Every finding on record at Aliya of Highwood

Based on observation, interview, and record review the facility failed to provide personal care in a safe manner and failed to supervise a resident on the patio to prevent a fall for 2 of 3 residents (R2, R3) reviewed for safety and supervision in the sample of 6. This failure resulted in R2 experiencing a fall from her bed on 3/11/26 during cares and sustaining a left femur fracture. The findings include:1. R2's face sheet showed she was admitted to the facility 1/28/2017 with diagnoses to include multiple sclerosis, anxiety disorder, hypertension, bipolar disorder, and paraplegia. R2's 6/9/2026 facility assessment showed she has no cognitive impairment, requires substantial to maximum assist for bed mobility, and is dependent on staff for transfers.R2's care plan initiated 8/20/2018 showed, I require assistance with bed mobility related to paraplegia, multiple sclerosis, osteoporosis, low back pain, cramps, and spasms. Interventions. Provide 1-2-person extensive assist.R2's care plan initiated 3/11/26 showed, I choose to refuse using the hoyer lift saying 'I don't like it', despite encouragement and redirection from staff.R2's care plan initiated 3/16/26 showed, the resident has displaced comminuted fracture of shaft of left femur.R2's care plan initiated 5/10/2018 showed, . ADL (activities of daily living) self-care deficit. Bed Mobility: Extensive assistance, One/two person physical assist; Transfer: total assist, Two plus persons physical assist.R2's care plan initiated 3/11/26 showed, [R2] is high risk for falls related to paraplegia, multiple sclerosis, osteoporosis, low back pain. Interventions: 3/11/26 Educate resident on safety awareness, educate on instructions of mechanical lift.R2's care plan initiated 2/6/2017 showed, I am at risk for injury related to weakness from Multiple Sclerosis. Assist with mobility as needed.R2's care plan initiated 9/10/2017 showed, I have an alteration in musculoskeletal status (Osteoporosis, paraplegia), potential for injury, pain, and other complications.R2's care plan initiated 2/8/2017 showed, I have Multiple Sclerosis affecting my mobility.R2's care plan initiated 9/10/2017 showed, I have paraplegia, and it affects my mobility and ADLs . Assist with ADLs and locomotion as required.The facility's State Report of Patient Incident with reported date 3/14/26 showed, . Fall with Serious Injury. On 3/11/26 at approximately 9:00 AM, resident was observed to have had a witnessed fall. No injuries observed. Resident declined pain. Resident stated to have pain to lower back on 3/12. On 3/13, resident was observed with edema on left knee and left ankle. Denied pain and declined x-ray. Resident agreed to have x-ray after further encouragement. Xray on left knee yielded mildly displaced fracture of the distal shaft of the femur. Summary of Investigation. Alert and oriented x 3, 2 person assist via mechanical lift. History of Multiple Sclerosis, age related osteoporosis, bipolar disorder, paraplegia, cramp and spasm. Resident was in bed in a supine position on top of mechanical lift sling. Resident quickly and unexpectedly grabbed the mechanical lift bar causing an imbalance which resulted in her rolling to the floor. Incident occurred too quickly for staff to intervene. Assisted to bed using 2-person mechanical lift. Resident had no prior history of sudden movement such as grabbing the mechanical lift bar. This investigation included education completed 3/11/26 through 3/13/26 for staff titled Use of Mechanical Lifts. The CNA (Certified Nursing Assistant) that was assisting R2 prior to her fall (V3) and the CNA who responded to the fall (V8) both received additional training on all transfers on 3/12/26.On 6/26/26 at 11:37 AM, R2 said she was in bed and V3 CNA was helping her when she was rolled out of the bed and onto the floor. R2 said she broke her leg that day.R2's 3/13/26 Nursing Note showed, Resident was readmitted back to facility post visit ER in [acute care hospital] . discharge diagnosis: fracture of the digital left femur and proximal Left tibia and proximal left fibula; verbal report was received from ER nurse. verbalizing the long post mold fiberglass splint was applied to the left leg. resident was referred to follow up with [orthopedic physician] in 2 weeks post hospital ER visit. On 6/26/26 at 9:32 AM, V3 CNA said she passed R2 her tray in the morning and she was moving about a lot and was excitable. V3 said she asked R2 if she wanted to transfer and she asked V8 for assistance with the transfer. V3 said she was putting the sling under R2 by herself and when she pushed R2 over to place the sling under her she started to move her hands a lot which caused her to roll out of bed and onto the floor. V3 said V8 was in the room standing in the corner with R2's wheelchair. V3 said she hadn't worked on R2's hall much and wasn't very familiar with her. V3 said she was sent home after R2's falls because when things like this happen, they have to investigate. V3 said this was just an accident. On 6/26/26 at 9:40 AM, V8 CNA said, [V8] asked me for help to transfer [R2] but I was in another room. I told her after I finished taking care of my patient I would come help. When I got inside the room to help, [R2] was on the floor next to the bed. The hoyer lift was next to [R2] she was not connected to it. She does move around a lot. She was mad when I went in there. I think she just rolled out of the bed.On 6/26/26 at 9:47 AM, V6 CNA said, We always need 2 people to do cares because [R2] is always leaning to the left, all the time, even in the wheelchair. We use two for people who are hard to do cares on, she is hard, so I normally use two people.On 6/26/26 at 11:02 AM, V5 (Previous Director of Nursing) said, I was making my rounds and the CNA said she was prepping the resident to transfer her to the chair. [R2] was on the floor, almost face down on the leg of the lift. I guess they had put her onto the sling, and they were positioning the mechanical lift above her. I guess she grabbed the bar, and it turned, and she went off the bed. It was just the one CNA putting her on the sling. I think she grabbed the bar and turned. The reason she got suspended was because of the investigation, not all CNAs are suspended for falls, just if there may be an issue with the transferring or something like that.On 6/26/26 at 12:55 PM, V2 DON (Director of Nursing) said [R2] rolled out of the bed during care. It could be an impulse from a resident that causes it and they can't predict what the resident is going to do. With [R2] being paralyzed, it puts her at an increased risk for rolling out of bed. It is okay to use one assist for her. If she is difficult to provide care for, they should ask for help but if the resident can roll over like that, one assist is fine. When the transfer process occurs, we would have the two CNAs. To prevent it from happening again we are emphasizing that the resident is a high fall risk. and understanding that she is a fall risk. We are reinforcing patient safety.The facility's policy and procedure with review date 5/1/26 showed, Activities of Daily Living. General: A program of activities of daily living is provided to prevent disability and return of maintain residents at their maximal level of functioning based on their diagnosis. The ability of each resident to meet the demands of daily living is determined by a Licensed Nurse.The facility's policy and procedure with revision date of 5/27/26 showed, Fall Prevention and Management. General: This facility is committed to maximizing each resident's physical, mental, and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventative strategies, and facilitate as safe an environment as possible. 2. R3's face sheet showed he was admitted to the facility 4/9/25 with diagnoses to include chronic congestive heart failure, primary osteoarthritis, hypertensive heart disease, cellulitis of left upper limb, and spinal stenosis. R3's facility assessment dated [DATE] showed he has moderate cognitive impairment, requires moderate assistance for most cares, and utilizes a wheelchair for mobility.R3's care plan initiated 6/20/26 showed, Resident is at high risk for falls. Educated resident safety precaution while using wheelchair. Ensuring resident wheelchair anti-tipping device is working properly. Encourage appropriate use of wheelchair. Alteration in musculoskeletal status related to arthritis-multiple sites, spinal stenosis, carpal tunnel syndrome, flexion deformity.On 6/26/26 at 11:41 AM, R3 said, I got lucky because I was wheeling myself outside, the grass was growing up behind the patio cement, I backed up my wheelchair and went off the edge of the patio. I was trying to get back up on the cement and I flipped my whole wheelchair backwards, and hit my head on the brick work. We had nobody on duty out there. There was no staff outside at all. They brought down two nurses and the two of them tipped me back up. they have got to do something about that, because it is too easy to drive off of the edge of the cement.On 6/26/26 at 11:14, V4 Activity Aide said, [R3] fell outside on the patio. I was in the activity room, but I was preparing for the next activity. When it happened, I was in the storage room that is in the activity room. I heard a resident, [R7] call me to let me know that a resident had fallen outside. I quickly went outside to check and [R3] was on his back with his head in the plants, and his wheelchair still under him. At the time, when he fell, the other activity aide that was there was bringing down residents for the next activity. I told her that [R3] had fallen, so she went upstairs and got a nurse. Two nurses came down. Both nurses and the other activity aide helped him back up in his chair, took him upstairs immediately to get checked. Usually there is someone out supervising the patio, but I was preparing the next activity, and the other aide was helping me bring down more residents.On 6/26/26 at 11:44 AM, R7 said she witnessed R3's fall. R7 said R3 backed himself up and he was stuck in the purple flowers. He kept going back and forth with his wheelchair and when I went to get help, he had already fallen backwards. I went to go tell the activity aide right away. When I went to get them, I was in the hall going toward physical therapy when V7 (Activity Aide) was coming off the elevator.R7's face sheet showed she was admitted to the facility 7/12/21 with diagnoses to include Type 2 Diabetes, obstructive sleep apnea, bipolar disorder, and spinal stenosis. R7's facility assessment dated [DATE] showed she is cognitively intact.On 6/26/26 at 11:54 AM, V9 LPN (Licensed Practical Nurse) said, I was on the floor and I didn't realize that [R3] was outside, no one notified me that he was outside. I was sitting down to chart. one of the activity aides had come up to the floor. She said [R3] had fallen outside. We went downstairs and there were a lot of residents outside. [R3] was on the right side of the patio with the wheelchair tipped over. I ran over there and I asked him if he hit his head, he said yes, his neck was tilted to the side, he was all over the place. As I was assessing [R3] I was trying to get a report from activities as to what happened. The two girls in activities didn't know what happened. [R3] said he was trying to get out of the way for someone, and he pushed his wheelchair too far back and got stuck in the bushes. I [V9] was told there were no staff out on the patio. I expressed my anger and said that is unacceptable, there is multiple people out here, I was mad. There needs to always be someone out there on the patio. The verbal residents told me [R3] was lying on the floor for a good 10 minutes. They were the two twin girls on that day. As far as where they were, I have no idea.

