V8 (Assistant Director of Nursing RN) and the area on the left buttocks was noted to be open. Both V2 and V8 confirmed that this area was now reopened and V8 stated he would notify the wound doctor. V17 (Wound Physician) was notified about the re-opened wound and was interviewed on February 7, 2023, at 1:15 PM and stated that R16 should be repositioned at least every two hours to remove pressure. V17 also stated that since he is not in the facility all of the time that he assumed the staff would change R16's position at least every two hours. V17 added that not providing position changes leads to new skin issues. 3. Face sheet, printed 2/1/23, shows R3's diagnoses included hemiplegia and hemiparesis following cerebral infarction, chronic respiratory failure with hypoxia, morbid obesity, and depression. MDS, dated [DATE], shows R3 was cognitively intact, required total assistance from staff for transfers, required the extensive assistance from two staff for bed mobility, dressing, toilet use, bathing and personal hygiene, and was always incontinent of bowel and bladder. Braden scale, dated 12/5/22, shows R3 was at mild risk for the development of a pressure ulcer. On 2/1/23 at 2:29 PM, R3 stated during the day shifts she usually waits approximately 45 minutes for staff to answer her call light. R3 stated staff fail to turn her every two hours and fail to provide R3 showers. R3 stated she had not had a shower for weeks. R3 stated, It makes me feel horrible. R3 stated front office staff had to help last time she was bathed because she needed so much cleaning. On 2/6/23 at 9:40 AM, V12 (CNA) stated in early December 2022, R3 was seen by her Nurse Practitioner who told the facility to give R3 a shower because R3 was unclean, had foul odor, and R3's hair was matted. V12 stated she showered R3 at that time and had not given her a shower since. On 2/6/23 at 11:48 AM, V20 (Nurse Practitioner) stated she did ask staff to give R3 a shower because R3's hair was not able to be combed out, R3 had an odor, and R3 had a denuded area under her breasts. Review of facility Bath/Shower Follow Up Question report, printed 2/6/23, shows R3 received only 3 showers between 1/1/23 and 1/31/23 (showered on 1/20/23, 1/27/23, and 1/31/23). The report shows the staff marked Not Applicable on 1/3/23, 1/10/23, 1/17/23 and 1/24/23 indicating no shower was offered. Hand-written shower sheets provided by V9 (Restorative Nurse), showed she provided R3 showers on 1/20/23, 1/27/23, and 1/31/23. On 2/6/34 at 3:50 PM, V9 (Restorative Nurse) stated the documentation she entered on 2/2/23 on the Bath/Shower Follow Up Question report showing R3 was provided multiple showers by V9 (1/6/23, 1/13/23) was not accurate and provided hand-written shower sheets which accurately showed the showers she provided for R3. The shower sheets showed V9 provided R3 showers only on 1/20/23, 1/27/23, 1/27/23, and 1/31/23. On 2/6/23 at 9:40 AM, V12 (Scheduler/CNA) stated R2 did not receive showers on 1/6/23, 1/13/23, 1/17/23, 1/20/23 and 1/21/23. V12 stated the CNAs responded, Not Applicable in the computer when the task comes up in the computer and it is not the resident's shower/bath day. V12 stated no baths were provide to R2 on those days. ADL care plan, revised 2/6/23, shows R3 required two staff assistance with bed mobility, transfers, toileting, grooming and bathing. The revision shows, Often declines ADL cares - showers, repositioning then says she was not offered care. Intervention, revised 2/6/23, shows, Provide resident with a sponge bath when a full bath cannot be tolerated. If [R3] declines cares offer her a different time. Re-approach- re-attempt task. Alteration in skin integrity care plan, revised 1/6/22, shows R3 was at risk for an alteration in skin integrity and refuses to allow staff to provide incontinence care in a timely manner and to turn and reposition off a skin tear to thighs. Interventions include staff to provide toileting and incontinence care with care rounds and as needed as well as turn and reposition every two hours as needed. Transfer care plan, dated 12/13/22, shows R3 requires the use of a mechanical lift for transfers. On 2/8/23 at 2:43 PM, V12 stated the care plan for R3 was inaccurate that R3 declined ADL cares including repositioning, incontinence care and showers. V12 stated she had worked with R3 every day for a couple of years and R3 never refused a shower, incontinence care, or turning/repositioning. V12 stated R3 had never declined a shower V12 was offered. On 2/8/23 at 12:24 PM, V1 (Administrator) stated V21 (Corporate Consultant) altered R3's care plan on 2/6/23. Attempts to reach V21 were unsuccessful. 4. Face sheet, printed 2/2/23, shows R10's diagnoses included pressure ulcer right heel, dementia, Alzheimer's disease, adult failure to thrive, restlessness and agitation, and legally blind. MDS, dated [DATE], shows R10 was severely cognitively impaired, was totally dependent on staff for bed mobility, transfers, dressing, toileting, required extensive assist from staff for bathing, eating, and personal hygiene, and was always incontinent of bowel and bladder. Braden scale, dated 12/26/22, shows R10 was at only mild risk for the development of pressure ulcers. Impaired skin integrity care plan, revised on 2/21/22, shows R10 was admitted with an alteration in skin integrity / pressure injury and interventions included R10 was to receive incontinence care with care rounds and as needed. Transfer care plan, initiated 12/29/22, shows R10 required the use of a mechanical lift for transfers and interventions included providing two staff assistance for transferring. Incontinence care plan, revised 12/29/22, shows R10 was incontinent related to dementia and interventions included provide assistance for toileting. On 2/1/23 at 9:30 AM, R10 was sitting reclined in her reclining wheelchair just outside the third floor dining room doorway. R10 yelled, I have to pee! What am I gonna do!? V7 (RN-Registered Nurse) responded to R10 and stated, Go ahead and pee. They will change your brief in a little bit. R10 responded to V7 and stated, That's embarrassing! Oh Lord! V7 then looked away from R10 and stated, She's a [mechanical] lift. R10 continued to ask to go to the bathroom and V7 left R10's vicinity. On 2/1/23 at 9:33 AM, V7 stated R10 was very demented and incontinent. R10 was observed sitting in her wheelchair on 2/6/23 from 9:47 AM-1:30 PM without being repositioned or having her incontinence brief checked/changed. R10 was noted with large amounts of facial hair, uncombed and matted hair, and strong body odor. R10's clothing was soiled with food and debris along with her chair. 5. Care plan, initiated 9/27/22, shows R4's diagnoses included dementia, cerebral infarction without residual deficits, muscle weakness, chronic obstructive pulmonary disease, non-pressure chronic ulcer of skin, chronic kidney disease, and diabetes. The ADL care plan, revised 9/27/22, shows R4 required assistance with transfer, bed mobility, hygiene, toileting and bathing. The care plan interventions included assisting R4 with ADLs and utilizing a mechanical lift for transfers. Skin integrity care plan, revised 9/27/22, shows R4 was at risk for alterations in skin integrity related to poor skin turgor, dementia, poor hygiene, dermatitis to scalp and feet, incontinence of bowels and bladders, and noncompliant with ADL care including turning, positioning, and incontinence care. The care plan shows R4 had chronic on and off redness to buttock and scrotum and a non-pressure wound to the right great toe and left second toe. Interventions included incontinence care with care rounds and as needed and turn and reposition as per schedule and as needed. Transfer care plan shows R4 required the use of a mechanical lift and two staff assisting R4 for transfers. Incontinence care plan shows R4 experienced bowel/bladder incontinence due to prostate enlargement and an inability to delay voiding. Interventions included checking R4 for incontinence. Repositioning care plan, revised 9/27/22, shows R4 required assistance from staff for bed mobility and was unable to turn/reposition himself in bed without physical assistance. Interventions included providing R4 weight bearing assistance as needed while sitting up, laying down, or turning side to side in bed. MDS, dated [DATE], shows R4 was severely cognitively impaired, required total assistance from staff for bathing, transfers and toileting, required extensive assistance from two staff for bed mobility, dressing, and required the extensive assistance of one staff for personal hygiene. The MDS shows R4 was always incontinent of bowel and bladder. Braden scale, dated 12/13/22, shows R4 was at mild risk for pressure ulcer development On 2/1/23 at 9:19 AM, R4 was sitting in the third floor dining room slightly reclined in his wheelchair and finishing breakfast. On 2/1/23 during continuous observation between 9:19 AM and 12:19 AM, R4 sat in the same reclined position with no staff repositioning R4 and no staff checking/changing R4's incontinence brief. At 12:19 PM, R4 was taken to his room to have his incontinence brief checked/changed. On 2/6/23 R4 was observed in his wheelchair from 9:15 AM until 1:36 PM and during this time, R4 was not repositioned or monitored for incontinence. R4 was noted with long jagged fingernails with a brownish substance underneath. R4 had food crumbs and debris on his clothing and face. R4 had dirty greasy hair, long facial hair, and strong body odor. At 1:36 PM, V13 (CNA) proceeded to provide personal care to R4. R4 was noted with saturated brief and hard dried fecal matter. R4's right buttock area was noted to be red and inflamed. V13 needed numerous wipes to clean the dried fecal matter from R4's buttock and anal area since the stool was dried. V13 stated that R4 will scratch his buttock and that is why R4 has fecal matter under his nails. V13 stated that this was the first time he had to change R4 since they only had 2 nurse aides on the floor. R4's skin assessment sheet dated February 7, 2023, documents that R4 has a pressure injury on the left buttock measuring 5.5 by 0.5 by 0.1 centimeters and another injury on the sacrum measuring 5.0 by 0.5 by 0.1 centimeters. 6. Face sheet, printed 2/1/23, shows R2's diagnoses included incontinence without sensory awareness, dementia, depression, and cervicalgia. MDS, dated [DATE], shows R2 was cognitively intact, was totally dependent on staff for transfers, required the extensive assistance of two staff for bed mobility and toileting, required the extensive assistance of one staff for bathing, dressing and personal hygiene, and was always incontinent of bowel and bladder. Braden scale, dated 11/11/22, shows R2 was at mild risk for development of a pressure ulcer. On 2/1/23 at 2:39 PM, R2 stated there were often only two CNA staff for the whole second floor of residents. R2 stated she sometimes waited 12-15 hours for her soiled briefs to be changed. R2 stated her last bed bath was 1/20/23 and before that she had not had a shower in a long time because there were not enough staff at the facility. R2 stated at times there is only one CNA working the entire second floor on a AM or PM shift. R2 stated the staff only reposition her when they change her incontinence brief. R2 stated the staff typically change her incontinence brief approximately three times a day - usually at 4:00 AM during the PM shift, at 10:00 AM after breakfast, and then at approximately 9:30 PM before she goes to sleep. On 2/8/23 at 2:43 PM, V12 (CNA/Scheduler) stated R2 preferred her showers on the AM shift per her shower schedule which had been followed for years. Review of Bath/Shower Follow Up Question Report, printed 2/6/23, shows R2 received only 4 showers from 1/1/23 to 1/31/23 (showered on 1/17/23, 1/24/23, 1/27/23, 1/31/23). The report shows on 1/6/23, 1/13/23, 1/20/23 and 1/21/23 the CNA responded, Not Applicable in the computer. Review of hand -written shower sheets, provided by V9 (Restorative Nurse), shows R2 received showers by V9 only on 1/17/23, 1/24/23, 1/27/23, and 1/31/23. No hand-written shower sheets were provided for 1/3/23 and 1/10/23. On 2/6/34 at 3:50 PM, V9 (Restorative Nurse) stated the documentation entered on 2/2/23 on the Bath/Shower Follow Up Question report showing R2 was provided multiple showers by V9 (1/3/23, 1/10/23) was not accurate and provided hand-written shower sheets which accurately showed the showers she provided for R2. The shower sheets showed V9 provided R2 showers on 1/17/23, 1/24/23, 1/27/23, and 1/31/23. On 2/6/23 at 9:40 AM, V12 (Scheduler/CNA) stated R2 did not receive showers on 1/6/23, 1/13/23, 1/20/23 and 1/21/23 because the CNAs responded, Not Applicable in the computer. V12 stated facility CNAs mark Not Applicable on the bath/shower task when the task comes up in the computer and it is not the resident's shower/bath day. ADL Care Plan, revised 11/18/22, shows R2 required staff assistance with ADLs related to weakness and pain. Interventions included one staff assistance for bed baths, assist with ADLs as needed, check for skin changes during bathing, Intervention, revised 7/24/18, shows R2 prefers bathing after dinner between 8:00 PM and 9:00 PM. On 2/8/23 at 2:31 PM, V12 (Scheduler/CNA) stated R2 prefers showers in the AM which had been her shower schedule for years. 7. Care plan, revised 9/22/21, shows R7's diagnoses included dementia, bipolar disorder, psychotic disorder, depression, and anxiety. Care plan, revised 9/21/21, shows R7 had a potential for impaired skin integrity and interventions included turning and repositioning every two hours as needed. MDS, dated [DATE], shows R7 was severely cognitively impaired, required the extensive assistance of staff for bathing, bed mobility, transfers, dressing, toileting, and personal hygiene, and was always incontinent of bowel and bladder. Braden scale, dated 9/30/33, shows R7 was at mild risk for the development of pressure ulcers. On 2/1/23 at 9:19 AM, R7 was sitting in her wheelchair finishing her breakfast in the third-floor main dining room. On 2/1/23, during continuous observation between 9:10 AM and 12:05 PM, R7 sat in her wheelchair without staff repositioning R7 or checking/changing R7's incontinence brief. At 2:05 PM, R7 was toileted by V5 (CNA). V5 stated he got R7 up from bed at approximately 8:00 AM and checked/changed R7's incontinence brief at that time. R7's incontinence brief had a very strong smell of urine. 8. Face sheet, printed 2/1/23, shows R9's diagnoses included dementia, anxiety, and depressive disorder. MDS, dated [DATE], shows R9 was severely cognitively impaired, was totally dependent on staff for bathing, required the extensive assistance of two staff for bed mobility and transfers, required the extensive assistance of one staff for dressing, eating, toileting and personal hygiene, and was always incontinent of bowel and bladder. Braden scale, dated 12/2/22, shows R9 was at mild risk for development of a pressure ulcer. On 2/1/23 at 9:24 AM, R9 was laying in her bed in her room on her back sleeping with a thick blanket covering her body from her toes to her neck. The room temperature was very warm. During continuous observation, R9 was laying in the same position without incontinence check/change or repositioning from 9:24 AM to 12:29 PM. As R9 laid in bed, R9's cheeks became more red and at 12:08 PM R9 pulled the blanket down from her chin to her chest. On 2/1/23 at 12:16 PM, V18 (Assistant Administrator) stated R9 required assistance from staff to reposition in bed every two hours. On 2/1/23 at 12:29 PM, V5 (CNA) changed her incontinence brief which had bowel movement in the brief. V5 stated he last changed / repositioned R9 at 8:00 AM that morning. 9. Face sheet, printed 2/2/23, shows R12's diagnoses included dementia and palliative care. MDS, dated [DATE], shows R12 was severely cognitively impaired, was totally dependent on staff for bathing, toileting, transfers, bed mobility, dressing, eating, and personal hygiene. The MDS shows R12 was always incontinent of bladder and bowel. Skin integrity alteration care plan, revised 8/24/22, shows R12 had a history of pressure ulcers and interventions included incontinence care with care rounds and as needed as well as turning and repositioning every two hours and as needed. Transfer care plan, revised 7/6/22, shows R12 required the use of a mechanical lift for transfers and interventions included providing two staff assistance for transfers. ADL care plan, revised 7/6/22, shows R12's ADL interventions included 1-2 staff to assist R12 with her ADLs. Turning/Repositioning care plan, revised 7/6/22, shows R12 required assistance from staff for bed mobility and R12 could not reposition herself without physical assistance from staff due to dementia, impaired cognition, and weakness/deconditioning. Interventions included staff to provide weight bearing assistance as needed for resident while sitting up, laying down, or turning side to side in bed. On 2/1/23 at 9:19 AM, R12 was sitting in her recliner wheelchair finishing breakfast in the main dining room of the third floor. On 2/1/23 during continuous observation between 9:29 AM and 12:01 PM, R12 sat in her wheelchair in the dining room and no staff repositioned R12 or checked/changed R12's incontinence brief. On 2/1/23 at 12:55 PM, V6 (CNA) stated the last time she toileted R12 was approximately 7:45 AM before breakfast. 10. POS (Physician Order Sheet), as of 2/2/23, shows R11's diagnoses included quadriplegia. dementia, anxiety, and depression. MDS, dated [DATE], shows R11's cognition was severely compromised, R11 required was totally dependent on staff for transfers and bathing, R11 required the extensive assistance of two staff for bed mobility and toileting, R11 required the extensive assistance of one staff for personal hygiene, eating, and dressing, and R11 was always incontinent. Care plan, revised 5/10/22, shows R11 had a potential for skin integrity alteration and approaches included turn and reposition per schedule and as needed. Care plan, revised 8/10/22, shows R11 required a mechanical lift for transfers including the assistance of two staff. On 2/1/22 at 9:19 AM, R11 was sitting in her wheelchair finishing breakfast in the third floor dining room in her wheelchair. On 2/1/22 during continuous observation between 9:19 AM - 11:44 AM, R11 remained in the same position in her wheelchair without staff repositioning R11 or checking/changing R11's incontinence brief. At 11:44 AM, R11 was removed from the dining room to have her incontinence brief checked/changed. On 2/1/23 at 12:52 PM, V5 (CNA) stated the last time R11 was repositioned or had her incontinence brief checked/changed was approximately 8:00 AM - 8:30 AM before R11 ate breakfast. 11. Care plan, revised 11/22/21, shows R5's diagnoses included dementia, muscle weakness, adult failure to thrive, and protein-calorie malnutrition. The care plan, revised 2/1/22, shows R5 had a history of pressure ulcers and interventions included turn and reposition as per schedule and as needed. Care plan, revised 11/6/22, shows R5 required two staff assistance and the use of a mechanical lift for transfers. MDS, dated [DATE], shows R5 was severely cognitively impaired, was totally dependent on staff for bathing, transfers, dressing, toileting use, and personal hygiene, required the extensive assistance of two staff for bed mobility, and was always incontinent of bowel and bladder. Braden scale, dated 1/13/23, shows R5 was at mild risk for the development of a pressure ulcer. On 2/1/23 at 9:19 AM, R5 was sitting in her wheelchair in the third floor main dining room finishing her breakfast. On 2/1/23 during continuous observations between 9:19 AM and 11:36 AM, R5 was not repositioned and R5's incontinence brief was not checked/changed by staff. On 2/1/23 at 12:45 PM, V6 (CNA) stated R5 was incontinent of bowel/bladder and she last toileted R5 at approximately 8-8:30 AM. 12. Face sheet, printed 2/1/23, shows R6's diagnoses included dementia and overactive bladder. MDS, dated [DATE], shows R6 was severely cognitively impaired, was totally dependent on staff for bathing, required the extensive assistance of two staff for transfers, required the extensive assistance from one staff for bed mobility, dressing, toileting, and personal hygiene, and was totally incontinent of bowel and bladder. Braden scale, dated 1/2/23, shows R6 was at mild risk for the development of a pressure ulcer. On 2/1/23 at 9:19 AM, R6 was sitting in her reclining wheelchair in the third floor dining room finishing breakfast. On 2/1/23, during continuous observation between 9:19 AM and 11:54 AM, R6 sat in her wheelchair with no staff repositioning her and no check/change of her incontinence brief. On 2/1/23 at 11:54 AM, facility staff asked R6 if she wanted to be toileted. On 2/1/23 at 12:53 PM, V5 (CNA) stated R6 was last toileted before breakfast at approximately 8:00 AM. 13. Face sheet, printed 2/1/23, shows R8's diagnoses included dementia, and restlessness and agitation. MDS, dated [DATE], shows R8 was severely cognitively compromised, was totally dependent on staff for toileting, required the extensive assistance from staff for bathing, bed mobility, transfers, dressing, personal hygiene, and was always incontinent of bowel and bladder. Braden scale, dated 1/25/23, shows R8 was at moderate risk for the development of a pressure ulcer. On 2/2/23 at 9:37 AM, R8 was sitting at the nursing station in her wheelchair. At 11:55 AM, staff wheeled R8 into the dining room for lunch without checking/changing R8's incontinence brief or repositioning R8. At 12:18, R8 was toileted by V6 (CNA). On 2/2/23 at 12:13 PM, V6 (CNA) stated R8 was last changed at approximately 9:00 AM. 14. R19 is an [AGE] year-old resident with the following diagnosis: Dementia with Behaviors, Cognitive Communication Deficit, Agitation, Major Dep [TRUNCATED]