Based on observation, interview, and record review, the facility failed to ensure that activities of daily living (ADL) assistance was provided to residents that were dependent on staff assistance for three of 21 residents (R24, R13, R73) reviewed for ADLs in the sample of 21. This failure contributed to R24 obtaining a reddened, excoriated, and painful peri area. The findings include: 1. R24's admission Record shows he was admitted to the facility on [DATE], with diagnoses including hemiplegia, hemiparesis, muscle weakness, cognitive communication deficit, abnormal posture, and heart disease. R24's Minimum Data Set (MDS) dated [DATE], shows R24 has limitations in Range of Motion to both upper and lower extremities. R24 requires substantial/maximal assistance with personal hygiene and is dependent on staff for toileting hygiene. On January 12, 2026, at 11:55 AM, R24 was lying in his bed. There was a large yellow circle noted on the incontinence pad that R24 was laying on. There was a darker yellow circle noted around this yellow circle. At 12:01 PM, V8 Certified Nursing Assistant (CNA) was notified of the yellow circle on R24's incontinence pad. V8 went into R24's room and introduced herself to R24 as R24's CNA. V8 let R24 know she was going to clean him up. V8 undid the sticker tabs on R24's incontinence briefs. R24 had two incontinence briefs on. Both incontinence briefs were completely saturated with urine. There was a strong urine odor coming from the incontinence briefs. V8 said she did not know who put the two incontinence briefs on R24. V8 said this was the first time she went into R24's room, because the hospice CNA was just in R24's room. V8 said, maybe hospice put two incontinence briefs on R24. V8 said hospice was there at about 8:00 AM and performed incontinence care on R24. V8 wiped R24's peri area. R24's peri area was reddened and excoriated on both groin areas. R24 moaned and said ouch multiple times while R24 was wiping the red excoriated areas in R24's peri area. R24's buttocks was also reddened when V8 wiped it. V8 did not apply any skin protectant onto R24's reddened peri area or buttocks. V8 placed a new brief onto R24 and exited R24's room. R24's Care Plan revised on January 1, 2026, shows R24 has an alteration in skin integrity due to moisture associated skin damage. Factors that may inhibit healing: diarrhea, moisture. Apply barrier cream after each incontinent episode and as needed. On January 13, 2026, at 11:35 AM, V2 Director of Nursing (DON) said if a resident is found with two saturated briefs and a saturated incontinence pad, I would say that mean the resident has voided quite a bit. V2 said he would not expect a resident to be that saturated if the resident was checked on every two hours. V2 also said that residents should not have two incontinence briefs on. The facility's Incontinence Care policy reviewed May 2025 shows, Incontinence care if provided to keep residents as dry, comfortable and odor free as possible. It also helps in preventing skin breakdown. Apply barrier cream if appropriate. The facility's Activities of Daily Living policy reviewed May 1, 2025, shows, A program of activities of daily living is provided to prevent disability and return or maintain residents at their maximal level of functioning based on their diagnosis. Elimination: Adaptive equipment, assistance and instruction are given as required. 2.On 01/13/2026 at 10:30AM, R13 was sitting up in a reclining wheelchair. R13 was sitting up in a position that places pressure directly on the coccyx in a reclining chair. R13's chair was pushed back into the corner of the room. R13 did not have any engaging activity. R13's left, and right upper arms were contracted against the chest. R13 was wearing left, and right removable volar splints that covered the mid-forearm to the fingertips. At 2:10PM, R13 was sitting up in a position that places pressure directly on the coccyx in a reclining chair. R13 was pushed into the corner of the room. R13 did not respond to verbal stimuli. R13 did not have any engaging activity. At 2:20PM, V14 CNA-Certified Nursing Assistant and V21 CNA used a full body mechanical sling lift to transfer R13 from the reclining wheelchair to the bed. There were dark blue lines visible on the front and rear exterior of R13's incontinent brief. V21 CNA removed R13's incontinent brief. R13 smelled like urine. R13's incontinent brief was saturated with dark yellow urine. V21 CNA lifted R13's right gluteal to expose R13's coccyx. The boney prominence of the coccyx had a 1-centimeter open area with exposed granulation tissue. The surrounding skin was discolored with pallor at the coccyx and mottled redness surrounding. Search of the bed and incontinent brief showed no dressing was present. On 01/13/2026 at 10:30AM, V14 CNA-Certified Nursing Assistant said, R13 gets out of bed after breakfast. I lay R13 down after lunch. R13 is changed every two hours. On 01/13/2026 at 2:20PM, V14 CNA was asked, when was the last time R13 was changed. V14 CNA said, when I got her up at breakfast. (3 hours and 50 minutes) On 01/13/2026 at 2:15 PM, V13 LPN said, the blue lines show the incontinent pad is wet. The open area was reported to me by the night shift. 3. R73's admission Record shows he was admitted to the facility on [DATE], with diagnoses including hemiplegia, repeated falls, aphasia, and chronic kidney disease. R73's MDS dated [DATE], shows R73 requires substantia/maximal assistance with personal hygiene. On January 12, 2026, at 11:08 AM, R73 was observed and interviewed in his room. R73 had a splint to his left hand. R73's right hand had long fingernails on it. There was a large amount of dark substances underneath R73's fingernails. When R73 was asked if he would like his nails to be cleaned and cut, R73 said yes. R73's Care Plan created on January 13, 2026, shows, R73 requires assistance with daily care needs related to hemiplegia, assist resident with ADLs. On January 13, 2026, at 11:35 AM, V2 DON said he would have to double check how often staff clip and clean residents' nails. V2 said residents' hands should be washed before meals. V2 said he would expect residents' nails to be clean. This concern was discussed with the facility on January 13, 2026. On January 14, 2026, at 12:39 PM, R73's nails were cut and cleaned. The facility's Nail Care policy reviewed May 1, 2025, shows, To provided care and maintain hygiene for the resident's nails. Remove dirt from underneath fingernails. Nail care is offered and performed on the resident's shower day and as needed.

Based on observation, interview, and record review, the facility failed to ensure a resident was provided with a bed suited for his height for one of 21 residents (R24) reviewed for accommodation of needs in the sample of 21.The findings include: R24's admission Record shows he was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, muscle weakness, cognitive communication deficit, aphasia, and dysphagia. R24's weights and vitals summary shows he is 73 inches long. On January 12, 2026 at 11:55 AM, R24 was observed laying in his bed. The head of his bed was elevated slightly. R24's knees were bent and his left foot was off of the wooden foot end of the bed. R24 said he had a stroke, had back pain and said he could not move his right arm. When R24 was asked if he was comfortable in bed he said he was six feet 2 inches tall and a longer bed would be more comfortable. R24 placed his foot against the wooden foot of the bed to demonstrate if he placed his feet on his bed, his knees were bent upward. The was a small amount of mattress above R24's head. On January 13, 2026 at 11:25 AM, V2 Director of Nursing (DON) said he was not sure if a longer bed was available for R24. This concern was discussed with the facility on January 13, 2026. On January 14, 2026 at 10:50 AM, V1 Administrator said facility staff did not know that R24 wanted a longer bed. When V1 was asked if any staff noticed that R24's feet were hanging off the foot of the bed, V1 said she did not know. On January 14, 2026 at 12:35 PM, R24 was lying in a new bed. There was a four-inch-wide extender added to the foot of R24's bed. R24's legs were straight and his feet were not touching the foot of the bed. R24 said his new bed was Much more comfortable. Thank you so much.The facility's Accommodation of Needs policy reviewed October 15, 2025 shows, The facility will treat every resident with respect and dignity. It will evaluate and make reasonable accommodations for each individual's needs and preferences except when the health and safety of the individual or other residents would be at risk of endangerment.

Based on observation, interview and record review the facility failed to ensure no new recommendations were made after a resident's orthopedic follow up appointment. This applies to 1 of 21 residents (R34) reviewed for quality of care in the sample of 21. The findings include:R34's face sheet lists her diagnoses to include: fracture of left hand and fracture of superior rim of left pubis (pelvic fracture). On 1/13/26 at 10:08 AM, during the morning medication pass, V10 Registered Nurse (RN) was passing R34's medications. R34's husband was also in the room. She observed R34 did not have a cast on her left arm anymore. R34 and her husband both agreed that she had an orthopedic follow up appointment the day before where the cast was removed. V10 RN asked, if they gave her a sling or splint for her arm. R34's husband stated, they gave her a brace and told her to wear it whenever she wanted. V10 RN said ok, she also observed that R34's left wrist was still slightly swollen. R34 had nothing on her left wrist and was not wearing the brace. R34's after visit summary dated 12/8/25 shows, You were admitted after a fall and found to have a fracture of the distal radius and ulna of the left wrist. Also noted was superior and inferior pubic ramus fracture in the left pelvis. No surgery was recommended. You are advised to use a left wrist splint and use a platform walker to avoid bearing weight through the left wrist. R34's electronic medical record (EMR) shows, she had a follow up appointment for her left wrist on 1/12/26. The after-visit summary does not show any information about a brace for R34 to wear. The summary only shows, an occupational therapy referral. On 1/13/26 at 3:05 PM, V3 Assistant Director of Nursing (ADON) stated, he wasn't aware of any brace sent with R34 after her follow up appointment and he would look into it. At the end of the day on 1/13/26, R34's EMR did not show, any nurses notes in regards to her orthopedic follow up appointment. R34's progress notes with a late entry of 1/12/26 4:00 PM entered on 1/13/26 at 3:00 PM by V3 ADON shows, Spoke to NOD (nurse on duty) about what happen at the ortho appointment. NOD stated that they removed the splint and gave a referral to occupational therapy at local hospital. Copy of instruction/referral sent to our in-home PT/OT (physical therapy/occupational therapy) services. R34's progress notes dated 1/13/26 shows, Spoke to the resident and the husband, confirmed that the office gave a brace but no proper instruction from them. Contacted doctors office, spoke with operator that will sed a message to the nurse for call back regarding the instruction for the brace. At 1430 (2:30 PM), received a call back from the office. Spoke to nurse, stating that they gave a brace to the husband. The brace is like for a transitional support as needed for resident's left wrist. She can when she is active [SIC- statement is correct]. Requested for a written instruction from the office. At 1530 (3:30 PM), received an instruction that resident was evaluated in the ortho clinic. Resident will wear the Velcro brace for the next 2 weeks. The husband and resident instructed. Verbalized understanding. R34's faxed progress note received at 3:29 PM dated 1/13/26 shows, To whom it may concern, R34 is a patient under the care of orthopedic doctor. She was evaluated in the office yesterday. A Velcro wrist brace was provided. The patient can wear this for transitional support for the next 2 weeks. Okay to remove the brace throughout the day for gentle hygiene/when inactive.On1/14/26 at 11:38 AM, V2 Director of Nursing stated, they got the brace clarified by the doctor.On 1/14/26 at 11:42 AM, V9 Regional therapy manager stated, R34 should be wearing her brace all the time except during showers/hygiene. He also questioned, her weight bearing status and was requesting more information. He was concerned because the patient was originally no weight bearing to the left wrist and he wanted to clarify if she is allowed to bear weight now or not. That information was still not clear. R34's current order summary report shows, may wear Velcro brace at left wrist for transitional support every day and evening shift for wrist support for 2 weeks may remove throughout the day for gentle hygiene/when inactive. The order was entered on 1/14/26 (2 days after follow up appointment).

Based on observation, interview, and record review the facility failed to ensure R13 and R12 received the minimum necessary treatments and services to promote healing and to prevent infection and to prevent new ulcers from developing for 2 of 4 resident reviewed for pressure ulcers in the sample of 21.The findings include:1.On 01/13/2026 at 10:30AM, R13 was sitting up in a position that placed pressure directly on the coccyx in a reclining chair. R13's left, and right heels were not off loaded and the boney area of the left and right heel was resting directly on the leg rest. At 2:10PM, R13 was sitting up in a position that placed pressure directly on the coccyx in a reclining chair. R13 did not have a pressure reducing pad in the seat of the chair. R13's left, and right heel were not off loaded. R13's left, and right heel was resting directly on the leg rest. On 01/13/2026 at 2:28PM, V7 Wound Nurse pointed to two undated dressing to the left heel and two undated dressing to the right heel and said, R13 was admitted with the Stage 4 Pressure Ulcer and an Unstageable Pressure Ulcer to the left heel as well as the two Unstageable Pressure Ulcers to the Right heel. R13 should wear the pressure reducing heel boots when in the chair and when in the bed. On 01/13/2026 at 2:30PM, V13 LPN-Licensed Practical Nurse said, R13's pressure reduction boots are in the closet. On 01/14/2026 at 6:52PM, V22 Wound Doctor said, pressure ulcers should be off loaded. R13 has pressure ulcers to the left and right heels. Pressure reduction heel protectors are a standard order to ensure offloading of pressure to the wounds. R13's Physician's Orders on 01/13/2026 shows, initiated 12/21/25 may offload heels with heel boot protector or pillow as tolerated while in bed every shift for protection. R13's Care Plan on 01/13/2026 shows, initiated 12/11/2025, Off Load Heels. R13's Minimum Data Set, dated [DATE] shows, R13 has severe cognitive impaired. R13 is Dependent, the helper does ALL the effort. Resident does none of the effort to complete the activity of putting on and take off socks, shoes, or other footwear. On 01/13/2026 at 3:00PM, R13's Wound Notes dated 01/07/2026 shows, Stage 4 Pressure Ulcer, and an Unstageable Pressure Ulcer to the left heel as well as the two Unstageable Pressure Ulcers to the Right heel. The facility's Skin Management policy dated 05/2025 shows, no guidance for off-loading pressure ulcers. 2. R12's admission Record shows she was admitted to the facility on [DATE] with diagnoses including major depressive disorder, dysphagia, pain in right hip, anxiety disorder, and history of urinary tract infections. R12's Scale for predicting pressure injury risk dated January 9, 2026 shows she is at risk for developing pressure injuries. R12's Order Summary Report dated January 13, 2026 shows Treatment: Left big toe-cleanse with normal saline, pat dry and apply skin prep and cover with a dry dressing every day shift for wound care and Treatment: Sacrum-cleanse with normal saline, pat dry, apply medi honey, apply xeroform, cover with dry dressing every day shift. These orders were entered on January 8, 2026. On January 12, 2026 at 1:53 PM, V5 and V6 Certified Nursing Assistants (CNA) provided incontinence care to R12. R12 was turned onto her right side. There was a large wound to R12's sacral area. The middle of R12's wound was a dark color close to black. The area surrounding the dark area was red. R12 complained of pain when this area was wiped. There was no dressing in place to this wound. V5 said she did not know when the dressing came off of R12's wound. At 10:36 AM, V7 Licensed Practical Nurse/Wound Care Nurse came into R12's room to clean R12's wound and to place a dressing on it. R12 was tensing up and moaning while V7 was cleaning her sacral wound. R12 was asked if she had pain to her sacrum and she nodded her head yes. V7 said that R12 also had an unstageable wound to her left great toe. R12's heels were directly on the bed. V7 removed R12's left sock and there was a pencil eraser sized darkened area on the tip of R12's left great toe. There was no dressing in place. V7 said staff are offloading R12's heels with pillows. R12's Wound Assessment Details Report dated January 9, 2026 shows R12 has a stage 3 pressure injury to her sacrum that measures 10 cm X 10 cm and an unstageable pressure injury to her left big toe that measures 0.8 cm X 0.9 cm. On January 13, 2026 at 11:35 AM, V2 Director of Nursing (DON) said the purpose of treatments in place to pressure injuries are to add protection. V2 said he expects treatments to be in place to pressure injuries, and if they are not, then the wound could get worse. The facility's Skin Management: Monitoring of Wounds and Documentation policy reviewed May 2025 shows, It is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility.

Based on observation, interview and record review the facility failed to address an increase in resident's pain after a urinary catheter change. The facility also failed to ensure a urinary drainage bag was kept below the level of the bladder. This applies to 2 of 6 residents (R55 & R25) reviewed for urinary catheters in the sample of 21. The findings include:1. On 1/12/26 at 10:30 AM, R55 was sitting up in his wheelchair. He stated, he was having a lot of pain in is groin area. The nurse changed his urinary catheter a few days ago and he has been in pain since. He described the pain as feeling like his groin area was on fire and felt no one paid any attention to it. He did state, the facility had given him something for it however it didn't really help the pain, it was still there. R55 had a urinary catheter that was attached to his wheelchair. He stated, he had the urinary catheter because he could not urinate on his own. On 1/13/26 at 1:46 PM, R55 was lying in bed. He stated, he was still in pain in his groin area. They hadn't done anything different and were just giving him the medication. He stated, the medication helps a little. He asked if he could have something for the pain at that time. On 1/13/26 at 1:48 PM, V10 Registered Nurse (RN) stated, R55 has had pain in his groin area and they have been giving him tramadol (pain medication) for it. He has a urology appointment on Friday (3 days later). She received in report he was complaining of pain and nothing else had been done about it. On 1/13/26 at 1:59 PM, V11 Dietitian stated, she saw R55 that day and he was in a lot of pain. He refused to eat his lunch because his groin was hurting. On 1/13/26 at 3:05 PM, V2 Director of Nursing (DON) and V3 Assistant Director of Nursing (ADON) stated, R55 had pain and was seeing the urology on Friday. They were not sure if anyone had contacted the doctor about his pain, they would find out. On 1/14/26 at 11:10 AM, V2 DON stated, no one had contacted the doctor. They were treating him with the tramadol and going to send him to the urologist on Friday. they contacted V12 Nurse Practitioner (NP) after being asked if the doctor was notified about R55's pain on 1/13/26. He stated, V12 NP ordered another medication that helps with urinary burning, a urine analysis and renal ultrasound. R55 would also continue to go to his appointment with the urologist on Friday. On 1/14/26 at 12:38 PM, R55 was sitting up in his room eating lunch. He stated, he was still in pain. The pain felt like razor blades and burning all the way to his scrotum. R55's Minimum Data Set, dated [DATE] shows, he is cognitively intact. R55's electronic medical record (EMR) did not show, any complaints of pain by R55 even though staff were aware he was in pain and they were giving him pain medication for it. The same EMR shows, R55's urinary catheter was changed on 1/7/26. R55 stated, he had pain since the urinary catheter was changed (5 days prior). R55's care plan date initiated 4/23/25 shows, Focus: R55 requires use of an indwelling catheter (urinary catheter) r/t (related too) (neurogenic bladder) is at risk for of infection [sic- statement is correct]. Interventions: Monitor for s/s (signs/symptoms) UTI (urinary tract infection): flank pain, strong odor, increased temp, decreased output, hematuria; Notify MD (medical doctor) of abnormal findings. The facility's indwelling catheter care policy dated 1/2023 does not address what to do if a resident is having pain with or because of their urinary catheter. The facility did not provide any other polices for urinary catheters. The facility's change in resident condition policy dated 1/2023 shows, General: It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician and resident's responsible party of a change in condition. Policy: 1. Nursing will notify the resident's physician or nurse practitioner when: . e. it is deemed necessary or appropriate in the best interest of the resident. The facility's pain management policy dated 1/20233 shows, General: To facilitate and provide guidance on pain observations and management. To facilitate resident independence, promote resident comfort and preserve resident dignity. This will be accomplished through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. Guideline: The pain management program is base don a facility-wide commitment to resident comfort. Pain is defined as whatever the experiencing person says it is and exists whenever he or she says it does. Pain Management is defined as the proves of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Pain management is a multidisciplinary care process that includes the following: Observing for the potential for pain, Effectively recognizing the presence of pain, Identifying the characteristics of pain, Addressing the underlying causes of the resident's pain. Policy: 5. Licensed Nursing may notify the Health Care Provider of any new development of pain, change in pain, change in condition that could potentially cause pain, for pharmacological interventions based on the individual's pain factors. 2. On 01/12/2026 at 12:51PM, R25 was lying on the right side. R25 had a urinary catheter that was coming out the back left leg of the incontinent brief. R25's urinary catheter was not secured. The collection tube was suspended off the bed by the indwelling urinary catheter until it touched the corner of the bed. The tube continued down the side of the bed and looped up into the collection bed. The indwelling urinary catheter was held taut by the weight of the collection tubing. was lifted off the On 01/12/2026 at 12:54 PM, V8 CNA-Certified Nursing Assistant with the assistance of another staff member rolled R25 to his back and pulled up in bed. The indwelling urinary catheter stretched as R25 was moved to the head of the bed. V8 CNA then covered R25 with a blanket with the catheter tubing under R25's left leg. V8 CNA was notified of the position of the indwelling urinary catheter. V8 CNA uncovered R25 and lifted the urinary collection bag over the top of the bladder. Urine in the collection tube ran back into the indwelling urinary catheter. On 01/12/2026 at 12:54PM, V8 CNA said, R25 should no be lying on the urinary catheter tubing. R25 does not like to get out of bed. The securing device came loose. The securing device is applied by the nurse. The facility's Indwelling Catheter Care policy revised 05/2025 shows, secure and anchor the catheter by utilizing a leg strap or other device.

Based on observation, interview, and record review, the facility failed to manage residents' pain for two of 21 residents reviewed for pain management in the sample of 21.The findings include: 1 R24's admission Record shows he was admitted to the facility on [DATE] with diagnoses including hemiplegia, hemiparesis, muscle weakness, abnormalities of gait, cognitive communication deficit, dysphagia, and abnormal posture. R24's Care plan created on December 18, 2025 shows, Pain/Resident will participate in development of a personal pain management program. Resident will receive education related to pain management including non-pharmacological approaches related to medications and recording pain rating. R24's Care Plan initiated January 5, 2026 shows, Pain management as needed. R24's Order Summary Report dated January 13, 2026 shows, an order for acetaminophen 325 mg give two tablets by mouth every four hours as needed for mild pain. On January 12, 2026 at 11:55 AM, R24 was interviewed while he was laying in his bed. R24 said he had back pain and was not able to move his right arm. At 12:01 PM, V8 Certified Nursing Assistant (CNA) provided incontinence care to R24. V8 lifted R24's Right arm up to change his shirt, and R24 hollered and moaned and said his right arm hurt. V8 apologized to R24. V8 removed R24's t shirt. V8 then removed R24's soiled incontinence brief. R24's peri area was very reddened. V8 wiped R24's peri area with a towel and R24 moaned and moved side to side complaining that his peri area hurt while V8 was wiping him. R24's Medication Administration Record shows he did not receive any medication for pain on January 12, 2026. R24 did receive medication for pain on January 13, 2026 for pain rated at a 7/10 scale. 2. R12's admission Record shows that R12 was admitted to the facility on [DATE] with diagnoses including fracture of right pubis, malignant neoplasm of bladder, major depressive disorder, pain in right hip, anxiety disorder, and osteoarthritis. R12's Order Summary Report dated January 13, 2026 shows an order for acetaminophen 325 mg give two tablets by mouth every six hours as needed for pain and hydromorphone (narcotic) 1mg/1ml give 0.5ml by mouth every eight hours as needed for pain. On January 12, 2026 at 10:17 AM, V5 and V6 Certified Nursing Assistants (CNAs) were providing peri care to R12. When V5 removed R12's incontinence brief, there was a moderate amount of blood in her brief. V5 said they were not sure where the blood was coming from but believed it to be coming from R12's rectum. When R12 was asked if she had any pain, R12 used her hands to pat her abdomen. There were two urinary drainage bags noted coming from her back area (directly in her kidneys). R12 has a history of bladder cancer. V7 Licensed Practical Nurse/Wound Care Nurse provided wound care to R12's sacral area. There was a large, uncovered wound noted to R12's sacrum. When V7 was cleaning R12's sacral wound, R12 was tensing up and moaning. V6 was holding R12's hand and told R12 V7 was almost done. When V7 was finished and R12 was laid back on her back, R12 was asked if her sacrum area hurt and R12 nodded her head yes. V6 lifted R12's right lower extremity up so that R12's heel was visible and R12 said Ow. R12's Medication Administration Record dated January 1, 2026-January 31, 2026 shows R12 was given acetaminophen on January 9, 2026 for pain rated a 9/10 and given hydromorphone on January 11, 2026 for pain rated a 8/10. R12 was not given any pain medication on January 12, 2026. The facility's Pain Management policy reviewed May 2025 shows, To facilitate and provide guidance on pain observations and management. To facilitate resident independence, promote resident comfort and preserve resident dignity. They will be accomplished through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. The pain management program is based on a facility wide commitment to resident comfort. Pain is defined as whatever the experiencing person says it is and exists whenever he or she says it does. Pain management is a multidisciplinary care process that includes the following: effectively recognizing the presence of pain, addressing the underlying causes of the residents' pain, and monitoring the effectiveness of interventions; and monitoring approaches as necessary. The findings include: 1 R24's admission Record shows he was admitted to the facility on [DATE] with diagnoses including hemiplegia, hemiparesis, muscle weakness, abnormalities of gait, cognitive communication deficit, dysphagia, and abnormal posture. R24's Care plan created on December 18, 2025 shows, Pain/Resident will participate in development of a personal pain management program. Resident will receive education related to pain management including non-pharmacological approaches related to medications and recording pain rating. R24's Care Plan initiated January 5, 2026 shows, Pain management as needed. R24's Order Summary Report dated January 13, 2026 shows, an order for acetaminophen 325 mg give two tablets by mouth every four hours as needed for mild pain. On January 12, 2026 at 11:55 AM, R24 was interviewed while he was laying in his bed. R24 said he had back pain and was not able to move his right arm. At 12:01 PM, V8 Certified Nursing Assistant (CNA) provided incontinence care to R24. V8 lifted R24's Right arm up to change his shirt, and R24 hollered and moaned and said his right arm hurt. V8 apologized to R24. V8 removed R24's t shirt. V8 then removed R24's soiled incontinence brief. R24's peri area was very reddened. V8 wiped R24's peri area with a towel and R24 moaned and moved side to side complaining that his peri area hurt while V8 was wiping him. R24's Medication Administration Record shows he did not receive any medication for pain on January 12, 2025. R24 did receive medication for pain on January 13, 2025 for pain rated at a 7/10 scale. 2 R12's admission Record shows that R12 was admitted to the facility on [DATE] with diagnoses including fracture of right pubis, malignant neoplasm of bladder, major depressive disorder, pain in right hip, anxiety disorder, and osteoarthritis. R12's Order Summary Report dated January 13, 2026 shows an order for acetaminophen 325 mg give two tablets by mouth every six hours as needed for pain and hydromorphone (narcotic) 1mg/1ml give 0.5ml by mouth every eight hours as needed for pain. On January 12, 2026 at 10:17 AM, V5 and V6 Certified Nursing Assistants (CNAs) were providing peri care to R12. When V5 removed R12's incontinence brief, there was a moderate amount of blood in her brief. V5 said they were not sure where the blood was coming from but believed it to be coming from R12's rectum. When R12 was asked if she had any pain, R12 used her hands to pat her abdomen. There were two urinary drainage bags noted coming from her back area (directly in her kidneys). R12 has a history of bladder cancer. V7 Licensed Practical Nurse/Wound Care Nurse provided wound care to R12's sacral area. There was a large, uncovered wound noted to R12's sacrum. When V7 was cleaning R12's sacral wound, R12 was tensing up and moaning. V6 was holding R12's hand and told R12 V7 was almost done. When V7 was finished and R12 was laid back on her back, R12 was asked if her sacrum area hurt and R12 nodded her head yes. V6 lifted R12's right lower extremity up so that R12's heel was visible and R12 said Ow. R12's Medication Administration Record dated January 1, 2026-January 31, 2026 shows R12 was given acetaminophen on January 9, 2026 for pain rated a 9/10 and given hydromorphone on January 11, 2026 for pain rated a 8/10. R12 was not given any pain medication on January 12, 2026. The facility's Pain Management policy reviewed May 2025 shows, To facilitate and provide guidance on pain observations and management. To facilitate resident independence, promote resident comfort and preserve resident dignity. They will be accomplished through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. The pain management program is based on a facility wide commitment to resident comfort. Pain is defined as whatever the experiencing person says it is and exists whenever he or she says it does. Pain management is a multidisciplinary care process that includes the following: effectively recognizing the presence of pain, addressing the underlying causes of the residents' pain, and monitoring the effectiveness of interventions; and monitoring approaches as necessary.