Based on observation, interview an record review, the facility failed to ensure facility provided sufficient staffing to meet the care needs of residents of the facility. This failure resulted in the physical harm to R1 who was observed to have two re-opened, previously healed pressure ulcers and scratch marks on her skin from skin irritation. In addition, R1 also experienced psychosocial harm after not receiving showering assistance from staff which she states caused her to become more depressed. The failure also resulted in the development of a reopening of a previously healed pressure injuries on R16, development of a new pressure injury on R4, as well as psychosocial harm to R3 and R10. This applies to 18 of 18 residents (R1-R12, R14-R17, R19 and R20) reviewed for staffing in a sample of 23. The findings include: On 2/1/23 at 1:43 PM with V16 (RN), V12 (CNA/Scheduler) stated the facility census had remained fairly stable for the last couple months and any census changes that did occur did not change staffing needs on the facility floors. V12 stated if she had sufficient staff, she would schedule 5 CNAs on the 2nd floor and 5 CNAs on the 3rd floor during both the AM and PM shifts. V12 stated those 5 CNAs scheduled would be in addition to any restorative staff working in the facility. V12 stated restorative staff only get pulled to help on the second or third floor if only 1 CNA shows up for a shift on a floor. V12 stated she was currently working as one of the two CNAs on the second floor and she alone was caring for 31 residents. V12 stated V10 (CNA) was the only other CNA working on the second floor during the AM shift on 2/1/23 and V12 alone was caring for 32 residents. V12 stated the second floor census is higher than usual and is almost at capacity as they have 63/68 beds filled. V12 stated there were 24 residents requiring mechanical lifts for transfers in addition to several other residents requiring two staff's assistance for ADLs. V12 stated 2 CNAs on the floor of approximately 63 residents had been typical at the facility for a long time. V12 stated she is only allowed to call staff employed by the facility. V12 stated, We just do not have the staff to call. V12 stated she has been requesting for the use of agency staff to help fill in the schedule for some time. Facility Roster, dated 2/1/23, shows the facility census was 160 residents. The roster shows there were 43 residents residing on the first floor, 63 residents residing on the second floor, and 54 residents residing on the third floor. Review of schedules, dated 1/30/23 to 2/6/23, show on the AM or PM shifts on either the second or third floors of the facility: 1. 13/36 shifts had only 2 CNAs working on the entire floor. 2. 4/36 shifts had three CNAs but one CNA only worked part of the shift 3. 17/36 shifts had only three CNAs working on the entire floor Review of Facility Nurses and CNAs list, provided 2/8/23, shows the facility only employed 15 full time CNAs, 4 part time CNAs, and 7 casual CNAs. On 2/1/23 at 12:48 PM, V5 (CNA) stated he was caring for 24 residents - six of which required two staff for mechanical lift transfers. On 2/1/23 at 12:45 PM, V6 (CNA) stated the third floor AM shift usually has only two CNAs scheduled on the floor for the 54 total residents. V6 stated each CNA was responsible for 27 residents on 2/1/23. V6 stated six of her residents require two staff to assist with mechanical lifts for transfers and four of her residents require two staff because of behaviors during care. At 12:55 PM, V6 stated when the CNAs have time they toilet residents before and after breakfast and again before lunch. V6 stated when there are only two CNAs working on the third floor, they are unable to toilet residents after breakfast or before lunch because they need to get residents out of bed that remain in bed for breakfast. V6 stated she had five residents that remained in bed during breakfast. V6 stated the CNAs are unable to give residents showers/bed baths when only two CNAs are scheduled on the third floor. V6 stated they document in the computer when they perform resident showers. V6 stated if there are three CNAs on the floor and a Resident Assistant (RA), the RA helps transport residents and they are sometimes able to give showers. Resident council Minutes, dated 12/26/22, show, Staffing issues are still working progress and is getting better Resident council minutes, dated 11/21/22, show, .CNA staffing is still being worked on Facility Assessment, reviewed 11/22/22, shows the facility average census was 153 residents. The assessment shows the total number of CNA full time equivalents required at the facility were 34-37. The assessment shows, .Facility budgets are established to act as a general guideline for facilities to follow when determining staffing levels needed to provide care to residents being serviced. These budgets are established based on the average resident census along with their projected needs for care and support. Facility budgets are maintained by the Administrator and are flexible based on the actual acuity and unique individual care needs of the residents. To promote continuity of care, and consistent practices, we avoid the use of contract staff and agency staff for direct care positions Individual staffing assignments are determined at the facility level and take into consideration the current support/care needs of the residents that include, but are not limited to medical/physical conditions, acuity, physician orders, therapeutic needs, infection prevention and control needs, behavioral support as well as any other special care needs as identified, Consultation with [NAME] Management Services in customizing and revising individual staffing assignment is obtained, if necessary. On 2/1/23 at 3:03 PM, V1 (Administrator) stated she was aware of the schedule being short staffed and stated the facility was offering financial incentives for staff to work longer or extra shifts. V1 stated the facility is only able to rely on the staff on the facility payroll and the facility recently lost two CNAs to another facility. V1 stated she was not given permission to utilize agency nursing staff by her corporate supervisors. Examples of residents directly impacted by the lack of staff include the following: 1. Face sheet, printed 2/1/23, shows R1's diagnoses included multiple sclerosis, quadriplegia, spinal stenosis, overactive bladder, anxiety, and depression. MDS (Minimum Data Set), dated 1/30/23, shows R1 was cognitively intact, was totally dependent on staff for transfers, personal hygiene, eating and dressing, and required extensive assistance from two staff for bed mobility, R1 was always incontinent of bowel and bladder, and R1 had an indwelling urinary catheter. Braden scale, dated 1/28/23, shows R1 was at moderate risk for development of a pressure ulcer and R1 was not able to make even slight changes in body or extremity position without staff assistance. ADL Care Plan, initiated 8/7/22, shows R1 required a mechanical lift for transfers and requires staff assistance for bathing, toileting, and personal hygiene. Interventions include R1 refuses to take showers on non-scheduled dates. Skin integrity care plan, revised on 2/17/22, shows R1 had a history of skin injuries to her sacrum, had a reopened injury to sacrum and impaired mobility. Interventions include inspect skin with showers and as needed and turn and reposition every two hours and as needed. Depression care plan, revised 1/29/23, shows R1 had a diagnosis of depression and was observed of feeling down and tearful. Incontinence care plan, dated 10/18/21, shows R1 was incontinent of bowel related to multiple sclerosis and quadriplegia and interventions included offering toileting opportunities based on R1's pattern of elimination. Bed mobility care plan, revised 4/19/18, shows R1 was unable to turn and reposition herself in bed without assistance with staff. On 2/1/23 at 2:00 PM with V14 (Sister) on speaker phone, R1 stated the facility did not have enough staff to care for residents including providing showers, repositioning, and checking/changing incontinence briefs. R1 stated she had not received a shower for two weeks. R1 stated had not received her showers twice a week for a few months and that was when R1 began having skin irritation. R1 stated not having showers twice weekly caused her to itch and scratch her skin until she bled. R1 had visible, scabbed, scratch marks on her left upper thigh, right upper arm near her shoulder, and bright red scabs on her right breast. R1 stated, Once I start scratching, I can't stop! It started a couple months ago when it began to be one shower a week. I started itching more as it declined. R1 also stated, I feel terrible, wouldn't you!? Sometimes I can smell myself! V14 (Sister) stated, I have called her and she has been so depressed and feels so bad about herself. She has told me it is depressing. R1 also stated, They're not turning me. The other day I was not moved for 13 hours. R1 stated she had pressure ulcers and her repositioning schedule is never followed by staff. R1 stated, When I am left sitting in one position for so long my pressure ulcer starts burning and I call my sister and she calls and talks to nurses and gets them in here. R1 stated she has waited two hours for staff to answer her call light for ADL assistance. R1 had a repositioning schedule over her bed that showed R1 was to be turned every two hours on the even hours. On 2/6/23 at 3:35 PM, R1 was observed with V8 (Assistant Director of Nursing RN) and two open areas were noted during the observation - one area on the sacrum and one area on the left buttock. Per V8, these areas had been healed and were previously closed. Facility's wound report, dated 2/2/23, shows R1's wounds were healed. On 2/7/23 V17 (Wound Physician) stated that he would expect that R1 be repositioned at least every two hours and that R1 has a history of skin breakdown. On 2/9/23 at 8:08 AM, V2 (Director of Nursing) stated R1 could not move her body and would not be able to scratch herself. At 9:20 AM, V2 stated she visited R1 and asked R1 to show her if she could reach the areas that were observed to have scratch marks on 2/1/23. V2 stated she bathed R1 on 2/3/23 and saw no scratch marks red marks, or skin irritation on R1. V2 stated the night nurse on 2/8/23-2/9/23 stated R1 was scratching all night and the nurse called the physician for cream the AM of 2/9/23. V2 stated she was unaware of any creams R1 was provided prior to 2/9/23 for her itching. At 10:09 AM, V2 stated R1 told V2 she could reach those areas R1 stated she had been scratching and had caused scratch marks. On 2/9/23 at 9:34 AM, V14 (Sister) stated she previously provided R1 with a back scratchier and creams because R1 became so itchy recently. V14 stated the staff gave her a tube of cream to put on her skin when she started itching. V14 stated I was just talking to her about the back scratchier. She just told me V2 and a nurse came in asking her about her scratch marks You can't tell them anything because they deny it or downplay it. I told them not to do that to me [R1] told them she could reach as far as the scratches are. Progress notes, dated 2/9/23, show, Prior to resident scratching no skin issues noted. Resident noted to scratch skin at times this shift with dry brownish scratch marks noted to both anterior thigh, right chest and pinkish discoloration noted to right arm, with complaint of itching and per resident she scratches her skin Review of Bath/Shower Follow Up Question Report, printed 2/6/23, shows R1 received only 5 showers from 1/1/23 to 1/31/23 (showered on 1/6/23, 1/10/23, 1/13/23, 1/16/23,1/20/23). The shower sheet shows R1 refused showers on 1/4/23, 1/25/23, and 2/1/23 all of which were documented by V9 (Restorative Nurse) on 2/2/23. On 2/6/34 at 3:50 PM, V9 (Restorative Nurse) stated the documentation entered on 2/2/23 on the Bath/Shower Follow Up Question report was not accurate and provided hand-written shower sheets for R1 showing she provided R1 a shower on 1/16/23. V9 stated the hand-written shower sheets were accurate documentation of showers she provided R1. V9 stated she filled out the shower sheet dated 1/20/23 for V12 (CNA/Scheduler) when V12 gave R1 a shower. V9 stated on 1/4/23 and 1/25/23 she offered R1 PM showers which she knew R1 did not prefer and R1 subsequently refused. V9 stated she only provided R1 one shower during January 2023 in spite of the documentation recorded on 2/2/23 on the Bath/Shower Follow Up Question Report. On 2/6/23 at 9:40 AM, V12 (Scheduler/CNA) stated R1 only preferred her showers in the morning and all staff are aware of her preferences. V12 stated if you try to offer R1 showers in the afternoon/evening, she normally refuses. V12 stated the prior week was the second week in a row R1 had not received showers. V12 stated the last time she gave R1 a shower was on 1/20/23. V12 stated she was able to give R1 showers on 1/6/23, 1/10/23, 1/13/23, and 1/16/23 because they had more CNA staff. V12 stated the CNAs choose Not Applicable as a response in the computer when a resident's shower task appears during a day/shift that R1 was not scheduled for a shower. V12 stated residents are not offered showers when the response in the computer was marked Not Applicable. Second floor facility shower list, dated 11/22/22, shows all residents are scheduled to receive two showers each week. Third floor facility shower list, dated 6/20/19, show all residents are scheduled to receive two showers each week. On 2/1/23 at 2:14 PM, V2 (Director of Nursing) stated staff were expected to check resident's incontinence briefs in their rooms every two hours if the residents were incontinent. 2. On 2/6/23 at 10:18 AM on the third floor, there was a strong smell of concentrated urine throughout each of the two hallways. R16 was a [AGE] year-old resident with multiple diagnosis including: Diabetes, Heart Failure, Hypertension, Protein Calorie Malnutrition, Gout, Dysphagia, and Muscle Weakness. Per R16's MDS (Minimum Data Assessment) dated December 27, 2022, R16 was dependent on staff for personal hygiene, transfers, position change, and is always incontinent of bowel and bladder. R16's care plan dated January 11, 2023, shows R16 required a two-person mechanical lift to transfer and R16's interventions included turning and repositioning R16 every two hours and as needed. R16 was assessed as cognitively impaired per the MDS assessment. The facility wound list of 2/2/23 shows R16 as having a healed wound to the left buttock and open Stage III wound to right buttock. R16 also has a previous Stage III pressure injury to the right heel that was documented as closed on October 25, 2022. R16's wound to the left buttock was noted as healed on January 24, 2023. Braden Scale, dated 2/1/23, shows R16 was at mild risk for development of a pressure injury. On 2/6/23, V13 (CNA) stated between 6:30 AM and 8:30 AM on 2/6/23, there was only one CNA working on the floor providing direct care for all 54 residents. At 8:30, a second CNA began working on the floor. On 2/6/23, R16 was observed on the third floor in the dining room or directly outside the dining room near the nursing station from 9:10 AM until 1:40 PM. R16 was noted sitting directly on the sling for the mechanical lift in an adult reclining chair. During this time, R16 was not checked for incontinence nor was her position altered or changed. At 3:20 PM, R16's wounds were observed with V2 (Director of Nursing RN) and V8 (Assistant Director of Nursing RN) and the area on the left buttocks was noted to be open. Both V2 and V8 confirmed that this area was now reopened and V8 stated he would notify the wound doctor. V17 (Wound Physician) was notified about the re-opened wound and was interviewed on February 7, 2023, at 1:15 PM and stated that R16 should be repositioned at least every two hours to remove pressure. V17 also stated that since he is not in the facility all of the time that he assumed the staff would change R16's position at least every two hours. V17 added that not providing position changes leads to new skin issues. 3. Face sheet, printed 2/1/23, shows R3's diagnoses included hemiplegia and hemiparesis following cerebral infarction, chronic respiratory failure with hypoxia, morbid obesity, and depression. MDS, dated [DATE], shows R3 was cognitively intact, required total assistance from staff for transfers, required the extensive assistance from two staff for bed mobility, dressing, toilet use, bathing and personal hygiene, and was always incontinent of bowel and bladder. Braden scale, dated 12/5/22, shows R3 was at mild risk for the development of a pressure ulcer. On 2/1/23 at 2:29 PM, R3 stated during the day shifts she usually waits approximately 45 minutes for staff to answer her call light. R3 stated staff fail to turn her every two hours and fail to provide R3 showers. R3 stated she had not had a shower for weeks. R3 stated, It makes me feel horrible. R3 stated front office staff had to help last time she was bathed because she needed so much cleaning. On 2/6/23 at 9:40 AM, V12 (CNA) stated in early December 2022, R3 was seen by her Nurse Practitioner who told the facility to give R3 a shower because R3 was unclean, had foul odor, and R3's hair was matted. V12 stated she showered R3 at that time and had not given her a shower since. On 2/6/23 at 11:48 AM, V20 (Nurse Practitioner) stated she did ask staff to give R3 a shower because R3's hair was not able to be combed out, R3 had an odor, and R3 had a denuded area under her breasts. Review of facility Bath/Shower Follow Up Question report, printed 2/6/23, shows R3 received only 3 showers between 1/1/23 and 1/31/23 (showered on 1/20/23, 1/27/23, and 1/31/23). The report shows the staff marked Not Applicable on 1/3/23, 1/10/23, 1/17/23 and 1/24/23 indicating no shower was offered. Hand-written shower sheets provided by V9 (Restorative Nurse), showed she provided R3 showers on 1/20/23, 1/27/23, and 1/31/23. On 2/6/34 at 3:50 PM, V9 (Restorative Nurse) stated the documentation she entered on 2/2/23 on the Bath/Shower Follow Up Question report showing R3 was provided multiple showers by V9 (1/6/23, 1/13/23) was not accurate and provided hand-written shower sheets which accurately showed the showers she provided for R3. The shower sheets showed V9 provided R3 showers only on 1/20/23, 1/27/23, 1/27/23, and 1/31/23. On 2/6/23 at 9:40 AM, V12 (Scheduler/CNA) stated R3 didnt receive showers on 1/6/23, 1/13/23, 1/17/23, 1/20/23 and 1/21/23. V12 stated the CNAs responded, Not Applicable in the computer when the task comes up in the computer and it is not the resident's shower/bath day. V12 stated no baths were provide to R3 on those days. ADL care plan, revised 2/6/23, shows R3 required two staff assistance with bed mobility, transfers, toileting, grooming and bathing. The revision shows, Often declines ADL cares - showers, repositioning then says she was not offered care. Intervention, revised 2/6/23, shows, Provide resident with a sponge bath when a full bath cannot be tolerated. If [R3] declines cares offer her a different time. Re-approach- re-attempt task. Alteration in skin integrity care plan, revised 1/6/22, shows R3 was at risk for an alteration in skin integrity and refuses to allow staff to provide incontinence care in a timely manner and to turn and reposition off a skin tear to thighs. Interventions include staff to provide toileting and incontinence care with care rounds and as needed as well as turn and reposition every two hours as needed. Transfer care plan, dated 12/13/22, shows R3 requires the use of a mechanical lift for transfers. On 2/8/23 at 2:43 PM, V12 stated the care plan for R3 was inaccurate that R3 declined ADL cares including repositioning, incontinence care and showers. V12 stated she had worked with R3 every day for a couple of years and R3 never refused a shower, incontinence care, or turning/repositioning. V12 stated R3 had never declined a shower V12 was offered. On 2/8/23 at 12:24 PM, V1 (Administrator) stated V21 (Corporate Consultant) altered R3's care plan on 2/6/23. Attempts to reach V21 were unsuccessful. 4. Face sheet, printed 2/2/23, shows R10's diagnoses included pressure ulcer right heel, dementia, Alzheimer's disease, adult failure to thrive, restlessness and agitation, and legally blind. MDS, dated [DATE], shows R10 was severely cognitively impaired, was totally dependent on staff for bed mobility, transfers, dressing, toileting, required extensive assist from staff for bathing, eating, and personal hygiene, and was always incontinent of bowel and bladder. Braden scale, dated 12/26/22, shows R10 was at only mild risk for the development of pressure ulcers. Impaired skin integrity care plan, revised on 2/21/22, shows R10 was admitted with an alteration in skin integrity / pressure injury and interventions included R10 was to receive incontinence care with care rounds and as needed. Transfer care plan, initiated 12/29/22, shows R10 required the use of a mechanical lift for transfers and interventions included providing two staff assistance for transferring. Incontinence care plan, revised 12/29/22, shows R10 was incontinent related to dementia and interventions included provide assistance for toileting. On 2/1/23 at 9:30 AM, R10 was sitting reclined in her reclining wheelchair just outside the third floor dining room doorway. R10 yelled, I have to pee! What am I gonna do!? V7 (RN-Registered Nurse) responded to R10 and stated, Go ahead and pee. They will change your brief in a little bit. R10 responded to V7 and stated, That's embarrassing! Oh Lord! V7 then looked away from R10 and stated, She's a [mechanical] lift. R10 continued to ask to go to the bathroom and V7 left R10's vicinity. On 2/1/23 at 9:33 AM, V7 stated R10 was very demented and incontinent. R10 was observed sitting in her wheelchair on 2/6/23 from 9:47 AM-1:30 PM without being repositioned or having her incontinence brief checked/changed. R10 was noted with large amounts of facial hair, uncombed and matted hair, and strong body odor. R10's clothing was soiled with food and debris along with her chair. 5. Care plan, initiated 9/27/22, shows R4's diagnoses included dementia, cerebral infarction without residual deficits, muscle weakness, chronic obstructive pulmonary disease, non-pressure chronic ulcer of skin, chronic kidney disease, and diabetes. The ADL care plan, revised 9/27/22, shows R4 required assistance with transfer, bed mobility, hygiene, toileting and bathing. The care plan interventions included assisting R4 with ADLs and utilizing a mechanical lift for transfers. Skin integrity care plan, revised 9/27/22, shows R4 was at risk for alterations in skin integrity related to poor skin turgor, dementia, poor hygiene, dermatitis to scalp and feet, incontinence of bowels and bladders, and noncompliant with ADL care including turning, positioning, and incontinence care. The care plan shows R4 had chronic on and off redness to buttock and scrotum and a non-pressure wound to the right great toe and left second toe. Interventions included incontinence care with care rounds and as needed and turn and reposition as per schedule and as needed. Transfer care plan shows R4 required the use of a mechanical lift and two staff assisting R4 for transfers. Incontinence care plan shows R4 experienced bowel/bladder incontinence due to prostate enlargement and an inability to delay voiding. Interventions included checking R4 for incontinence. Repositioning care plan, revised 9/27/22, shows R4 required assistance from staff for bed mobility and was unable to turn/reposition himself in bed without physical assistance. Interventions included providing R4 weight bearing assistance as needed while sitting up, laying down, or turning side to side in bed. MDS, dated [DATE], shows R4 was severely cognitively impaired, required total assistance from staff for bathing, transfers and toileting, required extensive assistance from two staff for bed mobility, dressing, and required the extensive assistance of one staff for personal hygiene. The MDS shows R4 was always incontinent of bowel and bladder. Braden scale, dated 12/13/22, shows R4 was at mild risk for pressure ulcer development On 2/1/23 at 9:19 AM, R4 was sitting in the third floor dining room slightly reclined in his wheelchair and finishing breakfast. On 2/1/23 during continuous observation between 9:19 AM and 12:19 AM, R4 sat in the same reclined position with no staff repositioning R4 and no staff checking/changing R4's incontinence brief. At 12:19 PM, R4 was taken to his room to have his incontinence brief checked/changed. On 2/6/23 R4 was observed in his wheelchair from 9:15 AM until 1:36 PM and during this time, R4 was not repositioned or monitored for incontinence. R4 was noted with long jagged fingernails with a brownish substance underneath. R4 had food crumbs and debris on his clothing and face. R4 had dirty greasy hair, long facial hair, and strong body odor. At 1:36 PM, V13 (CNA) proceeded to provide personal care to R4. R4 was noted with saturated brief and hard dried fecal matter. R4's right buttock area was noted to be red and inflamed. V13 needed numerous wipes to clean the dried fecal matter from R4's buttock and anal area since the stool was dried. V13 stated that R4 will scratch his buttock and that is why R4 has fecal matter under his nails. V13 stated that this was the first time he had to change R4 since they only had 2 nurse aides on the floor. R4's skin assessment sheet dated February 7, 2023, documents that R4 has a pressure injury on the left buttock measuring 5.5 by 0.5 by 0.1 centimeters and another injury on the sacrum measuring 5.0 by 0.5 by 0.1 centimeters. 6. Face sheet, printed 2/1/23, shows R2's diagnoses included incontinence without sensory awareness, dementia, depression, and cervicalgia. MDS, dated [DATE], shows R2 was cognitively intact, was totally dependent on staff for transfers, required the extensive assistance of two staff for bed mobility and toileting, required the extensive assistance of one staff for bathing, dressing and personal hygiene, and was always incontinent of bowel and bladder. Braden scale, dated 11/11/22, shows R2 was at mild risk for development of a pressure ulcer. On 2/1/23 at 2:39 PM, R2 stated there were often only two CNA staff for the whole second floor of residents. R2 stated she sometimes waited 12-15 hours for her soiled briefs to be changed. R2 stated her last bed bath was 1/20/23 and before that she had not had a shower in a long time because there were not enough staff at the facility. R2 stated at times there is only one CNA working the entire second floor on a AM or PM shift. R2 stated the staff only reposition her when they change her incontinence brief. R2 stated the staff typically change her incontinence brief approximately three times a day - usually at 4:00 AM during the PM shift, at 10:00 AM after breakfast, and then at approximately 9:30 PM before she goes to sleep. On 2/8/23 at 2:43 PM, V12 (CNA/Scheduler) stated R2 preferred her showers on the AM shift per her shower schedule which had been followed for years. Review of Bath/Shower Follow Up Question Report, printed 2/6/23, shows R2 received only 4 showers from 1/1/23 to 1/31/23 (showered on 1/17/23, 1/24/23, 1/27/23, 1/31/23). The report shows on 1/6/23, 1/13/23, 1/20/23 and 1/21/23 the CNA responded, Not Applicable in the computer. Review of hand -written shower sheets, provided by V9 (Restorative Nurse), shows R2 received showers by V9 only on 1/17/23, 1/24/23, 1/27/23, and 1/31/23. No hand-written shower sheets were provided for 1/3/23 and 1/10/23. On 2/6/23 at 3:50 PM, V9 (Restorative Nurse) stated the documentation entered on 2/2/23 on the Bath/Shower Follow Up Question report showing R2 was provided multiple showers by V9 (1/3/23, 1/10/23) was not accurate and provided hand-written shower sheets which accurately showed the showers she provided for R2. The shower sheets showed V9 provided R2 showers on 1/17/23, 1/24/23, 1/27/23, and 1/31/23. On 2/6/23 at 9:40 AM, V12 (Scheduler/CNA) stated R2 did not receive showers on 1/6/23, 1/13/23, 1/20/23 and 1/21/23 because the CNAs responded, Not Applicable in the computer. V12 stated facility CNAs mark Not Applicable on the bath/shower task when the task comes up in the computer and it is not the resident's shower/bath day. ADL Care Plan, revised 11/18/22, shows R2 required staff assistance with ADLs related to weakness and pain. Interventions included one staff assistance for bed baths, assist with ADLs as needed, check for skin changes during bathing, Intervention, revised 7/24/18, shows R2 prefers bathing after dinner between 8:00 PM and 9:00 PM. On 2/8/23 at 2:31 PM, V12 (Scheduler/CNA) stated R2 prefers showers in the AM which had been her shower schedule for years. 7. Care plan, revised 9/22/21, shows R7's diagnoses included dementia, bipolar disorder, psychotic disorder, depression, and anxiety. Care plan, revised 9/21/21, shows R7 had a potential for impaired skin integrity and interventions included turning and repositioning every two hours as needed. MDS, dated [DATE], shows R7 was severely cognitively impaired, required the extensive assistance of staff for bathing, bed mobility, transfers, dressing, toileting, and personal hygiene, and was always incontinent of bowel and bladder. Braden scale, dated 9/30/22, shows R7 was at mild risk for the development of pressure ulcers. On 2/1/23 at 9:19 AM, R7 was sitting in her wheelchair finishing her breakfast in the third-floor main dining room. On 2/1/23, during continuous observation between 9:10 AM and 12:05 PM, R7 sat in her wheelchair without staff repositioning R7 or checking/changing R7's incontinence brief. At 2:05 PM, R7 was toileted by V5 (CNA). V5 stated he got R7 up from bed at approximately 8:00 AM and checked/changed R7's incontinence brief at that time. R7's incontinence brief had a very strong smell of urine. 8. Face sheet, printed 2/1/23, shows R9's diagnoses included dementia, anxiety, and depressive disorder. MDS, dated [DATE], shows R9 was severely cognitively impaired, was totally dependent on staff for bathing, required the extensive assistance of two staff for bed mobility and transfers, required the extensive assistance of one staff for dressing, eating, toileting and personal hygiene, and was always incontinent of bowel and bladder. Braden scale, dated 12/2/22, shows R9 was at mild risk for development of a pressure ulcer. On 2/1/23 at 9:24 AM, R9 was laying in her bed in her room on her back sleeping with a thick blanket covering her body from her toes to her neck. The room temperature was very warm. During continuous observation, R9 was laying in the same position without incontinence check/change or repositioning from 9:24 AM to 12:29 PM. As R9 laid in bed, R9's cheeks became more red and at 12:08 PM, R 9 pulled the blanket down from her chin to her chest. On 2/1/23 at 12:16 PM, V18 (Assistant Administrator) stated R9 required assistance from staff to reposition in bed every two hours. On 2/1/23 at 12:29 PM, V5 (CNA) changed her incontinence brief which had bowel movement in the brief. V5 stated he last changed / repositioned R9 at 8:00 AM that morning. 9. Face sheet, printed 2/2/23, shows R12's diagnoses included dementia and palliative care. MDS, dated [DATE], shows R12 was severely cognitively impaired, was totally dependent on staff for bathing, toileting, transfers, bed mobility, dressing, eating, and personal hygiene. The MDS shows R12 was always incontinent of bladder and bowel. Skin integrity alteration care plan, revised 8/24/22, shows R12 had a history of pressure ulcers and interventions included incontinence care with care rounds and as needed as well a [TRUNCATED]

Based on observation, interview and record review the facility failed to follow a resident's care plan interventions for pressure injury prevention and treatment for 5 (R16, R1, R2, R4, R3) of 5 residents reviewed for pressure injuries from a total sample of 23. This failure resulted in R16's healed pressure injury redeveloping and R1's healed pressure injury redeveloping. This failure also resulted in R4 developing a new pressure injury. Findings include the following: 1. R16 is a [AGE] year-old resident with multiple diagnosis including: Diabetes, Heart Failure, Hypertension, Protein Calorie Malnutrition, Gout, Dysphagia, and Muscle Weakness. The facility wound list of February 2, 2023, documents R16 as having a healed wound to the left buttock and open Stage III wound to right buttock. R16 also has a previous Stage III pressure injury to the right heel that was documented as closed on October 25, 2022. R16's wound to the left buttock was noted as healed on January 24, 2023. Per R16's MDS (Minimum Data Assessment) dated December 27, 2022, R16 is dependent on staff for personal hygiene, transfers, position change, and is always incontinent of bowel and bladder. R16's care plan dated January 11, 2023, documents to use a two-person mechanical lift to transfer R16 and to turn and reposition R16 every two hours and as needed for skin issues. R16 is also cognitively impaired per the MDS assessment. The facility's Braden Scale for R16 dated February 1, 2023, scores R16 at mild risk. Under section 1 Sensory Perception, R16 is scored to have no impairment, yet R16 is unable to verbalize pain or reposition herself. Under Section 2 Moisture, R16 is scored 4 meaning rarely moist, yet R16 uses adult incontinence pads and is totally incontinent of urine and stool. Under section 5 Nutrition, R16 is scored 4, meaning an excellent nutrition yet R16 was noted with weight loss of 15 pounds in four months (January 2023 weight was 146 pounds and September 2022 weight was 161. In addition, R16 has a history of protein calorie malnutrition and has orders for a Puree No Concentrated Sweets Diet with Fortified Pudding twice a day. The assessment does not accurately assess R16's risk for pressure injury. On February 6, 2023, R16 was observed on the third floor in the dining room or directly outside the dining room near the nursing station from 9:10 AM until 1:40 PM. R16 was noted sitting directly on the sling for the mechanical lift on an adult reclining chair. During this time, R16 was not removed to monitor for incontinence nor was her position altered or changed. At 3:20 PM, R16's wounds were observed with V2 (Director of Nursing RN) and V8 (Assistant Director of Nursing RN) and the area on the left buttocks was noted to be open. A third new area was identified on the right buttock area. Both V2 and V8 confirmed that this area was now reopened and V8 stated he would notify the wound doctor. The facility skin assessment documents R16 left buttock to measure 1.5 by 0.5 by 0.1 centimeters and the new wound on the right buttock measured 1.0 by 2.0 by 0.2 centimeters. V17 (wound physician) was notified about the re-opened wound and was interviewed on February 7, 2023, at 1:15 PM and stated that R16 should be repositioned at least every two hours to remove pressure. V17 also stated that since he is not in the facility all the time that he assumed the staff would change R16's position at least every two hours. V17 added that not providing position changes leads to new skin issues. The Unavoidable pressure injury or condition document was completed by V2, V8 and V17 documents under comorbidities: Immobility, Incontinence-urine, Incontinence-fecal, previous pressure injuries and under preventative measures: turning and repositioning in bed/wheelchair. 2. Face sheet, printed February 1, 2023, shows R1's diagnoses included multiple sclerosis, quadriplegia, spinal stenosis, overactive bladder, anxiety, and depression. MDS, dated [DATE], shows R1 was cognitively intact, was totally dependent on staff for transfers, personal hygiene, eating and dressing, and required extensive assistance from two staff for bed mobility, R1 was always incontinent of bowel and bladder, and R1 had an indwelling urinary catheter. Braden scale, dated 1/28/23, shows R1 was at moderate risk for development of a pressure ulcer and R1 was not able to make even slight changes in body or extremity position without staff assistance. ADL Care Plan, initiated 8/7/22, shows R1 required a mechanical lift for transfers and requires staff assistance for bathing, toileting, and personal hygiene. Interventions include R1 refuses to take showers on non-scheduled dates. Skin integrity care plan, revised on 2/17/22, shows R4 had a history of skin injuries to her sacrum, had a reopened injury to sacrum and impaired mobility. Interventions include inspect skin with showers and as needed and turn and reposition every two hours and as needed. Depression care plan, revised 1/29/23, shows R1 had a diagnosis of depression and was observed of feeling down and tearful. Incontinence care plan, dated 10/18/21, shows R1 was incontinent of bowel related to multiple sclerosis and quadriplegia and interventions included offering toileting opportunities based on R1's pattern of elimination. Bed mobility care plan, revised 4/19/18, shows R1 was unable to turn and reposition herself in bed without assistance with staff. On 2/1/23 at 2:00 PM with V14 (Sister) on speaker phone, R1 stated the facility did not have enough staff to care for residents including providing showers, repositioning, and checking/changing incontinence briefs. R1 stated she had not received a shower for two weeks. R1 stated had not received her showers twice a week for a few months and that was when R1 began having skin irritation. R1 stated not having showers twice weekly caused her to itch and scratch her skin until she bled. R1 had visible, scabbed, scratch marks on her left upper thigh, fight upper arm near her shoulder, and bright red cabs on her right breast. R1 stated, Once I start scratching, I can't stop! It started a couple months ago when it began to be one shower a week. I started itching more as it declined. R1 also stated, I feel terrible, wouldn't you!? Sometimes I can smell myself! V14 stated, I have called her, and she has been so depressed and feels so bad about herself. She has told me it is depressing. R1 also stated, They're not turning me. The other day I was not moved for 13 hours. R1 stated she had pressure ulcers and her repositioning schedule is never followed by staff. R1 stated, When I am left sitting in one position for so long my pressure ulcer starts burning and I call my sister and she calls and talks to nurses and gets them in here. R1 stated she has waited two hours for staff to answer her call light for ADL assistance. R1 had a repositioning scheduled over her bed that showed R1 was to be turned every two hours on the even hours. R1 was observed with V8 (Assistant Director of Nursing RN) on February 6, 2023, at 3:35 PM. Per the facility's wound report of February 2, 2023, R1's wounds were healed. Two open areas were noted during the observation, one area on the sacrum and one area on the left buttock. Per V8, these areas had been healed and were closed. V17 (wound physician) was interviewed on February 7, 2023 about R1 and stated that he would expect that R1 be repositioned at least every two hours and that R1 has a history of skin breakdown. R1's left buttock injury was a Stage III and was noted to be healed on January 10, 2023, and R1's sacral injury was also noted to be a Stage III and noted to be healed on November 29, 2023. R1's care plan revised on August 17, 2022, documents to turn and reposition every two hours and provide incontinent care. 3. R4 is an [AGE] year-old resident with the following diagnosis: Heart Failure, Dementia, Obstructive Pulmonary Disease, Dysphagia, Dementia and Peripheral Vascular Disease. R4's care plan dated October 7, 2022, documents that R4 requires staff assistance with grooming, bed mobility, transfers, and dressing. R4 was observed on February 6, 2023, in the third-floor dining room or area near nursing station directly outside of the dining area from 9:15 AM until 1:36 PM and during this time, R4 was not repositioned or monitored for incontinence. R4 was noted with long jagged fingernails with a brownish substance underneath. R4 had food crumbs and debris on his clothing and face. R4 had dirty greasy hair, long facial hair, and strong body odor. At 1:36 PM, V13 proceeded to provide personal care to R4. R4 was noted with saturated brief and hard dried fecal matter. R4's left buttock area was noted to be red and inflamed. V13 needed numerous wipes to clean the dried fecal matter from R4's buttock and anal area since the stool was dried. V13 stated that R4 will scratch his buttock and that is why R4 has fecal matter under his nails. V13 stated that this was the first time he had to change R4 since they only had 2 nurse aides on the floor. R4 has a history of pressure injuries and his care plan dated October 7, 2022, documents potential for alterations of skin and list as interventions: turn and reposition as per schedule and needed, incontinent care, and keep nails short and clean. R4's skin assessment sheet dated February 7, 2023, documents that R4 has a pressure injury on the left buttock measuring 5.5 by 0.5 by 0.1 centimeters and another injury on the sacrum measuring 5.0 by 0.5 by 0.1 centimeters. 