Based on observation, interview and record review the facility failed to ensure medications ordered by a physician were available. This applies to 1 of 21 residents (R85) reviewed for pharmacy services in the sample of 21. The findings include:On 1/13/26 at 9:51 AM, V10 Registered Nurse (RN) was passing R85's morning medications. R85 had an order for dextromethorphan (cough suppressant) pills. V10 RN could not find the medication in the medication cart. She looked at the order and it showed, the medication was ordered from the pharmacy on 1/7/26. She stated, she would notify the doctor and find out what was going on after medication pass. On 1/14/26 at 11:31 AM, V2 Director of Nursing (DON) stated, the medication is an over the counter (OTC) medication so pharmacy does not send those medications. The facility provides them. The floor nurse that entered the order should have received a message from pharmacy saying they would not deliver the medication. They should have reported that to V2 DON or someone so they could get the medication.R85's January Medication Administration Record shows, dextromethorphan HBr oral tablet, 15 mg (milligrams), give 1 tablet by mouth at bedtime for TBI (traumatic brain injury) related mood instability for 3 days. The MAR shows, the medication was signed out and given by the nurses. The same MAR also shows, another order for dextromethorphan HBr oral tablet, 15 mg, give 1 tablet by mouth two times a day for TBI related mood instability with a start date of 1/10/26. The medication is signed out for the first dose on 1/10/26 at 9:00 AM but the rest of them are signed out as not available. The facility's ordering medications from the pharmacy policy does not address what to do if ordering a OTC medication from the pharmacy. The facility did not provide any other pharmacy policy.

Based on observation, interview and record review the facility failed to ensure a resident's pain patches were stored in a locked compartment and administered by a licensed nurse. This applies to 1 of 21 residents (R28) reviewed for medication storage in the sample of 21. The findings include:On 1/12/26 at 10:07 AM, R28 was lying in bed. There were medication patches lying on her bedside table. She stated, the patches were pain in her knees. She will put them on her knees when she was ready. During the conversation, she placed both patches below each knee. She stated, she always puts them on herself and will remove them later in the day. On 1/13/26 at 1:48 PM, V10 Registered Nurse (RN) stated, R28 puts her own patches on. The nurses give them to her and she does it herself. R28's January medication administration record (MAR) shows two separate orders, Lidocaine external patch 5% (lidocaine), apply to left knee topically in the morning for pain management. Lidocaine external patch 5% (lidocaine), apply to right knee topically for pain management. Both medications are signed out by the nurses as given. The facility provided a self- administration of medication assessment for R28 dated 6/27/24 that were for a different medication and not the lidocaine patches. They did not provide any other self-administration assessments. R28's electronic medical record did not show any other self -administration assessments or physician orders for the lidocaine patches and self administration. The facility's medication storage in the facility policy dated 1/2023 shows, General: Medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedure: .17. Residents who have been trained in self-administration will have access only to their individual drug supply.The facility's self-administration of medications and treatments policy dated 1/2023 shows, General: Self administration of medications and treatments are done to prepare a resident for discharge and to help the resident maintain their independence. The decision for self-administration is done by the interdisciplinary team. Guideline: 1. Self-administration of medications and treatments is determine by an order after determining the resident is able to self-administer.

Based on observation, interview and record review the facility failed to follow the menu serving size for the noon meal. This failure resulted in two residents not receiving the planned noon meal. This applies to 2 of 21 residents (R84 and R5) reviewed for dietary services in the sample of 21. The findings include: On 1/12/26 at 12:08 PM, during the noon meal service in the dining room. The noon meal being served was turkey casserole and chopped carrots. Two large steam pans of the turkey casserole dish were at the steam table with a white scoop. V17 (Cook) was plating the noon meal while staff were verbally requesting the type of meal (regular, puree or mechanical). Several staff were in line waiting for a plate, V1 (Administrator) went behind the steam table and began plating . V1 scooped heaping scoop sizes (a mound over the flat of the scoop) of the turkey casserole on the plates. V4 (Dietary Manager) was at the steam table preparing substitute meal requests. The last room cart was being plated by V17. V17 was scrapping the metal tray to fill the scoop and ran out of the turkey casserole. Staff told V17 they needed two more plates. V17 plated two plates with a hot dog and carrots, and placed in the cart. At 12:26 PM, V17 said she was short two servings, she said the turkey casserole was being served with the white scoop (6 ounces) because the meal had a starch and protein. She is not sure how they ran out of food; she was using the correct serving ladle. On 01/12/26 at 12:52 PM, V4 said during the noon meal they ran out of turkey casserole and two residents were served a hot dog. On 01/13/26 at 11:13 AM, V4 said on 1/12/26, R5 and R84 did not receive the regular meal. She said literally this is the only time it's happened running out of food. She said the right scoop was used, but the scoop sizes were to big. She said the scoop size should be flat and confirmed the scoop sizes were larger. On 1/13/26 at 1:49 PM, R84 was in his room and explained the facility ran out of the noon meal yesterday. R84 states, is that why, I was given a hot dog. Yesterday they handed me a tray and he thought that was the normal meal being served. Someone came in my room yesterday a female with long black hair someone higher up and told me they accidently gave me the hot dog. R84 told the staff he would have preferred the regular meal and she told me no, I wanted the hot dog.' He said he ate the hot dog because he thought that was the regular meal being served. I had to eat something. R84 said at optimal they should have given me a choice to choose an alternative and informed me of running out of meal. On 1/13/26 at 1:05 PM, V1 said she talked to R84. R84 said he was okay with the hotdog. V1 confirmed R84 was not informed of running out of turkey casserole and was not given a choice to choose an item from the alternative menu. The facility's Diet Spreadsheet Menu shows turkey casserole portion size is 6 oz (ounces), soft chopped carrots 4 oz and bread pudding.

Based on observation, interview, and record review the facility failed to provide R35 with food that accommodated R35's preferences for 1 of 21 residents (R35) reviewed for accommodations of food and drink preferences.The findings include:On 01/12/2026 at 1:02 PM, R37 was lying in bed. The head of the bed was at a 20-degree angle. R37's food tray was on the over bed table. There was an uneaten turkey casserole, uneaten carrots, one 120 milliliters cup of fluid. There was no health shake and no soup. On 01/12/2026 at 1:02PM, R37 stated, every day, every day they send the wrong thing. The facility never serves the food on the menu. I asked for soup, they did not send the soup. I cannot eat this food. On 01/12/2026 at 1:10PM, V19 RN said, dietary will usually send the health shakes up on the cart with the milk. V19 RN checked four dietary carts on the different hallways of the facility. V19 said, the kitchen did not send any health shake to the floor. On 01/12/2026 at 1:20PM, V20 Dietary Manager, looked at R37's dietary sheet and said, oh.well we don't have soup, the health shakes are on the carts with the milk. R37 dietary sheet dated 01/12/2026 shows, Supplements: HEALTH SHAKE-1each, Food Adds: SOUP-1 serving, NO CASSEROLES

Based on observation, interview and record review the facility failed to ensure staff were wearing PPE (personal protective equipment) in a residents room that is on contact isolation to prevent possible cross contamination. This applies to 1 of 21 residents (R91) reviewed for infection control in the sample of 21. The findings include:On 1/12/26 at 12:51 PM, V17 housekeeping and V19 Certified Nursing Assistant (CNA) were in R91's room. R91's room had a sign on his door that said, Contact isolation. V17 housekeeping was cleaning R91's room. She was only wearing gloves. V19 CNA was helping R91 and taking his dirty laundry out of his room. His laundry was in a yellow cinch bag and not an isolation bag. She carried the laundry out of the room, to the soiled utility room. She did not have any PPE on (gloves or gown). On 1/13/26 at 1:05 PM, V18 ICP (infection control preventionist) Nurse stated, if a resident is on contact isolation staff should wear gloves and a gown when they enter the room. R91 was the only resident on contact isolation in the facility. R91's current order summary report shows, Strict contact isolation precaution d/t (due too) c.diff (Clostridioides difficile (contagious bowel infection)). All needs to be rendered in the room to prevent cross contamination. The facility provided on 1/13/26 an isolation list that shows, R91 is on contact isolation for c-diff with a start date of 1/10/26 and a potential stop date of 1/20/26. The facility's transmission-based precautions policy dated 1/1/25 shows, General: Transmission Based Precautions are a second tier of basic infection control and are to be used in addition to standard precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Responsible party: All staff. Policy: Set up: Contact, Sign: sign on door, Hand hygiene: required, Gloves: required upon entry to room, must be removed before exiting, follow by hand hygiene, Gown: required, Mask: Only during high COVID-19 hospital admission levels or outbreak facility, N95 Mask: Required for residents in quarantine/COVID-19 positive.

4. On 7/2/25 at 9:30 AM R4 stated, The CNAs say they don't have any large diapers. They are given 5 large diapers per shift and they run out. I can change my own pull up so I use 1-2 of those a day and 6-8 diapers a day. This has been going on for a while. They say they are locked up in the supply room but then when the CNAs try to get them they say there aren't any. This happens on and off but for the past few months. They have some and then they don't. On 7/2/25 at 9:35 AM R5 stated, They do not have the large pullups- they keep bringing in the XL and they are too big. The CNAs say they do not have any. This is from last week. I go though 1-2 pull ups per day and 2-4 diapers. I can't understand how they can not have any! On 7/2/25 at 9:45 AM R7 stated, Staff tell me they don't have any. I need a size 3XL. This has happened quite often recently. I just got back from the hospital and I went about 3 days without any. They have the 2 XL and they have to double them up because they are not big enough and I take a water pill and I go a lot. On 7/2/25 at 1:10 PM R9 stated, I have talked to (V1- Administrator) directly and she has assured me that the diapers are here. I want the white ones. The green ones are a 2 x and they are too small - I need the 3 X. Over the weekend the nurse and the CNA said they are not here. (V1) told me maybe the CNAs are using the wrong sizes on residents and that is why they are running out. I have been here 9 months and this has happened every weekend to someone in this building- not always to me but this is about the 3rd time in the last 3 months. (V7- Central Supply) is always walking around here with diapers but then they say we don't have any. This past Sunday they said they looked in the storage area and they could not find them. (V1) said they are on site but maybe the CNAs are stashing the diapers. R4's Minimum Data Set (MDS) dated [DATE] shows she has no cognitive impairment. R5's MDS dated [DATE] shows she has no cognitive impairment. R7's MDS dated [DATE] shows she has no cognitive impairment. R9's MDS dated [DATE] shows he has no cognitive impairment. On 7/2/25 at 9:40 AM V5 stated, We have a problem with diapers. I have 12 residents and 3 of them are independent and do not use the diapers. They used to be in a storage room downstairs but now they are in the HR office and we can not get to them. They send 2 CNAs down in the morning to get a cart with all sizes of diapers on them and they distribute them to the CNAs. I get like 12 diapers for 8 hour shift- it is not enough. On 7/2/25 at 10:25 AM V6 (CNA) stated, All sizes of diapers are delivered before each shift- if there are not enough then we have to go to the HR office downstairs and get more. On 7/2/25 at 11:05 AM V7 (Central Supply) stated, We are still working out the kinks. At the beginning of each shift the Preceptor CNA comes down and gets the cart and with the diapers and distributes them to the other CNAs based on their assignment. Typically we have all sizes. Weekly the order is placed on Tuesday and it comes in on Wednesday. The past couple weeks I have been over budget and ordering more to make sure we have enough. Many residents hide or hoard them. We are just trying to control our supply. We order based on census. If we need more then we can have more. I didn't know they are asking for more. On 7/2/25 at 2:10 PM V1 (Administrator) stated, We have tried a couple different ways and I think the residents and the CNAs are hoarding them. We have diapers but sometimes they are using the wrong sizes on residents. I had (Supply company) come and re-measure everyone so we can order the sizes we need. They all want to see the bag of diapers in their room. Just yesterday, I gave R4 four of them and then later in the day she asked for another 4 and I had a staff go down and get them for her. When we first took over this building like so many residents had up to 10 packages of diapers in their room. I have talked to staff and we have a new system in place that we just started a few days ago. We also made an extra key at the nurse's station so the staff can have access to the supply downstairs. We will start giving them bags of them but again if we have to but they are all hoarding them. On 7/2/25 at 11:15 AM Surveyor observed the storage room with V7. V7 stated that the delivery of diapers was coming today. The storage room contained several packages of diapers from small to 3XL. Based on observation, interview, and record review the facility failed to ensure residents were treated in a dignified manner by other residents and also failed to ensure a resident's dignity by providing the preferred size incontinence briefs. This applies to 8 of 14 residents (R1, R4, R5, R7, R9, R10, R12, R14) reviewed for dignity in the sample of 14. The findings include: R14's Facesheet shows R14 has diagnoses that include, but are not limited to: insomnia, epilepsy, bipolar disorder, and conduction disorder. R14's Care Plan focus, created on 1/6/25 shows R14 has mental illness diagnoses and his care needs include aggression/anger/impulsivity management and psychiatric/mental health. R14's Care Plan also shows R14 may be short-tempered, anxious, easily annoyed. My behavior may include, verbal and socially inappropriate actions. These symptoms may represent feelings of anger, emotional distress, confusion, and insecurity. R14's Minimum Data Set (MDS) Section E dated 6/12/25 shows R14 exhibited verbal behavior symptoms directed towards others 1 to 3 days in one week. R1's MDS dated [DATE] shows he has no cognitive impairment. R9's MDS dated [DATE] shows he has no cognitive impairment. R10's MDS dated [DATE] shows he has no cognitive impairment. R12's MDS dated [DATE] shows he has no cognitive impairment. 1. On 7/2/25 at 10:47 AM, R12 said R14 has made fun of his weight and called him names. R12 said the behavior escalated over the last few weeks and the last interaction with R12 says R14 told R12, you're (R12) going to die and I'm (R14) going to piss on your grave. R12 said he did not tell any staff, including V1 (Administrator) of the incident. R12 said he has not experienced any emotional distress from R14 and he feels safe within the facility. On 7/2/25 at 1:15 PM, R9 said he has witnessed R14 making fun of R9's weight and is not sure if staff are aware. R9 also said he generally hears R9 be loud and rude to residents throughout the facility. 2. V3 (Assistant Director of Social Services) said on 6/24/25, V3 was in V3's office and overheard R14 yelling in the dining room during lunch. When V3 entered the dining room, V3 said R14 was yelling loudly at R1 and accusing R1 of being a thief. V3 said R1 was not retaliating and was calm. On 7/2/25 at 9:28 AM, R1 said the argument with R14 on 6/24/25 occurred after R14 asked R1 for coffee. R1 keeps instant coffee in R1's room and R14 asked R1 for some. R1 provided some in a cup for R14 and R1 stated when R1 handed R14 the cup, R14 looked into the cup, then back up at R1 and claimed it wasn't enough coffee. R1 told R14 that was all R1 was going to provide R14 and R14 started yelling and at R1. On 7/2/25 at 11:45 AM, R6, whose room is a few doors from the dining room, said she was not in the dining room at the time of the incident but heard yelling from inside her room. R6 said she went towards the dining room to see what was going on and R6 said when R6 entered the dining room, R14 was yelling at R1 and R1 was responding saying [R14] I don't want to talk to you in a calm manner. 3. On 7/2/25 at 11:55 AM, R10 said approximately two weeks ago, R10 and R14 had gotten into a verbal argument in the hallway. R10 said R14 has a smart mouth, they exchanged words, and went the other way with no further issues. On 7/2/25 at 12:23 PM, V1 said she was not aware of the allegations against R12 but knows R14 can be loud and very vocal towards others. At 3:35 PM, V1 said they have been trying and doing everything they can to prevent R14's behaviors including having R14 receive psych services, receive antipsychotic medications, have social services meet with him, and have him attend activities of his preferences. V1 agreed that R14 should not be going around and talking towards other residents in an undignified manner. Facility resident rights/dignity policy was requested on 7/2/25, but was not received.