4. R2's Face sheet, printed 2/1/23, shows R2's diagnoses included incontinence without sensory awareness, dementia, depression, and cervicalgia. Braden scale, dated 11/11/22, shows R2 was at mild risk for development of a pressure ulcer. MDS, dated [DATE], shows R2 was cognitively intact, was totally dependent on staff for transfers, required the extensive assistance of two staff for bed mobility and toileting, required the extensive assistance of one staff for bathing, dressing and personal hygiene, and was always incontinent of bowel and bladder. On 2/1/23 at 2:39 PM, R2 stated there were often only two CNA staff for the whole second floor of residents. R2 stated she sometimes waited 12-15 hours for her soiled briefs to be changed. R2 stated her last bed bath was 1/20/23 and before that she had not had a shower in a long time because there were not enough staff at the facility. R2 stated at times there is only one CNA working the entire second floor on a AM or PM shift. R2 stated the staff only reposition her when they change her incontinence brief. R2 stated the staff change her incontinence brief approximately three times a day - usually at 4 AM during the PM shift, at 10:00 AM after breakfast, and then at approximately 9:30 PM before she goes to sleep. 5. Face sheet, printed 2/1/23, shows R3's diagnoses included hemiplegia and hemiparesis following cerebral infarction, chronic respiratory failure with hypoxia, morbid obesity, and depression. MDS, dated [DATE], shows R3 was cognitively intact, required total assistance from staff for transfers, required the extensive assistance from two staff for bed mobility, dressing, toilet use, bathing and personal hygiene, and was always incontinent of bowel and bladder. Braden scale, dated 12/5/22, shows R3 was at mild risk for the development of a pressure ulcer. On 2/1/23 at 2:29 PM, R3 stated during the day shifts she usually waits approximately 45 minutes for staff to answer her call light. R3 stated staff fail to turn her every two hours and fail to provide R3 showers. R3 stated she had not had a shower in weeks. R3 stated, It makes me feel horrible. R3 stated front office staff had to help last time she was bathed because she needed so much cleaning. Facility clinical practice guidelines for prevention and treatment of pressure injury and other skin alterations documents, Implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan.

Based on observation, interview, and record review, the facility failed to ensure a resident identified as a high risk for elopement was provided adequate supervision to prevent elopement from the facility. This failure resulted in R1 eloping from the facility without being witnessed on December 8, 2022. R1 was found across a six lane busy road at a gas station and required warming with blankets from emergency medical services. R1 was found at approximately 4:57 AM. At the time of R1's elopement, V9 (RN/Registered Nurse) and V10 (CNA/Certified Nursing Assistant) were the staff members working on the unit R1 resided. V9 and V10 were responsible for monitoring 44 residents, and of the 44 residents, 16 residents required every 30 minute observations. This failure resulted in Immediate Jeopardy. This applies to 5 of 5 residents (R1-R5) reviewed for safety and supervision from the total sample of 16. The Immediate Jeopardy began on December 8, 2022, when R1 eloped from the facility without being witnessed by facility staff. R1 was found at a gas station, across a six lane, busy road. V1 (Administrator) and V2 (DON/Director of Nursing) were notified of the Immediate Jeopardy on December 12, 2022, at 11:47 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on December 9, 2022, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the removal plan. The findings include: On December 9, 2022, at 10:47 AM, the facility provided an undated list entitled At Risk of Elopement. The list identified R2-R16 as residents at risk of elopement who were residing on the first floor. On December 9, 2022, at 10:20 AM, V2 (DON) said staff are to perform every 30 minute observations on residents who's BIMS (Brief Interview for Mental Status) Score decreases and if the resident is not residing on the third floor of the facility. 1. The EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with diagnoses including: chronic kidney disease, dementia, and atrial fibrillation. R1's MDS (Minimum Data Set) dated October 4, 2022, showed R1 was moderately cognitively impaired and required supervision of facility staff for locomotion on and off the unit. R1's elopement care plan revised on December 8, 2022, showed [R1] is noted to have short term memory deficits and having difficulty in recall. [R1] is sometimes/often exploring/elopement/exit seeking as evidenced by: can't find place he wants to go. Attempts to get on elevator. Attempts to use alarmed, fire exit doors. The care plan continued to show multiple interventions date February 17, 2022, including, Orient resident to surroundings and situation as needed. Facility documentation titled, Exit Seeking/Wandering/Elopement Risk Assessment, dated October 4, 2022, showed R1 was at risk for elopement. On December 9, 2022, at 10:20 AM, V2 said R1 eloped from the facility using a side exit door. V2 continued to say R1 said he left the facility to go buy a soda. On December 9, 2022, at 1:40 PM, V9 (RN) said she was working when R1 eloped. V9 said the last time she saw R1 was around 4:25 AM and R1 was sleeping in his bed. V9 continued to say around 4:55 AM, V9 was on the opposite side of the unit where R1 resided. V9 said she was returning to the nurse's station and heard the exit door alarm sounding. V9 continued to say she did not hear the alarm until she was closer to the nurse's station. V9 said she was unsure how long the alarm was sounding for. V9 said emergency services dispatch called the facility and told V9 that R1 was across the street at the gas station. On December 12, 2022, at 9:40 AM, V10 (CNA) said she was working when R1 eloped from the facility. V10 continued to say she was providing care to a resident on the opposite side of the unit from where R1 resided. V10 said she did not hear the door exit alarm when R1 eloped from the facility. V10 continued to say emergency services dispatch called the facility and asked if the facility had a resident named [R1]. V10 said her and another facility staff member went to the gas station where R1 had eloped to and when V10 arrived, R1 was receiving care by emergency services inside of an ambulance. On December 9, 2022, at 1:07 PM, V11 (Fireman) said he was working on December 8, 2022, and responded to the gas station where R1 was found. V11 continued to say eye witnesses at the gas station said R1 was at the gas station for about an hour. V11 said when emergency services arrived at the gas station it was cold outside and R1 was very cold, requiring blankets to help warm him. V11 continued to say the street R1 crossed is a busy street and R1 had to cross six lanes to get to the gas station. On December 9, 2022, at 12:32 PM, R1 was standing near the elevator on the third floor of the facility. R1 said Why would I leave the facility to get a soda when I can just go in the basement? On December 9, 2022 at 1:30 PM, V7 (CNA) was completing documentation in the facility's elopement risk binder. V7 said the monitoring is for fall risk residents. V7 continued to say he completes hourly observations for residents at risk for falls. On December 9, 2022, at 10:54 AM, exit door alarms were checked with V3 (Building Director). The alarm on the exit door stops alarming once the door is closed. V3 said the alarm on the exit door stops once the door is closed, but there is a separate alarm at the nurse's station that sounds. V3 continued to say that staff can reset the door exit alarm at the nurse's station. Facility documentation titled Post Occurrence Documentation dated December 9, 2022, at 11:30 PM, by V2 showed, Report was received from [local] police that resident was noted lying on the ground from a gasoline station . 2. The EMR showed R2 was admitted to the facility on [DATE], with multiple diagnoses including: chronic kidney disease, malnutrition, and dementia. R2's MDS dated [DATE], showed R2 had moderate cognitive impairment and required supervision for locomotion off the unit. R2's elopement care plan dated September 6, 2022, showed, [R2] can be considered an elopement risk related to current cognitive status. The care plan continued to show multiple interventions dated September 7 2022, including Will be on 30 minute monitoring. On December 9, 2022, V2 (DON) said nurses and CNAs are to complete the 30 minute observation tool located in the Elopement Binder. V2 continued to say the purpose of the 30 minute observation is for residents at risk for elopement, and staff should be documenting the location of the resident every 30 minutes. On December 9, 2022, at 11:59 AM, V1 (Administrator) provided copies of the 30 minute observation tools from the elopement binder for the dates of December 8, 2022 and December 9, 2022. On December 9, 2022, at 12:30 PM, V2 provided the 30 minute observation tools from October 13, 2022 to December 6, 2022. The facility did not have documentation to show R2's 30 minute observations were completed on December 8, 2022, from 12:00 AM to 5:30 AM and from 3:30 PM to 10:30 PM. 3. The EMR showed R3 was admitted to the facility on [DATE], with multiple diagnoses including: heart failure, pacemaker, and cerebrovascular disease. R3's MDS dated [DATE], showed R3 had moderate cognitive impairment and required supervision for locomotion on and off the unit. R3's elopement care plan revised on September 2, 2022, showed [R3] is noted to have short term memory deficits. Resident can be considered an elopement risk related to current cognitive status. The care plan continued to show multiple interventions including the following intervention dated September 7, 2022, Will be on 30 minute monitoring. The facility does not have documentation to show R3's 30 minute observations were completed on December 5, 2022, from 3:30 PM to 11:30 PM and December 6, 2022 from 3:30 PM to 10:30 PM. 4. The EMR showed R4 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease and dementia. R4's MDS dated [DATE], showed R4 had severe cognitive impairment and required supervision from facility staff for locomotion on and off the unit. R4's elopement care plan dated September 6, 2022, [R4] can be considered an elopement risk related to current cognitive status. The care plan continued to show the following intervention dated December 7, 2022, Will be on 30 minute monitoring. On December 12, 2022, at 3:13 PM, R4 was standing in the hallway and said an old woman is walking around wanting to take his hair. R4 was able to ambulate independently into his room. The facility does not have documentation to show R4's 30 minute observations were completed on December 5, 2022, from 3:30 PM to 11:30 PM and December 6, 2022 from 3:30 PM to 10:30 PM. 5. The EMR showed R5 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease, alcohol dependence, and psychosis. R5's MDS dated [DATE], showed R5 had moderate cognitive impairment and required supervision from facility staff for locomotion on and off the unit. The MDS continued to show R5 was steady at all times when walking. R5's elopement care plan revised on December 12, 2022, showed, [R5] is at risk for impaired mobility with diagnosis of Parkinson's disease or other movement disorder. [R5] is at risk for elopement due to diagnosis of Parkinson's with impaired cognition. The care plan continued to show the following intervention dated, December 12, 2022, Complete 30 minute checks. On December 9, 2022, at 10:47 AM, the facility provided an undated list entitled At Risk of Elopement. R5 was included on the At Risk of Elopement list. On December 9, 2022, at 1:01 PM, V2 said staff are to complete the 30 minute observation tool for the residents on the At Risk of Elopement list. The facility does not have documentation to show R5 had 30 minute observations prior to December 9, 2022. The facility policy titled, EXIT SEEKING/ELOPEMENT VS. AN UNPLANNED DISCHARGE POLICY AND PROCEDURE, revised on 11/2017 showed, POLICY: Staff of [facility] will strive to respect the independence and dignity of all residents, as well as their right to self-determination by honoring all requests to be discharged , as most residents are voluntarily admitted to the facility. This will be done in a manner that also respects the facility's legal responsibility as well as the responsibility to maintain resident safety. An unplanned discharge incident is classified as a resident who is alert, oriented to at least three, is his/her own decision-maker, is not an immediate threat to him/herself or others and is making the decision to leave the facility. This includes not returning to the facility while out on pass and/or not returning from day program/community appointments without a proper discharge order. An exit seeking attempt/elopement incident is classified as a resident who is not alert, not oriented to at least thee, has a resident representative and/or is an immediate threat to him/herself or others and attempts/is successful in fleeing from the facility. PROCEDURE: . For an Elopement: Any resident who leaves under the following conditions will be considered to have eloped, and all elopement procedures will be followed: Resident is not considered to be alert and/or oriented times three. Resident has a legal/state guardian, Healthcare Surrogate, or active Power of Attorney and leaves without the permission of the responsible party. Resident is deemed to be an immediate risk to him/herself or others (e.g., suicidal, homicidal, etc.). Resident has been assessed at admission, quarterly, annually and episodically for elopement risk and is currently assessed as being 'At-Risk' for elopement . If a resident is evaluated at being 'At-Risk' for elopement, the following procedures will be implemented: 1. The resident's picture will be taken and provided to the nursing station of the unit the resident resides on and to the front office for monitoring of the front door to the facility. 2. Increased monitoring will be initiated if there is a change in condition for an elevated concern of elopement. 3. The resident will be re-assessed quarterly and/or as needed to continue monitoring the resident's behavior as it relates to elopement risk. The Immediate Jeopardy that began on December 8, 2022 was removed on December 9, 2022 when the facility took the following actions to remove the immediacy: Corrective Action Taken: Resident identified was placed on the third floor (locked unit) immediately on 12/08/2022 when the incident happened. Elopement risk assessment was performed on 12/08/22. Care plan was updated pertaining to elopement on 12/08/2022. Designated employee is assigned for door watch starting 12/09/22 every night, designated employee's job description is to watch the exit door for night shift. Emergency QA (Quality Assurance) meeting was held on 12/09/2022 with medical director pertaining to elopement and intervention in place. Identifying other residents having the potential to be affected by the same deficient practice: All resident's elopement risk were re-assessed on 12/08/22 and ongoing. All residents that are identified as at risk and high risk were care planned and pictures were placed in a binder on all floors on 12/08/2022 and ongoing. All residents with an active exit seeking behavior will be assigned on the third floor to keep resident away from the entrance door. Reassessments were performed on 12/08/2022. Exit doors were checked by building manager for patency of the alarms on 12/08/2022. Measures taken to ensure that the problem is corrected and will not recur: A review of Policy and procedure regarding elopement, in-service provided on 12/09/22 and ongoing. A designated employee started door watch on 12/09/2022. Measures or systems the facility will alter to ensure that the problem will be corrected and will not recur: A review of compliance using Quality Assurance Audit tool for elopement risk. A review of Quality improvement data collection pertaining to elopement risk. A review of compliance regarding patency of alarms on all exit doors using quality assurance audit tool. A review of quality improvement data collection pertaining to patency of exit doors. A review of results of audit regarding elopement and patency of exit doors with the facility's interdisciplinary team. Quality Assurance Plans to monitor facility performance: Audits on all residents requiring elopement risk and patency of exit doors will be reviewed to make sure that elopement risk was performed by the facility in a timely manner and identified residents were moved to designated floor either on second or third floor to keep residents away from the exit doors. Audits will be done weekly for four weeks, monthly times three months, and randomly by Administrator/designee. All audits will be reviewed by QA committee with evaluation of trends/patterns and corrective action implemented as indicated. Ongoing audit frequency will be based up goal attainment. Interdisciplinary team will review compliance weekly times four weeks, then monthly times three months, and randomly. Frequency will be based upon goal attainment. Compliance will be monitor using Quality Assurance tool for elopement risk by Administrator designee once a week for four weeks then monthly for three months and randomly, until concern with elopement is resolved. Administrator/designee will report the result of audits with the facility interdisciplinary team during the Quality Assurance and Performance improvement meeting.

Based on observation, interview and record review, the facility failed to ensure that a resident identified with exit seeking behavior, was provided adequate supervision to prevent elopement from the facility. The facility also failed to ensure that the main entrance sliding door alarm was working to alert facility staff to a resident's attempt to elope. This failure resulted in R1 eloping from the facility without being witnessed by the staff on August 31, 2022. R1 was found walking on the street by the local police department approximately 338 feet from the facility, on a six-lane road. This failure resulted in Immediate Jeopardy. This applies to 1 of 5 residents (R1) reviewed for elopement risk in the sample of 5. The Immediate Jeopardy began on August 31, 2022, when R1 eloped from the facility without being witnessed by the facility staff. R1 was found by the local police department approximately 338 feet from the facility, pushing her wheelchair to walk on the street of a six-lane road. The Immediate Jeopardy was identified on September 6, 2022. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on September 6, 2022 at 3:26 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on September 7, 2022 at 3:38 PM. Noncompliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of the removal plan, including in-service training of staff on the elopement policy, in-service training of staff regarding newly installed door alarms on the front center swing door and main entrance sliding door, what to do in the event the door alarms sound, checking door alarms for functionality, assessing all residents for elopement risk, every 30 minutes monitoring of residents identified as an elopement risk on the first floor, where to locate the elopement binders to identify who is at risk for elopement, and monitoring of the newly installed front center swing door and main entrance sliding door alarm system. The findings include: R1 is [AGE] years old, admitted to the facility on [DATE]. R1 has multiple diagnoses which included, acute respiratory failure with [CONDITION(S)], chronic diastolic (congestive) heart failure, [CONDITION(S)], congenital heart block and generalized muscle weakness, based on the face sheet. R1's admission MDS (minimum data set) dated August 1, 2022 shows R1 has severe cognitive impairment. R1 requires extensive assistance from the staff with most of her ADLs (activities of daily living) including transfer, walking in the room and locomotion on the unit. The same MDS shows that R1 has no functional limitation in range of motion on both upper and lower extremities and uses a walker or wheelchair for mobility. R1's exit seeking/wandering/elopement risk assessment, dated August 1, 2022 shows that the resident scored 1 which meant that R1 is not at risk. Under the evaluation section of the assessment, it asks if the resident have the physical ability to leave the building on their own? This was answered yes. The second question in the evaluation asks if the resident is cognitively impaired with deficits in orientation, decision making related to diagnosis of dementia, DD/ID (developmentally disabled/intellectually disabled), or severe mental illness and/or have an active decision maker (guardian, POA (Power of Attorney), healthcare surrogate? This was answered no. Under the same evaluation, there was no documentation that R1 had history or current behavior of elopement attempts, exit seeking behavior, wandering behavior or any factors which may contribute to R1's risk for elopement. R1's progress notes from admission (July 25, 2022) through August 31, 2022 shows multiple documentation regarding wandering/exit seeking behaviors, including, August 27, 2022 (12:30 PM) created by V5 (Nurse), resident was trying to go out with exit alarm door, resident reeducated not to use exit alarm door and on August 30, 2022 (10:50 PM) created by V3 (Nurse), Resident has been exhibiting wandering behavior the entire evening shift. She is constantly redirected by staff. Will continue to monitor. Further review of R1's progress notes dated August 31, 2022 (1:05 AM) created by V3 (Nurse) shows in-part, Resident was able to get out of building but was brought back in. Patient was then brought to room and being supervised every 30 minutes. Daughter was informed about the incident. Nurse Practitioner made aware of incident. Review of the facility's investigation of R1's elopement incident shows that V3 and V4 (CNA/Certified Nursing Assistant) were interviewed by V1 (Administrator). The facility documented time of events according to V3 shows, [R1] was at nursing station with nurse. New admission arrived just after 12:30 am. [V3] stated that at this time, he believes [R1] left through the front door of the building and headed toward the sidewalk. [V3] stated at some point during this time, Police found [R1] and brought her back to the facility at approximately 1:30 am. [V3] completed head-to-toe assessment noting no injuries to the resident, and resident returned to her room. DON (Director of Nursing) notified who was in the building on the third floor. Then, Administrator notified via phone call from nurse at approximately 1:50 am. Administrator called [V3] for statement on [August 31] at approximately 2 am. [V3] stated that [R1] was gone between 12:30 am - 1:50 am. [V3] stated I only remember her gone for 10-30 minutes. [V3] stated that the Police caught her at the side walk and brought her back to the facility. The facility documented time of events according to V4 shows, Upon interview, [V4] stated that she was assigned to first floor. She did try to exit but I caught her the first time and she went back to her room. Around 1:30 am, I saw her prior to going into the room to care for another resident and saw her again and redirected her back to her room. I then provided care to another resident. Police refused to speak to me and only spoke to [V3]. I am not sure of the conversation that happened. Later, I asked the nurse and they saw her on the sidewalk, near Army Trail Road by the building prior to being returned to us. [V4] stated that the resident was wandering more than usual this night and was getting up more than normal. On September 1, 2022 at 12:17 PM, V2 (Director of Nursing) stated that R1 was admitted to the facility for therapy services with the goal of going back to the assisted living after therapy. V2 stated that based on R1's MDS dated [DATE], the resident has a BIMS (Brief Interview for Mental Status) score of 04 which meant that the resident is severely impaired with cognition. According to V2, R1's exit seeking/wandering/elopement risk assessment dated [DATE] should reflect that the resident is cognitively impaired and the answer to the second evaluation question should be yes instead of no which puts R1 at risk for elopement. V2 added that based on the exit/seeking/wandering/ elopement risk assessment instructions, two or more yes responses to the questions place the resident at risk for elopement. According to V2 she was informed by V8 (manager on duty) on August 27, 2022 that R1 wanted to go down to the basement, but she was not aware that R1 had exit seeking behavior. V2 stated that when R1 manifested exit seeking and wandering behavior on August 27, 2022, as documented on the progress notes, a new exit/seeking/wandering/elopement risk assessment should have been completed because there was no doubt that (R1) was an elopement risk. V2 stated that any resident from the first floor identified as at risk for elopement like R1 will be moved to the 3rd floor for close monitoring because the 3rd floor is a locked unit that requires a code to leave. V2 added that if R1's family does not want R1 to be moved to the locked unit, the resident could stay on the first floor, but the staff should always have visual control of R1 when the resident is awake while ambulating and/or sitting on her wheelchair, and if R1 is sleeping the staff should check on the resident every hour to ensure safety and accountability of the resident. During this interview, V2 stated that the facility does not know how R1 got out of the facility unwitnessed during the early hours on August 31, 2022. On September 1, 2022 at 2:06 PM, V10 (Receptionist) stated that she normally works at the facility from 6:00 AM through 2:00 PM and at times would work from 2:00 PM through 8:00 PM as needed. V10 stated that when the receptionist leaves the building at 8:00 PM, the main entrance sliding door would automatically lock, not allowing anyone from the outside to come inside the facility. For the staff to come in after 8:00 PM, they have to use their swipe card for the main entrance sliding door to open. Visitors have to ring the door bell and the first floor staff would come to the main entrance sliding door to open. According to V10 since the main entrance sliding door automatically locks at 8:00 PM, the receptionist does not do any other procedure such as turning on the switch that is located on the upper right side of the door. V10 added that after 8:00 PM, from the inside of the facility, anyone can go outside including residents because the main entrance sliding door would automatically open and no alarm could be heard coming from the door. However, V10 does not know if there is an alarm going off on the first floor nursing station when someone leaves the building through the main entrance sliding door. On September 1, 2022 at 2:10 PM, V11 (Receptionist) stated that she regularly works at the facility from 2:00 PM through 8:00 PM. V11 stated that she was the receptionist who worked on August 30, 2022 from 2:00 PM through 8:00 PM. According to V11, when she left at 8:00 PM on August 30, 2022, it was just like all the other days that she worked. By 8:00 PM the main entrance sliding door would automatically lock from the outside, which meant that anyone coming in the facility cannot enter unless they have a swipe card (for staff), and if they are visitors, they need to ring the door bell and the first floor staff would come to the main entrance sliding door to open. Per V11 she does not touch the switch that is located on the upper right side of the door to lock the sliding door. According to V11, anyone can come out of the building (resident, visitor, or staff) through the main entrance sliding door because the door would open automatically without any alarm sounding on the door. V11 stated that she does not know if an alarm will go off at the first floor nursing station if someone leaves the building through the main entrance sliding door. On September 1, 2022 at 2:16 PM, R1 was residing at the locked unit of the facility, were in a code is needed to use the elevator to leave the unit. R1 was sitting in her wheelchair in front of the nursing station asking assistance to use the toilet. On September 1, 2022 at 2:22 PM, R1 was sitting in her wheelchair inside the locked unit dining room. R1 was alert, verbally responsive but confusion. V2 asked R1 if she remembered walking out of the facility and being taken back by the police. R1 responded incoherently and could not provide information why and how she left the facility during the early hours on August 31, 2022. On September 1, 2022 at 4:27 PM, V3 (Nurse) stated that on August 30, 2022 he was the assigned nurse for R1 during the afternoon shift (3:00 PM - 11:00 PM) and night shift (11:00 PM - 7:00 AM). V3 stated that during the night shift on August 30, 2022, he was working with V4 (CNA/Certified Nursing Assistant) on the first floor where R1 resides. V3 confirmed that he was the nurse who documented on August 30, 2022 at 10:50 PM, about R1 exhibiting wandering behavior of going into other residents rooms, the entire shift which required constant redirection from the staff. According to V3, on August 31, 2022 around 1:30 AM, R1 had opened the west side exit door on the first floor that triggered the alarm. V3 stated that they (V3 and V4 (CNA/Certified Nursing Assistant)) responded to the west side exit door alarm and saw R1 standing behind her wheelchair in front of the alarming exit door. V3 stated that they assisted R1 to sit in her wheelchair, placed R1 and her wheelchair between room 107 and 109 and instructed R1 to go to the nursing station, while they (V3 and V4) went inside room 109 to change a resident with the door closed for privacy. According to V3 that was the last time he saw R1 because he got busy attending to other residents, until a Police officer rang the facility doorbell between 1:50 AM and 1:55 AM asking him if R1 is one of the facility resident. V3 stated that the Police officer walked with him from the facility to the sidewalk of the Army Trail Road. It was there that he identified R1 as a facility resident. V3 was informed by the Police officer that they saw R1 pushing her wheelchair to walk on the Army Trail Road sidewalk. According to the Police officer, they asked R1 to sit on her wheelchair while one Police officer watched R1, and the other Police officer went to the facility to inquire. According to V3, the location where R1 was with the Police officer was on the sidewalk of the Army Trail Road outside of the facility parking lot, near the intersection stop light. V3 stated that he wheeled R1 back to the facility with the Police officers. When R1 was inside the facility he assessed the resident. R1 had no visible injury but appeared nervous. R1 was wearing a white shirt, gray pants, and a slip on shoes. V3 stated that on the night of August 30, 2022, R1's behavior of wandering to other resident's rooms and attempting to exit the facility was increased and he was aware that the resident had wandering behavior even prior to August 30, 2022. V3 was asked why he did not document on R1's progress notes about the resident triggering the west side exit door on August 31, 2022 at 1:30 AM. V3 responded, I forgot because I was busy attending to other residents. During the same interview V3 stated that after 8:00 PM, when the receptionist left the building, the facility's main entrance sliding door would automatically lock and when a visitor wants to come in the building, the visitor needs to ring the doorbell and the staff on the first floor would open the door to gain access. V3 stated that for staff, a swipe card is used to enter the building after 8:00 PM through the main entrance sliding door. According to V3, after 8:00 PM when someone (either staff or resident) wants to leave the building, the main entrance sliding door would automatically slide open when the person is in-front of the sliding door sensor, allowing the person to leave. V3 was asked if an alarm wound sound when someone leaves the building through the main entrance sliding door after 8:00 PM. V3 responded, there is no alarm on the main entrance, the sliding door just slides open, then they can go out. The only alarm are on the west, east and patio exit doors. V3 was asked if he heard any door alarm coming from the west, east, patio or main entrance door on August 31, 2022 after 1:30 AM, after R1 triggered the west exit door. V3 responded, no door alarms went off on the west, east or patio exit doors. V3 added, there was no door alarm on the main entrance door, it just slides open, and anyone can go out. V3 was asked how R1 could go out of the facility without any staff witnessing? V3 responded, I believe she got out through the main entrance sliding door because it would slide open automatically and then she can walk through the parking lot to the Army Trail side walk. V3 added that he does not believe R1 got out through the other exit doors because the west and east exit doors had alarm and it is heavy to push for the resident, while the patio exit door also has an alarm but is enclosed without access to leave. According to V3, R1 has short term memory problem with on and off confusion, a wanderer, able to ambulate by pushing her wheelchair using it like a walker and was capable of going out of the facility. V3 stated that because R1 had increased wandering and exiting behavior, the resident got out of the facility unwitnessed. On September 1, 2022 at 6:02 PM, V3 was asked about the electronic progress notes he created on August 31, 2022 at 1:05 AM, regarding R1 getting out of the building and was brought back. V3, responded that the electronic documentation was the elopement of R1 on August 31, 2022, however, V3 admitted that he changed the electronic documentation entry time to 1:05 AM, instead of documenting the time the Police officer came in the facility to inform him that R1 was found walking on the side walk. During the same interview, V3 verbalized that since he changed the documentation entry time on the electronic record, he had approximated the time of the elopement incident. On September 1, 2022 at 6:30 PM with V1 (Administrator), V2 (Director of Nursing) and V3 (Nurse), the distance from the facility entrance to the side walk where R1 was found by the Police officer was measured using the facility's digital measure wheel. The distance was approximately 338 feet. The side walk was located on the East Army Trail Road, a six-lane street, with three lanes going east and three lanes going west with a raised median in between. On September 1, 2022 at 8:12 PM, no reception personnel was observed by the front lobby. The State Agency personnel was able to swing open the front center swing (double) door by either pushing one of the door or by pressing the push pad/button on the wall which causes both of the doors to swing open. Upon reaching the main entrance sliding door, the said door slide open, as well as the second sliding door from the inside which was leading to the parking lot. An alarm was sounding on the panel inside the first floor nursing station when the main entrance sliding door was opened from the inside of the building. When outside of the facility, the State Agency personnel cannot gain access to the facility until a staff member opened the sliding door. During this observation V3 was at the first floor nursing station. V3 stated that he had been working at the facility for a while on a needed basis as a floater (first, second or third floor) at least two-three times per week. In front of V1 (Administrator) and V2 (Director of Nursing), V3 stated that after the elopement incident of R1 on August 31, 2022, he was informed by V7 (Nurse) that the first floor nurse is responsible for making sure that the main entrance sliding door alarm is working after 8:00 PM, by checking the door alarm panel on the back wall of the first floor nursing station. V3 stated that according to V7 the alarm should go off on the first floor nursing station door alarm panel every time someone leaves the building through the main entrance sliding door. V3 stated that he was never aware of this procedure before, until he was told by V7. In the presence of V1 and V2, V3 stated that on August 31, 2022 when R1 had eloped the facility, he did not hear an alarm after 1:30 AM to indicate that someone went out of the building from the main entrance sliding door or on any side exit doors. At 8:36 PM, the State Agency personnel again attempted to leave the facility using the main entrance sliding door. An alarm was sounding on the panel inside the first floor nursing station when the main entrance sliding door was opened from the inside of the building. With V2 it was observed that from the hallway outside of room 109 (located towards the end of the west side wing) the door alarm could barely be heard and when inside room 109 with the door closed, the alarm cannot be heard. During separate interviews held on September 2, 2022 at 2:45 PM and 3:15 PM respectively, V12 (CNA, who regularly works 10:00 PM - 6:00 AM) and V13 (CNA, who regularly works 2:00 PM - 10:00 PM) stated that they have taken care of R1 prior to the resident's elopement incident, while resident was resident at the first floor. V12 and V13 stated that R1 had wandering behavior, going in and out of other resident's rooms. According to V12, there are times that the first floor staff are busy taking care of other residents and no one is available at the nursing station to check the alarms. V12 and V13 stated that when the staff is inside a resident's room providing care with the door closed, the door alarms cannot be heard at times, especially if the room is towards the end of the hallway, away from the first floor nursing station alarm panel. V14 (Nurse) who was also interviewed on September 2, 2022 at 3:45 PM, stated that she regularly works the first floor from 3:00 PM through 11:00 PM. V14 stated that she has not taken care of R1 because she is assigned on the other hall but has heard from V5 (Nurse) that R1 would wander to other residents room. According to V14 there are times when there is no staff at the nursing station because they are attending to other residents. V14 stated that when the staff is inside the resident's room providing care with the door closed. The exit door alarms cannot be heard, especially if the room is located at the end of the hall, away from the nursing station alarm panel. On September 6, 2022 at 11:00 AM, V5 (Nurse) stated that she was the nurse who documented on R1's progress notes dated August 27, 2022 (12:30 PM). V5 stated that she documented that R1 was trying to go out of the building using the exit door. According to V5, on August 27, 2022, R1 had increased confusion, wandering