Based on observation interview and record review the facility failed to ensure staff donned all applicable Personal Protective Equipment (PPE) for a resident with Enhanced Barrier Precautions (EBP) and sign was posted indicating EBP for 2 of 3 residents (R2, R1) reviewed for infection control in the sample of 3. The findings include: On 4/29/25 this surveyor was provided a list of residents on Enhance Barrier Precaution (EBP) that included R2 and R1 due to chronic wounds. V2 (Director of Nursing (DON) said all residents that were on EBP have an orange dot by their names outside their rooms and on EBP sign inside the room. 1. On 4/29/25, at 10:10 AM, An orange dot was noted by R2's name outside of his room. V3 (Certified Nursing Assistant-CNA) was in R2's room providing morning care to R2. A sign was noted on R2's head of the bed, Enhance Barrier Precaution. (EBP). R2 was being gotten up from bed. V3 (CNA) applied new incontinent brief, pulled his pants up then V3 transferred R2 from his bed to his wheelchair. V3 (CNA) proceeded to remove R2's soiled linens from the bed and applied new linens. V3 completed all these tasks with gloves on but not wearing a gown. At 10:30 AM, V3 (CNA) said R2 was on EBP precautions due to his wounds. V3 said she should have worn gown and gloves to prevent cross contamination. R2's careplan dated 3/17/25 documents, Resident is on enhanced barrier precautions. Patient on EBP per applicable infection prevention and control standards and regulation. Prevent the spread of infection. Maintain precautions as indicated. 2. On 4/29/25 at 9AM, R1's name outside of his door had no orange dot. There was no EBP sign inside his room. R1 showed this surveyor a dressing to his right knee and said this was an unhealing wound from surgery last March 2025. R1 said he just completed his oral antibiotics for possible wound infection. On 4/29/25 at 10:50 AM, V2 (Director of Nursing) said R1 has a surgical wound that requires daily wound dressing. R1 is on EBP. R1 should have a sign to show precautions to be observed due to EBP. R1 used to be in a different room. R1's EBP sign might have been removed during the move or when housekeeping was cleaning his room. V2 also said when providing care to EBP residents, staff should wear PPE of gloves and gown to prevent the spread of infection. On 4/29/25 at 1:30 PM, V6 (Infection Control Nurse) said an EBP sign should be placed in the room of an EBP resident to indicate the precautions the staff has to observe and what PPE to wear. R1's careplan with initiated date of 4/29/25 (today) as confirmed by V2 (DON) show, Resident is on enhanced barrier precautions . per applicable infection prevention and control standards and regulation. Prevent the spread of infection. Maintain precautions as indicated The facility policy entitled Enhanced Barrier Precaution with revision date of 3/20/24 documents, EBP expands the use of PPE and refer to the use of gown and gloves during high-contact resident activities that provide opportunities for transfer of MDRO's to staff hands and clothing. MDRO's may be indirectly transferred from resident to resident during these high contact care activities. Nursing home residents with wounds and indwelling devices are especially high risk of both acquisition and colonization with MDRO's. The use of gown and gloves for high contact resident activities is indicated . High contact resident care activities requiring gown and glove use that trigger EBP use include: Wound care, dressing, bathing/showering, transferring, changing linens, changing brief/assisting in toileting, devices use-central line, urinary catheter, feeding tubes .

Based on observation, interview, and record review the facility failed to double lock the controlled substance box in a medication cart. This applies to 5 of 5 residents (R56, R85, R46, R65, R2) reviewed for medication storage in the sample of 20 and 5 residents (R86, R58, R19, R43, R3) outside the sample. The findings include: The facility provided list of residents with controlled substances in the long term medication cart showed; R56 had morphine (narcotic pain medication); R86 had hydrocodone/acetaminophen (combination narcotic and over-the-counter pain medication); R85 had oxycodone (narcotic pain medication); R46 had zolpidem (prescription sleep medication); R58 had hydrocodone/acetaminophen, methadone (narcotic pain medication), and alprazolam (anti-anxiety medication); R65 had tramadol (narcotic pain medication); R19 had clonazepam (anti-anxiety medication), codeine/acetaminophen (narcotic pain reliever), and methylphenidate (stimulant medication); R43 had tramadol; and R3 had tramadol. Beginning on 11/12/24 at 11:03 AM through 11/12/24 at 11:31 AM, a continuous observation of V5's morning medication administration was conducted while he administered R16, R56, and R17's medications. At 11:08 AM, V5 prepared R16's medications he then entered R16's room without locking the medication cart. During his time in R16's room, V5 was not able to see his medication cart. At 11:14 AM, V5 prepared R56's medications and then entered her room without locking the medication cart. While V5 was in R56's room, he was unable to maintain visual contact with his medication cart. At 11:24 AM, V5 prepared R17's medications and then entered her room without locking the medication cart. V5 was not able to see his medication cart while he was in R17's room. At 11:31 AM, when V5 exited R17's room, the medication drawer, which housed the controlled substanc lockbox, was pulled out. The controlled substance lockbox was not locked and was able to be opened without the key. The lockbox housed numerous controlled substances. V5 stated this was the long-term medication cart. (During the time the cart was out of view, the controlled substances were not single or double locked.) At 11/13/24 at 1:39 PM, V2 Director of Nursing stated the medications in the controlled substances box are the residents' medications that are prone to abuse and therefore, most likely to be stolen. V2 said the purpose of double locking is to prevent theft of the residents' medications. The facility's Medication Administration policy (1/2023) showed, .never leave the medication cart open and unattended .

Based on observation, interview, and record review the facility failed to ensure a resident with a reasonable suspicion of mental illness was referred for a Level II PASARR screening for 1 of 1 residents (R2) reviewed for PASARR screening in the sample of 20. The findings include: On 11/13/24 at 10:46 AM, R2 was lying in his bed, watching TV. The surveyor asked R2 how it was going at the facility. R2 replied, Not great, but there's nothing you can do about it. R2 had a flat affect and continued to make negative statements. R2 was alert and oriented and able to express himself. The surveyor asked R2 if he had any specific complaints. R2 looked at the ground and stated, It is what it is. R2 didn't want to speak any further. R2's Facesheet dated 11/14/24 showed diagnoses to include, but not limited to: epilepsy, heart failure; bipolar disorder; and suicidal ideations. This document showed R2 was admitted to the facility 6/21/19. R2's Care Plan initiated 10/26/19 showed R2 is on antipsychotic medications due to bipolar diagnosis. R2's Care Plan initiated 5/20/20 showed he was on antidepressant medications. R2's Care Plan initiated 6/21/19 showed he had a mood problem related to bipolar disorder and had depression and passive death wishes. R2's Interagency Certification Screening Results dated 12/6/19 showed R2 had a reasonable basis for suspicion mental illness and had been formally diagnosed with bipolar disorder. This form showed that if yes was marked in Part II or III of the form (both boxes contained a yes answer), then the facility should refer R2 to the appropriate agent to complete Part IV (PASARR Level II screening). The facility was unable to provide R2's PASARR Level II screening or any documentation to show that the referral had been made to the appropriate agency. (R2 had resided at the facility for 5 years. The surveyor requested R2's PASARR Level II screening on 11/12, 11/13, and 11/14/24. The facility was unable to provide it.) On 11/14/24 at 10:41 AM, V7 (RN - Registered Nurse) said R2 has behaviors sometimes due to his bipolar disorder. V7 said R2 gets irritated with other residents and argues with other residents. V7 stated, We just try to keep him calm and redirect. V7 said R2 is alert and oriented and is able to make his needs known. On 11/14/24 at 11:04 AM, V6 (Social Services Director) said she had been in the role for 2-3 years, but was working in Admissions when R2 admitted to the facility (2019). V6 said the residents initial screening is completed at the hospital, prior to admission. V6 said if the Level I screening showed there is a reasonable suspicion of mental illness, then she will reach out to the referral agency for further evaluation. V6 said the purpose of the PASARR Level II was to further evaluate mental illness and ensure the resident is in the appropriate care setting and determines any additional services that are needed. V6 said she was unable to find a PASARR Level II screening for R2. V6 said she didn't know why it wasn't completed. V6 said there should have been a referral to the proper agency and she would see if she could locate any documentation (V6 was unable to provide documentation that R2's referral had been made.). V6 said once the referral is made, then the agency usually comes to complete the assessment within a week. V6 said if they did not show up to complete the assessment, then she would call to follow-up. V6 said she was not the Social Service Director when R2 was admitted and was unsure what happened. V6 said R2 should have had a PASARR Level II screening completed. On 11/14/24 at 11:19 AM, V2 (DON - Director of Nursing) said R2 was alert and oriented. V2 said R2 does have mood changes due to his bipolar disorder. V2 said she wasn't involved in the PASARR Level I or II screenings for residents. V2 stated, I think that's more Admissions or Social Services. The facility's PAS Screening Policy reviewed 1/2024 showed, In accordance with Illinois regulatory standards and recommended practices, this organization requests Level I (one) and Level 2 (two, where applicable) Pre-Admission Screening documents prior to the individual's arrival at the facility . Responsible Party: Admissions, Social Services. Policy: It is the policy of this facility to: 1. Comply with Illinois standards addressing the PAS assessment/screening process. 2. Request full and complete PAS materials (Level 1 and 2) from each referral source prior to admission. 3. Review the PAS documents to help assess/ascertain what type of problems, needs and issues need to be addressed to help the resident function at his/her maximum level of well-being. 4. Provide a copy of OBRA -1 and PAS-MR 1 (as applicable) to an identified clinician (in most cases this will be the Director of Social Service). 5. Place the PAS paperwork in the resident's business file . Procedure: 1. Facility representative shall request the complete screening packet from appropriate screening agency/referral source. 2. A copy of all materials received will be placed in the resident's business file and a copy may be placed in the chart at the discretion of administration. 3. The screening agency/referral source may be contracted, as indicated via phone/fax/email and asked to provide any missing or incomplete documents. Facility documentation should include information addressing the date, time, and person contacted. 4. As indicated, the screening material should be reviewed as a component of the assessment process and treatment suggestions/recommendations should be identified and appropriately addressed .