from room to room, and attempting to open the first floor exit side doors on the east and west side which triggered the alarm. V5 stated that because the side exit doors are heavy to fully open and with the alarm sounding, R1 was not able to get out of the building. V5 added that because of R1's increased confusion and wandering behavior the physician was notified with order to check for [CONDITION(S)] (urinary tract infection). According to V5 she informed the manager on duty (V8) about R1's exit seeking behavior and V8 stated that she will inform the Director of Nursing. On September 6, 2022 at 11:30 AM, V4 (CNA/Certified Nursing Assistant) stated that she works at the facility on a needed basis at least once or twice per week as a floater, which meant she can be assigned to any of the floors (first, second or third). V4 stated that she was assigned to R1 on August 30, 2022 during the night shift (10:00 PM - 6:00 AM) on the first floor. V4 stated that on August 31, 2022 at approximately 1:30 AM, R1 attempted to open the west exit door that triggered the door alarm. According to V4, she and the nurse (V3) went to check on the west exit door and found R1 standing at the back of her wheelchair, pushing the west exit door but was not successful in going out. V4 stated that they (V3 and V4) assisted R1 to sit on her wheelchair and they (V3 and V4) went inside room 109-2 to change a resident with the door closed for privacy. According to V4, when she got out of room 109-2, R1 was still sitting in her wheelchair, so she assisted R1 to bed. However, she does not know what happen after she assisted R1 to bed because she got busy providing care to other residents. V4 stated that the next thing she knew, the Police was inside the facility with R1. During the same interview, V4 stated that during her shift on August 30, 2022 prior to R1 leaving the facility unsupervised, she observed R1 multiple times wandering to other resident rooms, and then at approximately 1:30 AM on August 31, 2022 the resident had exit seeking behavior when she triggered the west exit door. Per V4, most of the time R1 uses her wheelchair to ambulate by pushing the back of the wheelchair or at times uses a walker to ambulate. V4 stated that after 8:00 PM, prior to R1's elopement incident, the main entrance sliding door does not open from the outside unless the staff uses their swipe card to enter and for visitors, they have to ring the door bell and the staff would go to the main entrance sliding door to let them in. V4 added that to go out of the facility, anyone (a staff or resident) could walk or wheel out of the facility unnoticed, because the main entrance sliding door would automatically slide open and no alarm would go off. According to V4, she believes that R1 walked out of the main entrance sliding door while pushing the back of her wheelchair to ambulate. V4 stated that because the door would slide open automatically, R1 could easily go out of the facility to the parking lot, then walk to the side walk of Army Trail Road without being noticed by the staff. V4 added that there was no alarm sounding on the main entrance sliding door to indicate that someone used the said door to go out of the building, from the start of her shift on August 30, 2022 until the elopement incident of R1. According to V4, R1 can push open the other exit doors but she does not believe that R1 got out through those exit doors because the west and east exit doors had alarm and the doors are heavy to push, and the patio exit door also has an alarm but is enclosed. On September 7, 2022 at 11:40 AM, V7 (Nurse) stated that on August 31, 2022 at approximately 1:49 AM, she saw two Police officers coming out of the facility. When she reached the first floor unit, she saw V4 (CNA) sitting by the nursing station with R1. V4 informed her (V7) that R1 was found by the Police outside of the facility and was brought in. According to V7 at approximately 1:50 AM, the Police officers came back and was looking for V3 (Nurse) and was asking for R1's name. V7 stated that after the Police officers had left, she told V3 and V4 that the first floor staff should make sure that after 8:00 PM when the receptionist is no longer in the building and until the receptionist comes back in the morning, the alarm panel on the back wall of the first floor nursing station should have no red light on to ensure that the alarms on all exit doors including the east and west side exit doors, patio door and main entrance sliding door is activated. V7 stated that if all the door alarms are activated with no red light on, the alarm would sound off when any of the said exit doors are opened from the inside of the building, to ensure that first floor staff checks the sounding alarm to prevent any resident from getting out of the facility unnoticed. During the same interview, V7 stated that while she was explaining this procedure to V3 and V4, she noticed that a red light was on, on the alarm panel which she pointed to V3 and V4 stating, this light should be off, so the alarm would sound and she turned off the red light. However, V7 does not remember which exit door had a red light on to determine which exit door alarm was not activated at that time. Review of the facility's door alarm check verification from May 2022 through September 5, 2022 shows that the main entrance sliding door was not included in the checklist. There was no documentation that the main entrance sliding door was being checked to ensure functionality. Review of the facility's policy and procedure regarding door alarm function test dated March 2014 shows under policy, Exterior and Interior door alarms will be tested daily to ensure proper functioning. Under the procedure it shows, 1. All exterior door alarms will be tested twice a day by the Building Manager, House Supervisor or Designee at the beginning of his/her shift in the morning and at the end of the shift in the afternoon. 2. All interior door alarms will be tested on ce per shift (3 times daily), by the Building Manager, House Supervisor, or designee. 3. Testing will be performed by opening the door to verify that the alarm is functioning as designed (local alarm, alarm at nursing station or both). 4. Facility will develop a door alarm verification checklist that lists in logical order all exterior doors with alarms and all interior door alarms with spaces for testing individuals initials. 5. Every alarm tested will be initialed on the door alarm verification checklist. 6. Nonfunctioning alarms will be reported to the Administrator and Building Manager for repair or referral to contractor. Until repair is made the door must be made secure by placement of an additional temporary alarm or added supervision. Review of the invoice/service report created by an outside door company dated September 7, 2022 shows in-part, Reported Problem - Interior slide sensor Description of work completed - Inspection revealed loose wires at the switch for Interior sensor control during after-hours. Rewired switch with new wires. Reset slide door control program - completed. On September 8, 2022 at 2:06 PM, V9 (Building Manager) stated that according to the outside door company the loose wires at the switch affected the main entrance sliding door from the inside going out of the facility. However, according to the outside door company, the same switch which is located on the upper right side of the door should be switched on after 8:00 PM, to ensure that the sliding door does not open automatically until the staff deactivate/turn off the switch to allow passage. On September 8, 2022 at 2:18 PM, V2 (Director of Nursing) stated that the switch which is located on the upper right side of the sliding door was never switched on after 8:00 PM prior to September 7, 2022. V2 stated that prior to September 7, 2022 the sliding door of the main entrance door would automatically lock from the outside to ensure that only staff with swipe card can come in the building. The visitors who wants to come in the building after 8:00 PM needs to ring the door bell for the staff to open the sliding door from the lobby. Prior to September 7, 2022, after 8:00 PM, the main entrance sliding door would slide open when someone wants to leave the building and it should alarm on the first floor nursing station panel to alert first floor staff that someone left the building. The first floor staff should check if it was a staff, visitor or resident who left the building. On September 12, 2022 at 11:22 AM, V16 (Physician) stated that prior to admission to the facility, R1 was residing at the supportive living place. While at the supportive living, R1 was alert and oriented x 3 and would walk using her walker. R1 was admitted to the facility for therapy services. V16 stated that on August 27, 2022 while R1 was at the facility, she was informed by the staff that R1 was having confusion. According to V16 she ordered for R1 to be checked for [CONDITION(S)] (urinary tract infection) which turned out to be positive. V16 stated that it was possible that on the early morning of August 31, 2022, R1 was sleeping and woke up confused with sundowning and left the facility without being witnessed by the staff. On September 12, 2022 at 12:01 PM, V17 (Police Officer) stated that on August 31, 2022 at 1:30 AM, he saw R1 pushing behind her wheelchair, walking on the Army Trail Road going west bound coming towards the intersection of Glen Ellyn Road. V17 verified that R1 was walking on the street and not on the sidewalk. V17 described the Army Trail Road as a six-lane street with three lanes going east and three lanes going west with a raised median in between. V17 stated that he assisted R1 to the sidewalk and requested the Police department dispatch to call the facility to inquire if they have a missing resident, to which the facility responded that they do not have any missing resident at that time. V17 stated that since the facility was the closest place for possible resident to have eloped, another officer went to the facility to inquire about missing resident and had the nurse walk with the officer to the sidewalk where R1 was safely placed. According to V17, it was only then that the nurse identified R1 as their resident. R1 was then brought back to the facility by the nurse while being followed by the police officers. V17 added that when they found R1 walking on the street, there was a communication barrier, R1 was confused, does not know her name and without any identification with her. Through observation, interview and record review conducted on September 8, 2022, the surveyor confirmed th [TRUNCATED]

Based on interview and record review the facility failed to ensure that a gait belt was used during a resident's transfer and while assisting the resident to stand, to promote resident safety. This applies to 1 of 3 residents (R1) reviewed for incident of fall with injury. This failure resulted in R1 sustaining a fall while being assisted by a staff which resulted in hospitalization due to proximal left femoral fracture. Findings include: R1 has multiple diagnoses which included [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting right dominant side, [CONDITION(S)], generalized muscle weakness, primary [CONDITION(S)] of the right wrist, pain in right knee, abnormalities of gait and mobility, long term use of anticoagulant, based on R1's medical diagnosis list. R1's quarterly MDS (minimum data set) dated 2/16/21 shows that the resident is cognitively intact and would require extensive assistance from the staff with most of her ADL (activities of daily living) including transfers, ambulation, toilet use, personal hygiene and dressing. R1's care plan revised on 2/23/21 with a goal date of 5/17/21 shows that the resident is at risk for falls due to unsteady gait and balance, weakness and diagnosis of [CONDITION(S)]. R1's initial incident reported to the State Agency on 4/17/21 shows that on 4/16/21 at approximately 2:00 PM, During transfer from toilet in own room, (R1) was unable to continue to stand and bear weight and reported her leg gave out and needed to sit down right away landing on floor of bathroom. Initial nurse assessment no injury noted. Mild knee pain 2/10 ( 2 out of 10 on a scale of 0 to 10, with 0 being no pain and 10 being severe pain) per (R1) was same as usual and not new. Subsequent assessment still with usual mild knee discomfort but noted slight redness and swelling to left knee area. MD (Medical Director) order for portable x-ray left hip, knee. Result of x-ray left hip proximal femur fracture with [CONDITION(S)] changes. MD order for transfer to ER. R1's final incident reported to the State Agency on 4/23/21 shows that on 4/16/21 at approximately 2:00 PM, CNA (Certified Nursing Assistant) reported to nurse that during transfer from toilet in own room, (R1) was unable to continue to stand and bear weight and reported her leg gave out. Resident needed to sit down and CNA lowered resident to the floor. RN (Registered Nurse) observed the resident to be sitting on the bathroom floor with back against the wall by the door. Head to toes assessment was completed. After assessment was completed. When RN asked resident what happened, the resident stated, My leg gave out and I needed to sit down right away. Resident was asked by RN if she had any pain. Resident stated, 'just my legs. Resident reported pain to be mild & 2/10 at her baseline when RN questioned. CNA stated that she was in the bathroom with resident that time when resident's leg gave out. According to CNA as resident was standing up without gait belt, resident stated, I can't do this anymore. CNA tried to reach for the wheelchair but was unable to. CNA tried to place resident back to toilet but was also unable to. CNA braced resident and assisted her to the ground. CNA observed resident sitting on her left leg while on the ground. CNA positioned the resident to be more comfortable. Then proceeded to call Nurse on duty. Resident was placed in the bed and ensure resident was comfortable. Resident requested for pain medication. Tylenol was administered. RN checked on resident 5-10 minutes after incident to check for any pain and discomfort. Resident complaint of mild pain and requested to put pillow (between) legs and did not expressed any concerns. MD (Medical Doctor) notified and ordered X-RAY stat with results of proximal left femur fracture. MD ordered to send resident to ER. R1's x-ray results dated 4/16/21 shows under the interpretation of the left hip, Impacted subcapital fracture of proximal left femur with the impression of Proximal left femoral fracture. The same x-ray results shows under the interpretation of the left femur, Impacted left femoral fracture with the impression of, Proximal left femoral fracture. On 4/23/21 at 2:10 PM, V3 (CNA/Certified Nursing Assistant) stated that on 4/16/21 at approximately 2:00 PM she assisted R1 to the bathroom. V3 wheeled R1's wheelchair inside the bathroom and positioned the resident's wheelchair close to the toilet for R1 to reach the grab bar on the wall. R1 stood up using the grab bar. According to V3, while R1 was holding on to the grab bar, she moved the resident's wheelchair away from the resident and place it outside of the bathroom door. V3 then pulled down R1's pants and disposable brief and assisted the resident to sit on the toilet. V3 stated that while R1 was sitting on the toilet, she cleaned the resident's left thigh area because there was some fecal matter. After R1 finished using the toilet, R1 stood up by holding on to the grab bar (located on the right side of the toilet). According to V3, while R1 was standing and holding on to the grab bar she started cleaning R1 using the disposable wipes, then she put on a clean disposable brief for the resident. V3 stated that she secured the left side of R1's disposable brief first, then proceeded to fasten the right side and it was during that moment when R1 told her, I can't do this anymore which according to V3 meant that R1 cannot stand up anymore. V3 stated that it was after that statement from R1 that she noticed the resident losing her grip from the grab bar and her knees were bent as she was going down in a backward motion. According to V3, because she was positioned closer to R1's right side, she held R1's right arm with her right hand and placed her left leg on R1's back area to sit the resident down. V3 stated that when R1 was on her buttocks on the floor she noticed that R1's right leg was in a straight position parallel to the floor, while R1 was sitting on her left leg. According to V3, R1's position looked uncomfortable so, she assisted R1 in repositioning her left leg by straightening the resident's left leg parallel to the floor. V3 stated that R1 did not complain of pain. After repositioning R1, she (V3) went out of R1's room to call the nurse. V3 stated that V4 (nurse) came in and saw R1 on the bathroom floor. R1 kept on saying, I need help and that she wanted to go back to bed. According to V3, V4, another CNA and herself transferred R1 to bed using a full body mechanical lift. V3 stated that during the application of the lift sling and during the transfer process, R1 did not complain of pain. V3 stated that around 2:20 PM, after R1 was transferred in bed, she left the resident's room because V4 was in the room with R1. V3 stated that at around 2:50 PM, she went back to checked on R1 and according to the resident, she was alright. During the same interview V3 was asked if she is the regular CNA for R1. V3 responded that she is a floater and that she has taken care of R1 prior to 4/16/21. V3 was asked how she would know what type of assistance R1 need during transfer, ambulation, and toilet use. V3 responded that she would normally ask the nurse but with regards to R1 she did not ask because R1 has a card posted on her wall that gives instructions with regards to R1's care. According to V3 the posted card indicated that R1 needed one-person assistance during transfer, ambulation, and toilet use, but it did not indicate what device to use during the transfer/assistance. V3 was asked if she used a gait belt on 4/16/21 to transfer R1, when she assisted R1 on and off the toilet, and when R1 was standing and holding on to the grab bar during perineal care. V3 responded, no because she (R1) does not necessarily need the gait belt. According to V3, on 4/16/21 she had a gait belt inside her pocket when she transferred and toileted R1, however she did not use it to assist R1 because she did not feel that the resident needed it. V3 further stated that she had received training with regards to gait belt usage and was told during the training to use the gait belt as needed, when the staff feel that the resident is not strong enough or when the resident had history of fall. V3 was asked if she noticed any weakness on R1's body prior to assisting R1 to the toilet. V3 responded that R1 has weakness in her leg but she was not certain which leg it was. On 4/23/21 at 3:29 PM, V5 (Physical Therapist) stated that based on the discharge physical therapy notes, R1 received physical therapy services at the facility from 2/3/21 through 2/23/21. V5 stated that when R1 was discharged from physical therapy on 2/23/21, it was documented on the therapy notes that the resident has chronic right knee pain and would require assistance from the staff during transfers due to unsteadiness. According to V5, the discharge therapy notes documented that R1 can stand with support between 1 to 3 minutes, but her standing tolerance can decrease due to pain in the right knee, therefore R1 needed assistance from the staff during transfers, ambulation and during sit to stand with the use of the gait belt. V5 stated that in general, all nursing staff (CNAs and nurses) and therapist must use a gait belt on any resident during manual transfers, ambulation and during sit to stand with 1 or 2 staff assistance, to ensure the safety of the resident. According to V5, the gait belt is used to protect the resident. V5 further stated that proper use of the gait belt provides safety in case the resident feels weak, the staff would be able to hold on the gait belt to prevent any risk of fall and could lessen the impact of injury to a resident. The facility's gait belt/transfer belt policy and procedure dated 9/2020 shows under policy, To assist with a transfer or ambulation. A gait belt will be used with weight bearing residents who require hands on assistance. On 4/24/21 at 5:54 PM, V7 (Physician) was informed that based on R1's records, the resident was sent to the hospital on 4/16/21 for further evaluation and treatment because the result of R1's x-ray showed that the resident's left hip had an impacted subcapital fracture of proximal left femur and the resident's left femur had an impacted left femoral fracture. V7 stated that based on the x-ray result R1 did not have a spontaneous fracture but instead had a low or high-level impact that caused the impacted fracture. According to V7 the only reason he could think that caused the impacted fracture was from a fall. V7 was asked if the staff should have used a gait belt when R1 was being assisted during standing and during transfer on 4/16/21. V7 responded, If the physical therapist says the resident needs a gait belt, it should be followed, because they are the profession with regards to that.

Based on interview and record review, the facility failed to ensure that a resident is free of significant medication error when several anti- [MEDICAL CONDITION] medications were not provided as ordered by the physician. This failure resulted in 2 occurrences of gran mal [MEDICAL CONDITION] causing R2 to be hospitalized and required administration of large doses of anti-[MEDICAL CONDITION] ([MEDICATION NAME] Drip) medication. This applies to 1 of 3 residents (R2) reviewed for significant medication in the sample of 13. The findings include: The EHR (Electronic Health Record) report shows that R2 was admitted to the facility on [DATE] from the hospital. R2, a [AGE] year old had [DIAGNOSES REDACTED]. Review of the R2's MAR (Medication Administration Record) from 9/12/2020 through 9/14/2020 showed the following Physician Medication Orders (Anti-[MEDICAL CONDITION] meds) and medications that were not administered: 1) Date Ordered: 9/12/2020: [MEDICATION NAME] Infa tablets chewable 50 mg. Give 3 tablets (150 mg.) via gastric tube every evening scheduled to be given every 5:00 P.M.= missed this dose on 9/12/2020 at 5:00 P.M.=150 mg. 2) Date Ordered: 9/12/2020: [MEDICATION NAME] Infa tablets, 50 mg. 3 tablets daily for [MEDICAL CONDITION] schedule to be given daily at 9:00 P.M. = missed this dose on 9/12/2020 at 9:00 P.M. = 150 mg. This was a total of 300 mg of [MEDICATION NAME] that was missed on 9/12/2020. 3) Date Ordered: Onfi Suspension 2.5 mg. /ml. Give 16 ml. = 40 mg. scheduled to be given daily at 5:00 P.M. = this was missed at 5:00 P.M. on 9/12/2020 and 9/13/2020 (missed 2 doses). 4) Date Ordered: Onfi Suspension 2.5 mg. /ml. Give 2 ml. = 5 mg. daily scheduled to be given 9:00 A.M. = this was missed on 9/13/2020 at 9:00 A.M. This was a total 85 mg. of Onfi Suspension that was missed on 9/12/2020 at 5:00 P.M. and 9/13/2020; and 9:00 A.M. on 9/13/2020. 5. Date Ordered: Keepra 100 mg. /ml. Give 22.5 ml. = 2,250 mg. to be given twice a day, schedule to be given daily 9:00 A.M. and 5:00 P.M. = this was missed on 9/12/2020 at 5:00 P.M. This was a total of 6 doses of anti-[MEDICAL CONDITION] medications for a period of approximately one and ½ day (9/12/2020 at 5:00 P.M. through 9/14/2020 at 6:30 P.M.). R2 was sent to hospital via emergency medical support (911) on 9/14/2020 at 6:30 A.M. due to grand mal [MEDICAL CONDITION]. R2 was admitted with [DIAGNOSES REDACTED]. The nurse's notes dated 9/13/2020 at 2:50 P.M. showed that R2 had a generalized [MEDICAL CONDITION]. There was no documentation that V17 (Attending Physician) was notified. Again, on 9/14/2020 at 6:30 A.M., R2 had another gran mal [MEDICAL CONDITION]. R2 was sent to the hospital precipitated by this [MEDICAL CONDITION] via 911. This was a total of 2 gran mal [MEDICAL CONDITION] for a period of approximately one and ½ day (since the day of admission at around 3:00 P.M. to the time of transfer to hospital on [DATE] at 6:30 A.M.). On 9/23/2020 at 6:45 P.M., V10 (Registered Nurse) stated that she had admitted R2 on 9/12/2020 at around 3-4 P.M. V10 further added that she entered the R2's initial assessment into the electronic charting around 5:00 P.M. and finished the documentation at 10:32 P.M. V10 added that R2 has dow[DIAGNOSES REDACTED], restless, anxious, agitated and had multiple attempts of unassisted transfer. V10 also added that R2 had missed his due scheduled medications that included the anti-[MEDICAL CONDITION] medications at 5:00 P.M. and 9:00 P.M on 9/12/2020 because the medications were not available. V10 also added that she did not call the pharmacy for a stat delivery nor had tried to follow up what was going with R2's undelivered medications. V10 also that she was again assigned to R2 on 9/13/2020 on the morning shift. V10 added that R2's scheduled anti-[MEDICAL CONDITION] medication was not given because it was not available and was not yet delivered from the pharmacy. V10 also stated that on 9/13/2020 at 2:50 P.M., R2 had a generalized [MEDICAL CONDITION], a grand mal [MEDICAL CONDITION] which was characterized by involuntary jerking movements throughout the entire body. V10 also stated that she did not call V17 (R2's Attending Physician) for the missed doses of anti-[MEDICAL CONDITION] medications and the episode of gran mal [MEDICAL CONDITION] on 9/13/2020 at 2:50 P.M. On 9/23/2020 at 7:00 P.M., V13 (Registered Nurse) stated that he worked on 9/12/2020, 3:00 P.M.-11:00 P.M. shift. V13 also added that he had shared the same floor assignment with V10. V13 added that when he came on duty at around 3:00 P.M. on 9/12/2020, R2 was already been admitted and settled in bed. V13 also added that R2 had missed an anti-[MEDICAL CONDITION] medication on his shift on 9/13/2020 when he took care of R2 for the evening shift. V13 also added that he was not sure why the anti-[MEDICAL CONDITION] medication (Onfi) was not delivered therefore it was not administered as ordered. V13 also added that R2 had exhibited intermittent agitation, restlessness and multiple attempts of getting out of wheelchair without assistance. On 9/23/2020 at 6:55 P.M., V14 (Licensed Practical Nurse) stated that R2 was under her care from 11:00 P.M of 9/13/2020 through 6:30 A.M. of 9/14/2020. V14 stated that on 9/14/2020 at around 6:30 A.M., (R2) had a gran mal [MEDICAL CONDITION] jerking involuntary all throughout so I called (V17) and sent R2 to the hospital via 911. On 9/23/2020 at 6:20 P.M., V15 (Registered Nurse) stated that she came on duty at around 7:05 A.M. on 9/14/2020. V15 also stated that when she came on for duty, R2 was already been sent out to the hospital. V15 also added that she called the hospital at 10:00 A.M. to follow up R2's condition. V15 also stated that R2 was admitted at the hospital with admitting [DIAGNOSES REDACTED]. On 9/24/2020 at 10:49 A.M. and 11:39 A.M., V16 (Registered Pharmacist) stated that R2's medications was sent into their system as an order on 9/12/2020: Keepra at 9:01 P.M. and [MEDICATION NAME] order at 9:04 P.M. V16 also added that a hard copy for script for Onfi should have been sent to the pharmacy to fill the prescription. V16 also added that there was no script provided, so the next step was for the facility to fax the physician order [REDACTED]. V16 also stated that the facility had faxed the physician order [REDACTED].M. and faxed the hospital MAR indicated [REDACTED]. V16 also stated the pharmacy had paged V17 at 6:39 P.M. on 9/13/2020 for verbal order for the Onfi medication. V16 also stated that something could have been done regarding coordination of obtaining medication order. V16 also added that Keepra and [MEDICATION NAME] orders were not received by the pharmacy until 9:04 P.M. on 9/12/2020, so it was not delivered for timely administration. On 9/24/2020 at 11:06 A.M., V17 (R2's Attending Physician) stated that she was not made aware that R2 had a generalized/gran mal [MEDICAL CONDITION] on 9/13/2020. V17 also stated that she also was not notified that R2 had missed several doses of the anti-[MEDICAL CONDITION] medications. As V17 explained, R2 has severe mental [MEDICAL CONDITION], Dow[DIAGNOSES REDACTED], history of brain surgery, [MEDICAL CONDITION] and histories of [MEDICAL CONDITION]. V17 added that R2's anti-[MEDICAL CONDITION] medications were a must to be administer timely as ordered because these medications were significant and would definitely impact R2's stability and also to prevent [MEDICAL CONDITION] and other complications of having [MEDICAL CONDITION] episodes. V17 further stated if she had been called by the facility when anti-[MEDICAL CONDITION] medications were not administered as ordered, she would have ordered a stat [MEDICATION NAME] level blood draw for R2 and adjust anti-[MEDICAL CONDITION] medications as indicated. V17 also stated that R2 required the medications to prevent the occurrence of [MEDICAL CONDITION] and, without the medications, R2 would experience [MEDICAL CONDITION]. V17 also stated that when R2 was transferred to the hospital from the facility on 9/14/20, R2's [MEDICATION NAME] blood level was a critical low value, was given large doses of [MEDICATION NAME], and remained in the hospital for a few days of treatment. V17 stated when R2 was admitted to the facility on [DATE] from the hospital, R2's [MEDICAL CONDITION] and medications had been stabilized enough to be discharged to the facility. V17 stated from the time R2 arrived on 9/12/20 up to the time of discharge on 9/14/20, the missed anti-[MEDICAL CONDITION] medications had caused R2's acute [MEDICAL CONDITION] episodes at the facility. V18 stated a Neurology consult was obtained for possible transfer in the event R2's [MEDICAL CONDITION] could not be controlled, however R2 was able to remain in the hospital and the [MEDICATION NAME] level was stabilized. Facility document New Admissions P-7037, undated, shows, Policy/Purpose: Medications for newly admitted residents are ordered, provided by the pharmacy, and initiated on a timely basis 12. Fax the signed physician's orders [REDACTED]. Call the pharmacy ahead of time if submitting urgently needed orders after delivery cutoff or if an unusual or complicated therapy is anticipated 17.(NAME)out orders as documented. Initiate medication when received from pharmacy

Based on interview and record review, the facility failed to ensure a resident's safe positioning when she received a bed bath. This failure resulted in the resident rolling off her air mattress to the floor and sustaining fractures to both of her legs. This applies to 1 of 3 residents (R1) reviewed for air mattress safety in the sample of 9. The findings include: R1's (MONTH) 4, 2019 hospital Admission Documents after her fall showed R1 had bilateral distal femur fractures which were both displaced . R1's hospital note further showed the fracture to her right femur was splintered into more than two fragments. R1's Face Sheet showed she had [DIAGNOSES REDACTED]. R1's Weights list showed she weighed 212 pounds and was five feet tall. R1's (MONTH) 8, 2019 Minimum Data Set (MDS) showed her cognition was moderately impaired, she required extensive assistance of two people for bed mobility, she was totally dependent on two persons for bathing, and she had impairments to both of her arms and both of her legs. On (MONTH) 10, 2019 at 3:10 PM, V5 CNA (Certified Nursing Assistant) stated he was giving R1 a bed bath by himself on (MONTH) 3, 2019 when R1 rolled off of bed. V5 stated R1 was on an air mattress. V5 stated when he rolled R1 away from him to wash her back, the far side of the air mattress squished down so there was more air on one side of the bed than the other, and R1's feet and knees went out of the bed and she fell to the floor. On (MONTH) 11, 2019 at 12:30 PM, V6 (R1's Physician) stated R1 was extremely fragile and really had no mobility in her lower extremities so she would have had no way to assist herself as she was going off the bed. V6 stated it would not have taken too much force for her to sustain fractures. V6 stated she expected the facility to be aware of how fragile and frail R1 was, and to roll her over slowly in the bed and not near the edge of the bed. V6 stated she knew R1 used an air mattress and she expects staff to have an understanding of how the beds can work. V6 stated air mattresses can be tricky. R1's air mattress 2002 Service Manual showed the option of Max Inflate - The air mattress can be maximally inflated by pushing the 'Max Inflate' button on the control unit, to assist in patient ingress/egress as well as normal nursing procedures . On (MONTH) 11, 2019 at 9:15 AM, V13 (mattress company representative) stated the Max Inflate setting is designed to create a surface for patient repositioning, transfers, or CPR. V13 continued Max Inflate creates a firm surface so patients don't sink .to be on the safe side, (staff) should go to Max Inflate to not get 'dipping' with the air mattresses. On (MONTH) 11, 2019 at 1:05 PM, V7 LPN (Licensed Practical Nurse- Restorative Nurse) stated he participated in the re-enactment of R1's fall from her air mattress. V7 stated when R1 was rolled over in bed, all of R1's weight was sent to the far side of her bed and R1's weight compressed the mattress there. V7 stated the combination of R1's mattress compression and her legs going over the side of the mattress was the root cause of R1's fall. After reviewing R1's air mattress 2002 Service Manual, V7 stated if the Max Inflate button is used, the mattress will inflate to the firmest level and you can roll someone over in bed and the mattress will not deflate. V7 stated it turns into a regular mattress and it would stay firm. V7 stated he was not aware of the Max Inflate option. On (MONTH) 11, 2019 at 2:45 PM, V2 RN (Registered Nurse, Director of Nursing) stated she was not aware of staff ever altering the air mattress settings or using the buttons on the air mattress pump, including turning pressures on or off when getting up or laying back down. V2 stated the only time staff would change a setting would be if CPR were required. V2 stated V8 (Wound Care LPN) does all the training for the air mattresses. On (MONTH) 10, 2019 at 2:45 PM, V8 stated the training she provides to staff is to tell them not to unlock or change the air mattress pump settings and to report if a resident's family or a resident is seen changing the settings. V8 stated R1's setting was in the middle (between soft and firm) .maybe at a five. On (MONTH) 10, 2019, V5 (CNA) stated he did not adjust the setting on the mattress the night R1 fell , and did not recall ever receiving any special training with air mattresses. On (MONTH) 9, 2019 at 1:15 PM, V12 (CNA) stated she never touches the buttons on the air mattress pumps, and she has never seen other CNAs touch the buttons either. On (MONTH) 9, 2019 at 3:20 PM, V9 (LPN) and V10 (RN) stated they have never touched the buttons on the air mattress pumps and never adjust the firmness. On (MONTH) 9, 2019 at 3:45 PM, V4 (LPN) stated R1 used an air mattress and they don't want us to touch the settings. On (MONTH) 10, 2019 at 2:55 PM, V17 (CNA) stated she never messes with the (air mattress) pumps at the foot of the beds. R1's (MONTH) 3, 2019 Post-Occurrence Documentation showed Resident was in bed having a bed bath around 7:45 PM by CNA at this time she was laying on her back and was being turned to her right side and started sliding off the bed. Resident has an air loss mattress, and when she was turned the mattress shifted causing the resident to slide . The Safety Precautions section of R1's air mattress 2007 Operator's Manual showed the mattresses .are not intended to be and do not function as a patient fall safety device. Side rails must be used with the (brand name) mattress to help prevent falls, unless determined unnecessary based on the facility protocol or the patient's medical needs as determined by the facility, in these cases, the use of other suitable patient safety measures are recommended. The facility's (MONTH) 2019 Alternating Pressure Air Mattress policy showed 5. Allow pad to inflate by setting pressure per manufacturer's recommendations .