Based on observation, interview, and record review the facility failed to assess a new wound and failed to document treatment orders for 1 of 2 residents (R51) reviewed for non-pressure wounds in the sample of 20. The findings include: R51's face sheet printed on 11/14/24 showed diagnoses including but not limited to cellulitis of the left lower limb, lymphedema, morbid obesity, and heart failure. R51's facility assessment dated [DATE] showed moderate cognitive impairment. R51's wound summary report printed on 11/14/24 showed a history of venous stasis wounds to the left lateral and left posterior leg. The same report showed a history of lymphedema to the right leg. On 11/12/24 at 11:38 AM, R51 was seated on the edge of his bed and was wearing shorts. Both lower extremities were wrapped with bandages from just below the knees to the toes. R51 stated he has poor circulation to his lower legs and trouble with fluid build-up. R51 said the staff found a new sore on his right leg yesterday. R51 said he was unsure what was being done for the new wound. R51's electronic wound round reports were reviewed on 11/12/24 and did not show any open or active wounds. On 11/13/24 at 9:39 AM, R51 was seated on the edge of his bed and wearing shorts. Both lower extremities were still wrapped from the knee to the toes. R51 stated he was due for a shower in the afternoon and was very concerned about the new sore getting wet. On 11/13/24 at 1:26 PM, V8 (Registered Nurse) stated R51 has a history of open wounds but all have been healed. V8 stated there are no current skin issues and no orders for any wound treatments. V8 stated the wound care nurse wraps his legs a few times per week to treat his lymphedema but there are no active wounds. On 11/13/24 at 1:32 PM, V3 (WCN-Wound Care Nurse) stated R51 has his leg wraps changed three times per week. V3 said R51 has a history of venous ulcers and was being followed by the wound doctor in the past. V3 said since he is healed, the doctor no longer sees him at the weekly visits. V3 said R51 has no current skin issues and nothing has been reported to her. V3 said any new skin changes should be reported to her immediately and the wound doctor needs to be notified. V3 said R51 is cognitively alert and only has slight short term memory problems. On 11/13/24 at 1:42 PM, R51 was lying on his bed and V3 (WCN) unwrapped both bandages on his lower legs. R51 had a 4 inch by 4 inch dressing on his right lateral calf area. V3 said it was the first time she was aware of any skin issues and removed the dressing. An oblong, egg size fluid filled blister was under the it. V3 said the blister should have been reported to her the day it was found. V3 said she did not know how it was being treated or when it was discovered. V3 said the wound looked to be venous related. V3 said the wound doctor should have been notified and a treatment order should have been received. V3 stated there are no wound orders or wound assessments in R51's medical record. On 11/13/24 at 2:48 PM, V2 (Director of Nursing) and V7 (Registered Nurse) stated they both were aware of R51's blister on his right leg on 11/11/24 (two days ago). The nurses said it was discovered when the leg wraps were being changed. The nurses said the nurse practitioner was notified and an order to cover it was obtained. The nurses stated they failed to document the new order or perform any assessment of the new skin issue. On 11/14/24 at 11:20 AM, V3 (WCN) stated the wound doctor just looked at R51's leg yesterday and a new treatment order was obtained. V3 stated yesterday was the first time the wound was assessed. V3 said the wound should have been assessed the day it was found, and treatment orders placed directly in the medical record. V3 stated R51 had open sores on his lower legs in the past and is already a high risk for more to develop. V3 said the assessment is important to have an ongoing comparison of any improvement or decline. Clearly documented orders ensure the next shift's nurse can follow through and do the treatment properly. R51's wound evaluation dated 11/13/24 (two days after identified) showed a lymphademic wound to the right lateral leg measuring 1.5 x 4.5 centimeters with a duration of greater than two days. The report showed an order for xerofoam gauze three times per week and as needed for 30 days. The facility's Skin Management policy review dated 1/2024 states: It is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility.

Based on observation, interview, and record review the facility failed to safely transport a resident in a wheelchair for 1 of 4 residents (R83) in the sample of 20. The findings include: On 11/12/24 at 10:08 AM, R83 was sitting in his wheelchair, at the nurses' station, drawing in a sketch book. V6 (SSD - Social Service Director) asked R83 if he wanted to go participate in activities. V6 stood and pushed R83's wheelchair down the length of the hall to the elevator. R83 did not have foot pedals on his wheelchair. R83 was wearing running shoes. Initially, R83 crossed his ankles and attempted to lift his feet under the wheelchair, with his toes pointing toward the ground. R83's toes hit the ground multiple times, slowing the transport. V6 reminded R83 to lift his feet and stopped. R83 then moved his feet forward, easily lifting the left foot 2 inches off the floor, but was unable to consistently hold his right foot off the ground. R83 put his right foot down multiple times from the middle of the hallway to the elevator. R83's Facesheet dated 11/14/24 showed diagnoses to include, but not limited to: Alzheimer's; restlessness and agitation; epilepsy; and cerebral amyloid angiopathy. This document showed R83 was admitted on [DATE]. R83's facility assessment dated [DATE] showed he had severe cognitive impairment and required substantial/maximal assistance from staff for personal hygiene, sit to stand and transfers. R83's Admission Evaluation dated 10/14/24 showed he was at High Fall Risk. R83's Progress notes showed he had a fall on 10/20/24 and 11/8/24. On 11/14/24 at 10:41 AM, V7 (RN - Registered Nurse) said R83 had dementia was very confused. V7 said R83 was at high risk for falls and required frequent monitoring. V7 said R83 can self-propel his wheelchair, but if staff are pushing him in the wheelchair, then he needs to have foot pedals on the wheelchair. V7 said R83 had a tendency to put his feet down. V7 said using foot pedals on R83's wheelchair, during transport, will prevent him from putting his feet down and possible getting injured or falling from the chair. V7 stated, It's a safety thing. On 11/14/24 at 11:19 AM, V2 (DON - Director of Nursing) said if a resident is being pushed in a wheelchair by staff, then the wheelchair should have food rests in place for safety. V2 said the purpose of foot rests is to prevent any injury to the resident's leg or reduce the risk of falls. A policy for Safely Transporting a Resident in a Wheelchair was requested and not provided.

Based on observation, interview, and record review the facility failed to check placement of a gastrostomy tube (G-tube) prior to performing water flushes for 1 of 1 resident (R35) reviewed for feeding tubes in the sample of 20. The findings include: R35's face sheet printed on 11/14/24 showed diagnoses including but not limited to chronic respiratory failure, cerebral infarction, dysphagia (difficulty swallowing), use of a tracheostomy tube (tube through neck and trachea for breathing) and gastrostomy tube (tube through abdomen to supply liquid nutrition to stomach). R35's facility assessment dated [DATE] showed severe cognitive impairment and staff assistance for all activities of daily living. R35's November 2024 physician orders showed an order start dated 8/21/24 for: Enteral feed order every 4 hours rec (receive) 200 milliliters flush every 4 hours. On 11/13/24 at 2:08 PM, V8 (Registered Nurse) stated R35 receives water flushes through the G-tube every shift and medications via the G-tube. V8 gathered supplies for the flush and went to the bedside. V8 connected a piston syringe onto the G-tube and poured the water flush directly into the tube. V8 did not check for tube placement prior to performing the flush. On 11/14/24 at 10:36 AM, V2 (Director of Nurses) stated staff should be checking for the proper placement of the tube before inserting any medications or water flushes into it. It is important to ensure it is open and in the proper position. The resident is at a high risk of aspiration if it is not in the stomach. Nurses should be checking gastric residual levels or listening for an air swoosh. V2 said our policy does not directly state how to check placement, but it is necessary. It is important and is a standard of safe nursing care. The facility's Enteral Tube Medication policy dated 1/2023 states: The facility assures safe and effective administration of enteral formulas, route and methods of administration .

Based on observation, interview, and record review the facility failed to follow manufacturer instructions regarding the use of an insulin pen. This applies to one resident (R21) reviewed for insulin administration outside the sample of 20. The findings include: R21's Admission Record showed he had type II diabetes. R21's Order Summary Report (Physician Order Sheet) showed an active order for 5 units of rapid-acting insulin to be given at meals. In addition to the 5 units of rapid-acting insulin, R21 order sheet showed an order for blood sugar dependent (Sliding Scale) insulin. The order showed 8 units of the same rapid-acting insulin should be given for a blood sugar between 301 and 350. On 11/12/24 at 12:41 PM, V5 Registered Nurse (RN) began preparing R21's rapid acting insulin pen. V5 removed the pen cap, dialed in 2 units of insulin, held the pen horizontally and depressed the injection button. V5 then selected 2 more units, held the pen horizontally, and depressed the injection button. (During this priming process, the needle was not attached.) V5 then attached the needle and selected 13 units of insulin for a blood sugar reading of 311. The manufacturer instructions for the rapid-acting insulin pen (Dated July 2023) showed, Step 4: Push the capped needle straight onto the pen and twist the needle on until it is tight. The instructions continue with steps 5 and 6 which were removing the outer caps of the needle. The instructions continued, Step 7: Turn the dose selector to select 2 units. Step 8: Hold the pen with the needle point up. Tap the top of the pen gently a few times to let any air bubbles rise to the top. Step 9: Hold the pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin repeat steps 7 to 9. If you still do not see a drop of insulin change the needle and repeat steps 7 to 9 . On 11/13/24 at 1:39 PM, V2 Director of Nursing stated the purpose of priming the insulin pen is to ensure the resident receives the full dose of insulin. V2 said the needle should be attached prior to priming the insulin pen. V2 said the purpose of holding the pen vertically is to expel any bubbles so the resident receives the full dose of insulin.

Based on observation, interview, and record review the facility failed to develop and implement interventions to prevent pressure injuries. The facility also failed to identify two pressure wounds prior to becoming unstageable. This failure resulted in R1 developing two unstageable pressure injuries to her heels. The facility also failed to accurately implement pressure injury prevention interventions for two residents (R3,R4) with pressure injuries. This applies to 3 of 3 residents (R1, R3, R4) reviewed for pressure injuries in the sample of 6. The findings include: 1. R1's Admission Record (Face Sheet) showed an original admitted [DATE] with diagnoses to include dementia, Parkinson's disease (a brain disorder that causes a lack of coordination and uncontrollable movements), diabetes type two, weakness, and hypertension (High blood pressure). R1's 7/24/23 Minimum Data Set (MDS) showed she used a wheelchair for mobility. The MDS showed she required extensive assistance of two people for bed mobility (turning from side to side and positioning herself in bed), she required extensive assistance of one person for locomotion on and off the unit (the amount of assistance she required after she was in her wheelchair), and she required extensive assistance of two people for dressing. R1's 9/11/23 Nurses Note from 10:10 AM showed, Upon assessment, noted resident with blister on right heel and diabetic ulcer on left heel . Resident is alert but has confusion and forgetfulness at times. Resident was complaining of tight shoes but still insisting to use it; eventually, resident developed blisters and opened up. Family is aware that she's wearing tight shoes. Resident is encouraged not to use the shoes anymore, advised family to bring a larger pair of shoes . (The note was authored by V3 Assistant Director of Nursing/Wound Care nurse.) R1's 9/12/23 Nurse Practitioner wound note showed, Patient has left and right unstageable pressure ulcers identified . The note showed the left heel had a .medium amount of necrotic (dead) tissue within the wound bed . The note stated the right heel had .medium amount of necrotic (dead) tissue within the wound bed . On 10/25/23 at 1:15 PM, V6 Licensed Practical Nurse stated, .I did tell her daughter (V12 R1's daughter) that she should have slippers because her shoes were too tight. The resident still wanted to wear her shoes anyways but I told the CNAs (Certified Nursing Assistannts) not to put them on her. I'm not sure when she stopped wearing the shoes, if it was before or after the wounds developed but she did have the slippers after the pressure ulcers developed. If I want to know the pressure ulcer interventions for a resident, I go to the orders or the care plan. Those are the only places I can think of to look for them . On 10/25/23 at 1:35 PM, V8 Certified Nursing Assistant (CNA) stated it had been some time since she provided care for R1, but she did recall R1. V8 said she required a mechanical lift to get out of bed. V8 said, I remember she always wanted to wear her purple shoes. She also did have house slippers, she had them for a long time. I don't recall ever being told that we couldn't use her shoes. On 10/25/23 at 1:20 PM, V7 CNA stated R1 had tennis shoes that she liked to wear. V7 said she does not recall ever being told R1 should not wear her shoes. On 10/25/23 at 2:30 PM, V12 R1's Daughter said she saw her mother often, and on September 9th or 10th, 2023 (Saturday or Sunday) she saw her mother in her room. V12 said her mother was wearing her shoes and she could see her socks were bloody. V12 said she took off her mother's shoes and socks and there was no dressing in place. V12 said, Yes, she was wearing her shoes and not her slippers .[V6] did talk to me about her shoes and she said she needed slippers, but it was up to them (facility staff) to put them on. The CNAs would always just put on the her gym shoes and not use the slippers. No one ever said the shoes were too tight, but she had slippers, that's why I got the slippers because they were easier for the staff to put on. They never should have put the gym shoes on her with those wounds, that's just common sense. She was not able to make any decisions for herself prior to developing the wounds, I would have to make her decisions. If the staff had asked me if they could take away her shoes, I absolutely would have been okay with taking them away even if she liked to wear them. I could have gone up and talked to her (R1) about why they needed to take them (shoes) away, but no one asked me to do anything like that. Especially if they were going to hurt her. The CNAs just kept putting her in the gym shoes even though she had the slippers. On 10/25/23 at 10:30 AM, V3 Wound Care Nurse/Assistant Director of Nursing stated, on 9/11 she had developed bilateral heel wounds. Prior to that the CNA's were saying her shoes were too tight, but she wanted to use the same shoes and I talked to [V12] about bringing bigger shoes. She had two pairs of shoes, but they were the same size, so I told the CNA to use the socks and not the shoes. V3 stated she believes she may have been notified of the heel wounds on the 9th or 10th of September and then assessed the wounds on 9/11/23 when she came to work. V3 stated R1 was at risk for pressure wound development, due to her history. She is diabetic, she has Parkinson's disease, she is hypertensive (high blood pressure), she has weakness, and dementia . V3 said, while reviewing her documentation and the images of the wounds, the right heel wound should have been identified prior to becoming unstageable. On 10/25/23 at 1:57 PM V3 stated, .She should have had a pressure ulcer prevention care plan in place prior to developing pressure wounds. I do not see that she has one. They (care plans) are important, it is the backbone of their care, so we know what our plans are for the resident, and we are addressing the medical problems they have. I would agree that the care plan is an effort of us sitting down and looking at a [R1's] medical history and addressing the issues that would lead to her developing pressure. V3 was asked what she believed caused the wounds, to which she replied, One thing to consider is her tight shoes and the CNA's have difficulty putting on her shoes. The CNA's told me about it (tight shoes) and I'm not sure when I discussed it with [V12]. I tried to find her bigger shoes. I do think the shoes were a contributing factor to her getting the heel wounds. V3 said, When the CNA said the shoes were tight, I think I put foam in her shoes (V3 added more material inside an already tight shoe), but she kept on wearing them. She did wear the shoes until she got the wounds. She stopped when she got the blisters. V3 said she did not take away the shoes because, She (R1) loved them. She was confused at this point. She had hallucinations .I did not discuss with [V12] taking away the shoes but we did discuss with [V12] about getting a new pair of shoes. She has the right to wear the shoes. [R1] would not have been able to make her own decisions. I think we should have asked the daughter about taking away the shoes until she (V12) could get her (R1) new shoes. On 10/25/23 at 2:55 PM, V11 Wound Care Nurse Practitioner stated a pressure wound occurs when tissue, generally over a bony prominence, is in prolonged contact with a surface for an extended period. V11 said certain areas are more prone to developing pressure wounds such as the heels and the sacrum (lower back area.) V11 said certain health conditions put a resident at higher risk such as Parkinson's, dementia, diabetes, hypertension, and weakness. V11 said, based on R1's history, she was at risk for developing pressure injuries. V11 said shoes that are too tight can cause pressure injuries. V11 said, For residents with these comorbidities it is important to have a care plan for prevention. Once they have the care plan then they should put interventions in place to prevent the pressure injury. Interventions like repositioning and offloading of the heels. It is possible they can still develop pressure wounds even with interventions in place. It is better to try and prevent the wound before it develops. Depending on the situation it can be difficult to prevent pressure wounds, but they should still try. I would have a concern, if a resident with DM, Parkinson, dementia, and hypertension had shoes that are too tight, my recommendation would be to get them another pair of shoes and get podiatry on board to get them a different pair of shoes. They should wear slippers instead of shoes that are too tight. No one made me aware that she had shoes that were too tight, either before or after she developed the heel wounds. V11 said, They should have been able to notice them (heel wounds) prior to them becoming unstageable. On 10/25/23 at 11:50 AM, R1's pressure ulcer prevention care plan, prior to 9/11/23, was requested. On 10/25/23 at 3:50 PM V1 Administrator stated, R1's Care Plan Focus area skin integrity was R1's pressure ulcer prevention care plan. R1's care plan (Provided by the facility following the request on 10/25/23) showed I have a potential for impairment to skin integrity r/t (related to) aging/disease process, decreased mobility, incontinence The care plan was initiated 6/13/22. The following list of interventions is all inclusive and were initiated on 6/13/22: Avoid scratching and keep hand and body parts from excessive moisture. Keep fingernails short. Keep skin clean and dry. Use Lotion on dry skin. Protective skin barrier cream as ordered. Provide diet as ordered and monitor nutritional status and dietary needs. (The care plan does not discuss shoes, air mattress, or offloading of heels.) R1's Orders showed an order to Use Pillows to off load bilateral (both) heels. The order stopped on 7/21/23. The next order to off load heels was not until the wounds were found on 9/11/23. R1's September 2023 Treatment Administration Record showed no heel offloading or air mattress interventions. The facility's Comprehensive Care Plan policy showed, the purpose is To develop a comprehensive care plan that directs and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The policy showed, The comprehensive care plan must describe the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Any services that would otherwise be required but are not provided due to the resident's exercise of rights, including the right to refuse treatment . The facility Pressure Ulcer Prevention policy (Revised 1/15/18) showed, the purpose is To prevent and treat pressure sores/pressure injury Inspect the skin several times daily during bathing, hygiene, and repositioning measures .Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protecting bony prominences as indicated . 2. R3's Admission Record (Face Sheet) showed an original admitted [DATE] with diagnoses to include: myasthenia gravis (Muscle weakness), dementia, heart failure, and blood clots in her legs. R3's 8/17/23 Significant Change Minimum Data Set (MDS) showed she had severe cognitive impairment. The MDS also showed she required extensive assistance of two people for bed mobility and transfers. R3's 10/17/23 Progress Note (Wound Note by V11 Nurse Practitioner/Wound Care) showed she has unstageable pressure ulcer to the right and left heel. R3's Order Summary Sheet showed an order to Ensure low air loss mattress functioning properly to be done every shift. The order was active as of 10/25/23 and was started on 10/16/23. R3's October 2023 Treatment Administration Record showed, beginning the night of 10/16/23, an order to Ensure low air loss mattress functioning properly. The order was documented as being done three times a day; 10/21/23 through 10/25/23. On 10/20/23 at 11:54 AM, R3 was in bed, her low air loss mattress was on and set to 400 pounds. On 10/24/23 at 2:25 PM, R3 was asleep in bed, her low air loss mattress was on and set to 400 pounds. On 10/25/23 at 9:35 AM, R3 was in her reclining high back chair and her low air loss mattress was set to 400 pounds. R3's air mattress had a digital read out with push buttons to adjust the pressure. R3's electronic charting showed her weight on 10/4/23 was 156.3 pounds. (A difference of 243.7 pounds between her measured weight and the low air loss mattress.) On 10/25/23 at 1:15 PM, V6 Licensed Practical Nurse (LPN) stated she was the nurse for R3's hallway. V6 stated she does not check or adjust air mattress pressure. V6 said she believes the pressure is set when the air mattress is delivered. On 10/25/23 at 1:20 PM, V7 Certified Nursing Assistant (CNA) stated she does not adjust or check air mattress pressures. On 10/25/23 at 10:30 AM, V3 Assistant Director of Nursing/Wound Care Nurse stated, the low air loss mattresses are used for residents at risk of developing pressure injury and for those residents with pressure injuries. V3 stated, the air mattress helps to distribute the pressure across the residents entire body instead of localized areas of the body. V3 said the air mattresses do have settings and one of those settings is a weight setting. V3 said the setting should be set as close as possible to the resident's actual weight. V3 said a pressure too high will make the mattress too firm and not work as intended. V3 did not know why R4's air mattress was set incorrectly. V3 said she checks all air mattresses in the facility once a week. V3 said all residents with an air mattress should have an order and a corresponding treatment intervention to be done once a shift. V3 said the purpose of the intervention is for nursing staff to verify the air mattress is functioning properly and it is set to the resident's weight. The facilities Pressure Ulcer Prevention policy (Revision 1/15/18) showed, .Specialty mattresses such as low air loss, alternating pressure may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple Stage 2 wounds or one or more Stage 3 or Stage 4 wounds . 3. R4's Admission Record (Face Sheet) showed an original admitted [DATE] with diagnoses to include: dementia, diabetes, and chronic obstructive pulmonary disorder (COPD). R4's 9/29/23 Quarterly Minimum Data Set (MDS) showed he required extensive assistance of two people for bed mobility. R4's 10/17/23 Progress Note (Wound Note by V11 Nurse Practitioner/Wound Care) showed he had a 13 centimeter by 8 centimeter wound to his lower back that had 11 centimeters of tunneling. R4's Order Summary Sheet showed an order to Ensure low air loss mattress functioning properly to be done every shift. The order was active as of 10/25/23 and was started on 10/16/23. R4's October 2023 Treatment Administration Record (TAR) showed, beginning the night of 10/16/23, an order to Ensure low air loss mattress functioning properly. The TAR showed this intervention was documented as being done three times a day; 10/21/23 through 10/25/23. On 10/20/23 at 12:30 PM, R4 was in bed, his low air loss mattress was on and set to 300 pounds. On 10/24/23 at 2:30 PM, R4 was in bed, his low air loss mattress was on and set to 300 pounds. The adjustment for R4's air mattress weight setting was a dial type with a range of weights. On 10/25/23 at 9:50 AM, V3 Assistant Director of Nursing/Wound care nurse provided wound care for R4. At the completion of R4's wound care, V3 doffed her personal protective equipment and exited the room. R4's air mattress was set to 320 pounds. R4's electronic charting showed his weight on 10/4/23 was 179.0 pounds. (A difference of more than 120 pounds between his measured weight and the low air loss mattress weight setting.) On 10/25/23 at 1:15 PM, V6 Licensed Practical Nurse (LPN) stated she was the nurse for R4's hallway. V6 stated she does not check or adjust air mattress pressure. V6 said she believes the pressure is set when the air mattress is delivered. On 10/25/23 at 1:20 PM, V7 Certified Nursing Assistant (CNA) stated she does not adjust or check air mattress pressures. On 10/25/23 at 10:30 AM, V3 Assistant Director of Nursing/Wound Care Nurse stated, the low air loss mattresses are used for residents at risk of developing pressure injury and for those residents with pressure injuries. V3 stated, the air mattress helps to distribute the pressure across the residents entire body instead of localized areas of the body. V3 said the air mattresses do have settings and one of those settings is a weight setting. V3 said the setting should be set as close as possible to the resident's actual weight. V3 said a pressure too high will make the mattress too firm and not work as intended. V3 did not know why R4's air mattress was set incorrectly. V3 said she checks all air mattresses in the facility once a week. V3 said all residents with an air mattress should have an order and a corresponding treatment intervention to be done once a shift. V3 said the purpose of the intervention is for nursing staff to verify the air mattress is functioning properly and it is set to the resident's weight. The facilities Pressure Ulcer Prevention policy (Revision 1/15/18) showed, .Specialty mattresses such as low air loss, alternating pressure may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple Stage 2 wounds or one or more Stage 3 or Stage 4 wounds .