Based on observation, interview, and record review, the facility failed to toilet and reposition a resident that required extensive assistance from staff for toileting, transfers, and mobility. This failure resulted in the development of a Stage 3 and Stage 2 pressure sore on a resident who required extensive assistance for toileting and transfers. This applies to 2 of 9 residents (R55 and R70) reviewed for pressure ulcers in a sample of 36, and 1 resident (R67) in the supplemental sample. The findings include: 1. Face sheet, dated (MONTH) 18, (YEAR), shows R55's [DIAGNOSES REDACTED]. MDS (Minimum Data Set), dated (MONTH) 10, (YEAR), shows R55's cognitive status was severely impaired and R55 required the extensive assistance of two staff for bed mobility, toileting and transfers. Skin integrity care plan, initiated (MONTH) 16, (YEAR) and resolved on (MONTH) 3, (YEAR), shows R55 had a potential for alteration in skin integrity related to incontinent of bowel and bladder, decreased mobility, gait dysfunction . , and [MEDICAL CONDITION] Care plan interventions include, Turn and reposition every two hours and as needed. Skin integrity care plan, initiated (MONTH) 3, (YEAR), shows R55 has pressure ulcer development related to history of ulcers, immobility, incontinent of bowel and bladder, to sacrum. Care plan interventions include, R55 needs assistance to turn/reposition at least every two hours, more often as needed or requested. Bowel/Bladder care plan, dated (MONTH) 18, (YEAR), shows R55 was incontinent of both bowel and bladder. The care plan showed R55 was to be prompted to the toilet about every two hours and checked and changed as needed. Braden Scale, dated (MONTH) 3, (YEAR), shows R55 was at high risk for pressure ulcers, had very limited response to pressure-related discomfort, R55's skin was often very moist, was chairfast, had very limited ability to change/control body position, and required moderate to maximum assistance from staff in moving. On (MONTH) 17, (YEAR) at 10:23 AM with V5 (Family), V5 stated R55 had two newly-developed pressure ulcers on his buttocks. V5 stated, since the recent development of pressure ulcers, R55 stays in bed all day except when he gets up for his three meals. V5 stated that prior to the pressure ulcers, V5 sat up all day in his wheel chair and did not lay down during the day for naps. V5 stated R55 slept in his wheelchair during the day instead of staff laying him down in bed. V5 stated R55 developed sores because he was up in his chair too long during the day. On (MONTH) 19, (YEAR) at 1 :25 PM, V5 stated she visited R55 every day from approximately 10:00 AM to 7:00 PM. V5 stated R55 remained in his chair throughout the entirety of their visits and R55 was never repositioned in the wheelchair by staff. V5 stated the facility staff did not start putting R55 down to bed after meals until after R55's pressure sores started. V5 stated the staff did not start repositioning R55 in his chair or bed until after sores started. Now goes to bed after meals since sores occurred to relieve pressure. V5 stated the wounds are healing now that R55 is staying off his buttocks. On 07/19/2018 at 1:48PM, V7 (CNA· Certified Nursing Assistant) stated R55 would spend the entire day with V5 either wheeling around the facility or sitting in the dining room with V5. V7 stated V5 would never ask staff to put R55 back to bed because she wanted to spend as much time with R55 as she could. V7 stated the staff began placing R55 in bed after meals to relieve pressure since the development of R55's pressure sores. On (MONTH) 20, (YEAR) at 10:20 AM, V4 (Wound Care Nurse) stated she was called to assess R55's wounds when they were found to be open wounds. V4 stated R5 was previously having incontinence and loose stools and she determined the wounds were related to moisture associated [MEDICAL CONDITION]. V4 stated the wound development was unavoidable because V4 felt facility staff were cleaning, turning, and putting barrier on R55, however, could not verify in any way the care was being delivered. V4 stated V5 was present with R55 all the time and that V5 would be able to describe how often the staff were turning him and changing R55. Nursing skin /wound assessment note, dated June 29, (YEAR), shows R55 had no open areas on his body and R55's skin was intact. Nursing note, dated (MONTH) 1, (YEAR), shows area to buttocks getting worse -notify NP (Nurse Practitioner). Wound assessment form, dated (MONTH) 3, (YEAR), shows R55 developed a Stage 3 pressure ulcer on his left sacrum measuring 1.2 cm (centimeters) by 1.5 cm by 0.2 cm with fifty percent granulation and fifty percent slough, and a scant amount of serous exudate. Wound assessment form, dated (MONTH) 3, (YEAR), shows R55 had a Stage 2 pressure ulcer measuring 2.0 cm by 2.0 cm by 0.0 cm with one hundred percent granulation and slight redness to periwound area. Comprehensive Pressure Ulcer Assessment, dated (MONTH) 3, (YEAR), shows R55's pressure ulcer to sacrum is unavoidable, and R55 was up for meals only and is back to bed. The document shows R55 had a history of [REDACTED]. sacrum in the past due to frequent stooling has history of MASO (moisture associated skin disease) to peri-area and sacrum. The assessment shows R55 was incontinent of bowel and bladder, and required maximum assistance with ADLs (Activities of Daily Living), transfers, turning positioning and eating. Master Skin Audit Flow Sheet, dated (MONTH) 6, (YEAR), shows R55 had a facility-acquired left sacrum pressure ulcer assessed as Stage Ill measuring 1.2 cm (centimeters) x 1.5 cm x 0.2 cm and barrier cream was to be applied to the wound area for treatment. The audit shows R55 has a facility-acquired right sacrum pressure ulcer assessed as Stage 2, measured 2.0 cm by 2.0 cm by 0.0 cm, and barrier cream was to be applied to the wound area for treatment. On (MONTH) 20, (YEAR) at 11 :14 AM, V12 (Physician) stated R55's ulcer could be prevented and the staff should have offloaded R55 while sitting in the wheelchair regularly. R55 stated, ''Technically, it could be prevented. On (MONTH) 20, (YEAR) at 10:39 AM, V4 stated she was not notified when there was a change in R55's skin condition. V4 stated she reviewed the skin nursing note which stated the skin was red and opened. V4 stated the skin assessments were performed on a weekly basis. V4 stated they changed from zinc oxide treatment to a different barrier cream at the time she discovered the wound was opened. V4 stated the facility staff should turn R55, monitoring R55's skin, and reporting any changes in R55's skin to V4. V4 stated R55's wound care team at the Veteran's Administration is treating R55's pressure sores. Between (MONTH) 18- 20, (YEAR), the facility failed to provide any physician documentation regarding R55's pressure wounds. R55's clinical record fails to show any physician documentation of R55's wounds. 2. Face sheet, dated (MONTH) 18, (YEAR), shows R70's [DIAGNOSES REDACTED]. MDS, dated (MONTH) 15, (YEAR), shows R70's cognition was severely compromised and R70 required the extensive assistance of two staff for bed mobility, transfers, and toileting. Visual/Bedside Kardex Report, dated (MONTH) 19, (YEAR), shows R70 requires turning and repositioning every two hours and as needed. Incontinence care plan, dated (MONTH) 20, (YEAR), shows R70 was incontinent of both bowel and bladder and required incontinence care after each incontinent episode. Skin care plan, dated (MONTH) 6, (YEAR), shows R70 had the potential for skin integrity alteration related to incontinence, dementia, and impaired mobility. The care plan shows R70 required turning and repositioning every two hours and as needed. On (MONTH) 18, (YEAR) during continuous observation between 9:47 and 1 :27 PM, R70 sat in his wheel chair in the main dining room during activities and throughout lunch. R70 received no incontinence checks, no prompts to toilet, and no repositioning in his wheelchair during the observation. 3. Face sheet, dated (MONTH) 18, (YEAR), shows R67's [DIAGNOSES REDACTED]. MOS, dated (MONTH) 16, (YEAR), shows R67 required the extensive assistance of staff for transfers, locomotion, toilet use, and bed mobility. ADL care plan, dated (MONTH) 15, (YEAR), shows R67 required assistance with transfers, bed mobility, toileting, and locomotion. Visual/Bedside Kardex Report, dated (MONTH) 19, (YEAR), shows R67 was to be turned and repositioned every two hours and as needed. Incontinence care plan, dated (MONTH) 17, (YEAR), shows R67 was incontinent of bowel and bladder and R67 was to be prompted to the toilet about every two hours and check and change if wet. Sitting balance care plan, dated (MONTH) 17, (YEAR), shows R67 was to be repositioned as needed. Skin care plan, dated (MONTH) 20, (YEAR), shows R67 had a potential for skin integrity alteration due to incontinence, being chair fast, decreased mobility, [DIAGNOSES REDACTED]. Turned and repositioned every two hours and as needed; 2. Skin to be kept clean and dry; 3. Receive pericare after each incontinent episode; 4. Body positioned with pillows to relieve pressure, and 5. Provided pressure reduction sitting/wheelchair surface. On (MONTH) 17, (YEAR) between 9:47 AM and 1 :27 PM during continuous observation, R67 sat in the main dining room in her wheelchair during activities and lunch. R67 received no incontinence checks, no attempts to prompt R67 to toilet, and received no repositioning in her wheelchair during the observation. On (MONTH) 19, (YEAR) at 10:00 AM, V2 (Director of Nursing) stated residents seated in wheel chairs should be repositioned every two hours and residents should be offered toileting/incontinence checks every two hours. Facility document Prevention and treatment of [REDACTED]. Residents who developed a clinically unavoidable pressure injury, the Physician I NP (Nurse Practitioner) completes a progress note or Unavoidable form. 8. At least daily, staff should remain alert for potential changes in the skin condition during resident care. Facility document Toileting Residents, dated (MONTH) (YEAR), shows, Residents are toileted safely on a routine basis in a timely manner according to their individualized plan of care .4. If the resident is unable to utilize the toilet, commode, bed pan or urinal, assist resident to their bed in adherence to a check and change program 7. Assist resident with perineal care as required per plan of care. 12. Notify nurse of any unusual odors, colors, complaints of discomfort, or changes in skin integrity.

Based on interview and record review the facility failed to develop, initiate and ensure interventions were in place to prevent falls for 3 residents. This failure resulted in 3 residents falling and resulted in one resident R1 sustaining a fracture to the left wrist, one resident R65 sustaining a fracture to the right hip and one resident R331 sustaining a subdural hematoma. This applies to 3 of 7 residents (R1, R65 and R331) reviewed for falls in the sample of 36. The findings include: R65 was admitted to the facility (MONTH) 23, (YEAR) per the admission face sheet. The current physician orders [REDACTED]. On (MONTH) 17, (YEAR) at 12:15 R65 was in a wheelchair in the dining room on the third floor. R65 was not able to say what R65 was eating for lunch. R65 did not recall having falls in the past. R65 kept eyes closed most of the time and did not offer conversation. R65 had a urinary catheter in place that was in a privacy bag. The report showed that the resident was independent for toileting. The conclusion of the report showed that R65 was trying to pull the curtain next to R65's bed and fell . The MDS (Minimum Data Set) dated (MONTH) 8, (YEAR) showed that R65 was cognitively impaired had a low BIMS (Brief Interview of Mental Status) score of 5. R65 was not able to give the correct year or month and had very poor recall. The MDS showed that R65 required 2 person assist for transfers and 1 person assist for ambulation in room and halls. The MDS showed that R65 was only able to stabilize with staff assistance for walking, turning around and moving from sitting to standing. The MDS showed that R65 used a walker and or wheelchair for mobility. An occurrence report dated (MONTH) 15, (YEAR) showed that R65 was found on the floor. The note showed that R65 said that she lost her balance when trying to close the drapes. The facility had no incident report for this date with no root cause or investigation of the fall. An incident report from the facility dated (MONTH) 1, (YEAR) showed that at 8:40pm R65 was found lying on the floor with right leg externally rotated and an abrasion to the right elbow with a small amount of bleeding noted. Care plans for falls in R65's clinical record lacked interventions to increase monitoring or supervision. The intervention for the fall after (MONTH) 15, (YEAR) showed to offer to assist closing blinds for the resident. The final report sent to the Illinois Department of Public Health dated (MONTH) 1, (YEAR) showed that R65 had an unwitnessed fall on (MONTH) 1, (YEAR) at 9:45 pm. The report showed that R65 had been sent to the community hospital and was admitted with a fracture to the right hip. On (MONTH) 20, (YEAR) at 9:10am V2 DON (Director of Nursing) stated that R65 used the wheelchair for mobility. V2 could not tell on the report if the wheelchair was locked or not when R65 got out of the chair. V2 stated, Our nurse's make rounds every 2 hours and our aides make rounds every 2 hours. V2 did not say the root cause of the fall and did not say what interventions were in place after the first fall. R331 was admitted to the facility (MONTH) 9, (YEAR) per the admission face sheet. The face sheet showed that R331 had the [DIAGNOSES REDACTED]. Initial nursing assessment dated (MONTH) 9, (YEAR) (no time) showed that R331 was orientated to person and place only. There was no assessment of gait. The initial care plan for falls in R331's clinical record showed that R331 was at high risk for falls related to unsteady gait, uses a walker and has a history of fall. The interventions included provide and maintain proper footwear. The nursing notes dated (MONTH) 9, (YEAR) showed that R331 was admitted to the facility and was alert and oriented times two from the community hospital. The note showed that R331 was treated for [REDACTED]. The note showed that R331 had altered mental status appearing mildly confused at times. The notes showed that R331 received Trazadone 100 milligrams at 6:23pm, and [MEDICATION NAME] 50 milligrams and [MEDICATION NAME] 50 milligrams at 8:47pm. On (MONTH) 19, (YEAR) at 3:03pm in the hall on the lower level V17 RN (Registered Nurse) said that she could not remember when R331 was admitted the facility. V17 said that she received report on R 331 by a supervisor. V17 stated, I remember he was a post fall with head injury. Part of my job is to look at the medical records. In report I was told he had an unsteady gait. I gave report to the night shift before I left. V17 could not recall any other information regarding how she left the bed. V 17 said that R331 refused to take off his Ted hose. V17 did state that R331 was left in his shoes. A document dated (MONTH) 20, (YEAR) written by V17 showed that she assisted the resident to bed with his clothes and shoes as he requested. At no time during the interview on (MONTH) 19, (YEAR) did V17 say that this occurred. The nursing notes written on (MONTH) 10, (YEAR) at 4:00am showed that 3:40am R331 was found on his back on the floor. The note showed that R331 had blood from the back of his head. The note showed that R331 was wearing Ted hose on both of his legs. The note showed that R331 was nonresponsive but breathing. The note showed that 911 was called and R331 was taken to the community hospital. On (MONTH) 20, (YEAR) at 10:47am V1 MD (Physician and Medical Director of the facility) said that he had just seen R331 at the community hospital in the intensive care unit. V18 stated, R331 is in bad shape. R331 suffered a subdural hematoma and continues on life support. R331 has no power of attorney to make end of life decisions. R331 went the facility after a stay at the hospital for a previous fall. He should have been on very strict fall precautions. R331 should not have just had Ted hose on without some kind of non-skid slipper. It's a safety issue. R1 was admitted to the facility on (MONTH) 26, (YEAR) per the admission face sheet. The face sheet showed [DIAGNOSES REDACTED]. R1's MDS dated (MONTH) 4, (YEAR) showed that R1 has a low BIMS of 6 and is not able to state the correct day or month. The report showed that R1 is not able to recall 2 out of 3 words when asked to recall. The MDS showed that R1 required 1 person physical assist for walking, and locomotion in the hall or off of the unit. The MDS showed that R1 required 2 person assist for transfer from bed to chair or bed. The MDS showed that R1 uses a wheelchair for ambulation. An occurrence report dated (MONTH) 18, (YEAR) showed that 4:50am R1 had an unwitnessed fall and sustained a fracture to the left wrist. The record showed that R1 was found lying on the floor and complained of pain to the wrist. The record showed R1 was barefoot and was not using her walker. The note showed that R1 was soiled with urine. The report showed that R1 was sent to the community hospital and returned to the facility with a short arm cast. Initial care plan initiated (MONTH) 26, (YEAR) showed to encourage R1 to use a walker, keep the environment free of clutter, and to place the resident on the falling star program. The facility policy for the falling star program does not give specific guidelines of fall prevention. On (MONTH) 20 at 12:30pm V2 DON stated, The program simply identifies residents who are at risk for falls and need to have a closer eye on those residents. The facility fall policy dated (MONTH) 2013 showed that the facility will assess hazards and risks, develop a plan of care to address those hazards and risks and implement interventions that would minimize the risk for falls and or injuries to the resident. On (MONTH) 20, (YEAR) at 10:47am via telephone V1 MD said that R1 needed assistance with ambulating and transfers. V1 stated, R1 has a very unsteady gait and should be assisted with ambulating. R1 fell unfortunately and fractured her wrist.

Based on interview and record review the facility failed to: Provide supervision to one(R1) of two residents investigated, who was identified as high risk for falls, assess & analyze the causes of R 1 ' s falls & risk factors, develop & implement interventions, including adequate supervision to reduce the risk of falls/accidents. The facility also failed to monitor the effectiveness of the interventions and modify the interventions as needed. These failures resulted in R 1 sustaining fracture of the left clavicle on 06-25-11. Findings include: The incident tracking log showed R 1 has multiple falls. She has four incidents for the month of [DATE], one for the month of March and two for the month June where R 1 sustained fracture of the clavicle. She has two more incidents of falls for the month of July after the fracture on 06-25-11. Review of the facility incident reports showed R 1 had the following incidents: 1. 02-11-11 at 1:10 AM- resident (R1) yelling for help at 1:10 AM. ..Found sitting on the floor ...resident had removed her diaper and stated she was on her way to the toilet...does not remember how she fell on the floor ... Root cause- while going to the toilet. 2. 02-18-11- resident yelling for help at 12:00 AM ...found resident sitting on the side of her roommates bed on the floor ... Root cause - lost balance. 3. 02-22-11 at 22:00 - heard someone calling my name. The C.N.A rushed to the room to find resident (R 1) on the floor. Root cause - legs gave in. 4. 02-26-11 at 21:50 -staff interview " I heard a noise when I was making rounds & saw (R 1) sitting on the floor. Root cause- attempts to get up d/t poor safety awareness. 5. 03-13-11 at 7:45 - was found kneeling on the floor. Root cause - rolled out of bed while turning. 6. 06-04-11 at 2200 - stand up and got out of balance and fell on her buttocks " I want a diaper change. " Root cause -lost balance. Resident is alert with periods of confusion. 7. 06-25-11 at 16:15 - Resident was sitting in the wheelchair at the nursing station. Resident tried to stand up from the wheelchair and she lost balance and fell on the floor on the left side. Resident was complaining of pain in the left side of the head and the left shoulder. Resident was sent out to the hospital for evaluation per Medical Doctor. She had a CT clavicle fracture and was negative for any head injuries. .. Hospital x ray result of the shoulder dated June 25, 2011 showed: Impression: fracture mid shaft left clavicle. 8. 07-07-11 at 1400 - found sitting on the floor close to bathroom door and resident stated she slipped and fell in sitting position on the floor ... Resident stated: " I went to bathroom and I slipped & fell on sitting position on the floor. " 9. 07-14-11 at 9:30 - was in the shower room when she fell . She tried to pull her pants by herself and lost her balance. Resident claimed she hit her head, complaint of back pain, shoulder pain and head pain .... On 07-20-11 at 11:10 AM, the Director of Nursing/E2 stated " she is high risk for falls. She has history of falls. She has a very impulsive behavior. She wants to walk. We put a chair alarm on her due to falls. She does whatever she wants to do. She has poor safety awareness. " R 1 ' s Care Area Assessment (CAA) dated 04-24-11 # 1 Delirium showed: with recent decline in ADL(activities of daily living) status, increase risk for falls, recent change in mood; CAA #2. Cognitive Loss/ Dementia- hearing or vision impairment, lack of frequent reorientation, reassurance, reminders to help make sense of things. Resident has a [DIAGNOSES REDACTED]. CAA #5 Activities of Daily Living Functional status/Rehabilitation potential. Physical limitations such as weakness, limited range of motion, poor coordination, poor balance, visual impairment, or pain. Analysis of findings: resident (R1) uses wheelchair as primary mode of locomotion, resident is able to ambulate with staff assistance & use of rolling walker. Resident is experiencing occasionally incontinent of bladder. CAA # 11.Falls. Internal risk factors- Incontinence, anxiety disorder. Gait problem, such as unsteady gait ... Medications - Anti anxiety agents, Diuretics. Analysis of findings: Resident (R1) uses wheelchair as primary mode of locomotion. Resident is at high risk for (falls) due to unsteady gait. On 07-20-11 at 3:00 PM, the Restorative Nurse (E3) confirmed there was no restorative documentation found in the chart regarding R 1 ' s restorative program, progress or decline with her Activities of Daily Living. E 3 also confirmed R 1 was not in any Bowel & Bladder program. There were no specific interventions implemented to reduced resident risk for R 1's avoidable incidents. There were no documentation the facility evaluated R 1 for alternative mobility devices and this was confirmed by E 3 on 07-20-11 at 3:10 PM. R 1's fall care plan interventions includes: wedge on one side of the mattress ... Evaluate psych meds... Call light within reach ... Appropriate ambulation device. ..Monitor for changes in gait & ability to ambulate. ..Encourage resident (R1) to report falls ... Staff to offer resident to the toilet when awake at night ... R 1 ' s walking (ambulation) care plan reads: resident requires assistance from staff to ambulate due to unsteady gait. On 08-03-11 at 11:10 am the Physical Therapist (E4) stated " she (R1) was on Physical Therapy on Feb. 22 through April 8, 2011 because of multiple falls. The goal was to ambulate her for 200 feet with rolling walker (from room to dining room) with supervision twice a day. She was not safe to ambulate independently. Safety is the biggest concern. She is high risk for falls. She needs supervision when ambulating. The facility provided her with a wheelchair for mobility. The Physical Therapist said, " I didn ' t recommend that because of her [DIAGNOSES REDACTED]. She has very poor safety awareness. With supervision she's okay. She attempts to get up by herself if she can ' t wait for someone. For safety she needs supervision." On 07-20-11 at 11:20 AM, the Director of Nursing/E2 stated, " Her falls are mostly due to behavior and unsteady gait. "