Based on observation, interview, and record review the facility failed to follow recommended guidelines from Centers for Disease Control (CDC) by not wearing Personal Protective Equipment (PPE) for new admissions on transmission based precautions (contact/droplet precautions). These failures have the potential to infect high risk residents with COVID-19 and spread the disease of COVID-19 to negative residents. This applies to all 75 residents residing in the facility. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on March 15, 2021 when the facility staff did not wear PPE when entering a new admission resident room who was on contact/droplet isolation. The Immediate Jeopardy was identified on March 15, 2021. V1 Administrator was informed of the Immediate Jeopardy on March 17, 2021. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on March 17, 2021; however noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The Resident Census and Conditions Report (Form 672) dated March 15, 2021 shows that there are 75 residents residing in the facility. The undated facility provided list shows that R73 and R174 are new admissions on contact/droplet isolation. On 3/15/21 at 9:52 AM, V3 (Infection Preventionist) said that they do not have a separate unit for their new admissions. They are located throughout the facility but they are in a private room. V3 said that all staff are required to wear a surgical face mask and a face shield at all times. V3 said that all new admissions are required to be put on contact/droplet isolation on admission for 14 days. The required PPE for a resident who is on contact/droplet isolation is: a N95 mask, face shield, goggles, gown, and gloves any time you enter the room. R174's Face Sheet shows that she was admitted to the facility on [DATE]. On 3/15/21 at 11:41 AM, R174's room door had a sign on it that read, Quarantine/Observation Yellow Zone Droplet/Contact Precautions .Full PPE to be used. N95 mask or KN95 (if N95 not available)-MUST WEAR Goggles or face shield .gloves (always) .gown when entering room for any reason only when gown supply is adequate At 11:41 AM, V5, Certified Nursing Assistant (CNA) entered R174's room with a surgical mask on that was below her nose and a face shield. V5 did not have any addition PPE on. At 11:45 AM, V5 entered R174's room again with a surgical mask on that was below her nose and a face shield with no additional PPE on. While V5 was in the room, R174 came out of the bathroom and was standing within 3 feet of V5. On 3/15/21 at 11:45 AM, V5 said oh, no. I am so sorry, I did not even realize that she is on isolation, we are supposed to wear a gown, gloves, face shield and a white mask (N95) when we enter the room. I am so sorry. On 3/15/21 at 12:30 PM, V4 (Nurse Practitioner) was in R174's room wearing an isolation gown that was hanging from her shoulders and not tied. V4 was wearing a surgical mask (not an N95). On 03/15/21 at 1:17 PM, V10 (CNA) went into R174's room and removed the room tray. V10 had a surgical mask on and did not have an N95 mask on. V10 then proceed to enter non-isolation rooms in the 200 hallway picking up room trays. R73's Face Sheet shows that she was admitted to the facility on [DATE]. On 3/15/21 at 1:23 PM, R73's room door had a sign on it that read, Quarantine/Observation Yellow Zone Droplet/Contact Precautions .Full PPE to be used. N95 mask or KN95 (if N95 not available)-MUST WEAR Goggles or face shield .gloves .gown when entering room for any reason only when gown supply is adequate V7 (Registered Nurse) exited the room wearing only a surgical mask and face shield. V7 acknowledged that she only wore a surgical mask into the room to give medication. On 3/15/21 at 1:45 PM, V6 (CNA) said that she only has to wear an N95 mask if the resident is COVID positive. On 3/16/21 at 12:00 PM, V1 (Administrator) said that R73 and R174 have not had the COVID vaccine and have not had COVID in the past and this was also verified with the family. On 3/15/21 at 1:56 PM, V1 said that they have plenty of PPE. V1 said that they have a three month supply of emergency PPE that includes gloves, gowns, goggles, face shields, masks, N95s and sanitizer. The facility provided schedule for 3/15/21 shows that V7 and V10 both worked with residents on contact/droplet isolation and non-isolation. The facility provide schedule for V4 shows that she saw contact/droplet isolation and non-isolation residents on 3/15/21. The facility's Infection Control-Interim Policy Addressing Healthcare Crisis Related to Human [MEDICAL CONDITION] revised 3/11/21 shows, New Admission/Readmission Guidelines per CDC Responding to Coronavirus in Nursing Homes All recommended COVID 19 PPE should be worn during care of residents under 14 day quarantine observation, which includes use of eye protection (i.e., goggles or disposable face shield that covers the front and side of the face), N95 mask, gloves, and gown. The CDC's preparing for COVID-19 in nursing homes last updated November 20, 2020 shows, Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown: Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP (healthcare professional) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents . The Immediate Jeopardy that began on March 15, 2021 was removed on March 17, 2021 when the facility took the following actions to remove the immediacy. 1. All staff will be inserviced on CDC guidance and facility's COVID 19 policy which includes the necessity of wearing N95, face shield, gown, and gloves in resident rooms that require contact/droplet precautions by nurse management Corrected 3/17/21. 2. All providers will be inserviced on CDC guidance and facility's COVID 19 policy which includes the necessity of wearing N95, face shield, gown, and gloves in resident rooms that require contact/droplet precautions by nurse management. Corrected 3/17/21. 3. All observation zone residents were reviewed for their vaccination status. Corrected 3/17/21. 4. A QA tool was implemented to monitor staff PPE usage and compliance of PPE in the new resident rooms that under contact/droplet precautions. QA tool will ensure the use of N95, face shield, gloves, and gowns in contact droplet/precaution rooms. This will be done daily by nurse management or designee for next 4 weeks. Corrected 3/17/21. 5. The facility COVID 19 policy was reviewed. Policy review ensured that policy specifies which residents need to be under contact/droplet precautions and that appropriate PPE usage in contact/droplet rooms include N95, face shield, gloves, and gown. Corrected 3/17/21. 6. QAPI review with Medical Director to review infection control concerns, root cause and plan of action. Action plan will be reviewed monthly at QAPI meeting. Corrected 3/17/21.

Based on observation, interview and record review the facility failed to adequately supervise R2, 1 of 3 sampled residents reviewed for falls. This failure resulted in R2 falling out of bed and sustaining a right hip fracture. Findings include: According to the medical record R2 is a [AGE] year old female who was admitted to the facility on [DATE] for rehabilitation due to a left hip fracture after a fall at home. R2's other admitting [DIAGNOSES REDACTED]. R2 is Polish speaking and understands very little English. A fall risk observation dated 10/19/12 placed R2 at risk for falls. R2 was also triggered for falls in the initial MDS (Minimum Data Set) dated 10/31/12. Review of facility incident/accident reports contained the following: On 10/29/12 at 9:30am R2 was found on the floor of her room next to the bed lying on her right side. No apparent injury noted. The incident was unwitnessed. On 10/29/12 at 9:30pm R2 was again found on the floor in her room next to the bed. No apparent injury and the incident was unwitnessed. R2's careplan for falls dated 10/30/12 (after the first two falls) lists the following interventions: Observe, record and report unsafe conditions and situations. Encourage resident to ask for assistance, instruct resident on use of adaptive equipment. Place stuffed animal on call light to increase resident's ability to find cord. Bed pad alarm. Bed in lower locked position. On 11/06/12 at 4:40am R2 was found on the floor of her room. R2 communicated to staff that she was trying to go from her bed to the wheelchair when she fell . R2 did not use the call light. This fall was unwitnessed by staff. R2's careplan update after the fall of 11/06/12 lists the following interventions: Nurses, encourage resident to ask for assistance, especially at night. Staff to offer toileting assistance every two hours. There was no follow up documentation in the incident report or the careplan of the use or effectiveness of the bed pad alarm, the stuffed animal or other interventions listed in the careplan. On 11/08/12 at 7:20pm R2 was again found on the floor of her room by the bathroom. On assessment R2 complained of pain to her right hip and right lower leg. An x-ray was ordered and R2 was transferred to the hospital with a [DIAGNOSES REDACTED]. This fall was also unwitnessed. On 12/01/12 at 4:00pm R2 was again found on the floor of her room. The incident report noted, "unable to provide teaching due to some confusion and language barrier. Call light system provided." E2, DON (director of nursing) who is also the MDS coordinator was asked on 02/01/13 why R2 was left unsupervised in her room after multiple unwitnessed falls while in bed. E2 stated the family is in the facility a lot and often visit with R2 in her room. We asked them to let the staff know when they leave so we can make sure R2 is closer to the nurses station. There were no further fall prevention interventions listed in the careplan after the fall of 11/08/12. There was also no evaluation of the effectiveness of previous interventions. On 02/01/13 at 10:30am R2 was observed alone in her room. She was lying in bed with a half siderail in place. The bed was not in the lowest position. R2's bed alarm was in place but the switch was turned off and there was no stuffed animal near the call light. E1, LPN (licensed practical nurse) was asked about R2's careplan interventions for falls. E1 was unable to produce R2's careplan but she did lower R1's bed to the lowest position and switched on the bed alarm when she was asked about them. E1 also stated R1 understands a little English but does not use the call light.

Based on interview and record review the facility failed to analyze data to identify trends and patterns, perform root cause analysis of falls, and implement individualized interventions to prevent recurrent falls, for one of three residents sampled for falls, (R2). As a result of the facility failure R2 fell nine times in fourteen months and required outside medical treatment and diagnostic testing, for scalp lacerations, on four of these occasions. On the ninth successive fall, R2 required seventeen sutures, seven staples, and steri strips to the bridge of the nose. Findings include: The undated Fall Risk and Post Fall Assessment Policy and Procedure provided 10-26-2011 at 12:10pm. by E2, (DON/Director of Nursing) is: "Purpose: To detect reversible causes of falls and to identify supportive aids to prevent falls. Policy: A Fall Risk and other appropriate assessments will be completed at the time of admission, reviewed/updated quarterly. A Post Fall Assessment will be performed after each fall and additional interventions promptly initiated to prevent future falls, when possible. Procedure: 07. If the Fall Prevention Plan failed, initiate an immediate new intervention. 13. Communicate fall and new interventions to care givers and supervisors. 14. Revise the Care Plan to include all new fall interventions." Physician order [REDACTED]. MDS, (Minimum Data Set)s of 5-12-2011 and 8-11-2011, Section C, Cognitive Patterns, R2 has "Short and long term memory deficits Section G, Functional Status, R2 requires "extensive one person physical assistance for walking." Section G0300 Balance During Transitions and Walking, documents R2 is "not steady, only able to stabilize with human assistance moving from seated to standing position, moving on and off toilet, and surface to surface transfers." On 10-26-2011 at 3:15pm. E3, (Care Plan Coordinator) stated, "This is (R2's) complete Care Plan, from the very beginning." R2's Care Plans of 8-27- through 10-24-2011 document R2 has "Loss of memory, cognitive impairment, difficulty with decision making, alzheimer's dementia, confusion, disorientation, short term memory problems, unable to recall after five minutes, long term memory problem, unable to recall long past. Transfer Problems, Walking Problems: Unsafe transfers due to decreased strength and endurance, inability to support weight. Problem: Fall Care Plan: At risk for falls, decreased strength and endurance, unsteady gait, confusion, inability to make safe decisions, fell prior to admit, has fallen since admission." The Facility Incident/Skin Tear/Bruise Investigation Forms contain documentation that R2 fell on the following dates: 1. 8-27-2010 "Fall (R2) found on floor, sent to hospital emergency room ." On 11-1-2011 at 3:15pm. Z1, (Hospital Senior Director of Nursing) stated, "(R2's) 8-27-2010 through 8-28-2010 Hospital records document R2 had a five centimeter linear, irregular laceration to the left upper forehead, requiring sutures and diagnostic testing that included computerized tomography and x-ray." 2. 10-24-2010 at 6:05pm. "Fall (R2) observed on floor, sitting in front of wheelchair. (R2) was eating dinner in his room in wheelchair." 3. 12-14-2010 at 12:30am. "Fall (R2) observed on floor on floor mat in room. (R2) tried to get out of bed without assist, found on floor mat. Resident has a history of getting out of bed to go to the washroom." 4. 3-28-2011 at 6:00pm. "Fall with head laceration. (R2) attempted self transfer in room, wearing socks but no shoes, fell and caused scalp laceration, (Mid-forehead). (R2) to hospital emergency room ." Nursing Note of 3-30-2011 at 12:08am. is, "Laceration to right forehead, hematoma to left forehead." On 11-1-2011 at 3:15pm. Z1, (Hospital Senior Director of Nursing) stated, "(R2's) 3-28-2011 through 3-29-2011 Hospital records document R2 was administered morphine for pain and received stitches to the right side of the forehead and diagnostic testing that included computerized tomography and x-rays." 5. 5-29-2011 at 10:35am. "Fall (R2) found on floor in room, attempted to transfer self from wheel chair to bed." 6. 6-17-2011 at 8:15am. "Fall (R2) found on floor in room, attempting to transfer." 7. 9-2-2011 at 10:30pm. "Fall (R2) found on floor in room, attempting to transfer." 8. 9-15-2011 at 7:45am. "Fall (R2) attempting self-transfer in dining room, hematoma on forehead, cranial x-ray." 9. 10-5-2011 at 9:45am. "Fall, (R2) observed on floor in hallway, bleeding from forehead, laceration and swelling of nasal bridge, to hospital emergency room ." Nursing Note of 10-6-2011 at 3:50pm. is, "Bruise to left outer mid-arm, nose, and under eyes. Lacerated forehead with seventeen sutures and seven staples, steri strips to nose bridge." On 11-1-2011 at 3:15pm. Z1, (Hospital Senior Director of Nursing) stated, "Hospital records of 10-5-2011 document (R2) fell forward and received a laceration to the forehead with suture repair and diagnostic testing of computerized tomography and x-ray. Hospital records of 10-6-2011 document (R2's) sutures were oozing and staples were placed." R2's file contains documentation of seven falls prior to 8-27-2010, in which R2 is "found on floor." On 10-24-2011 at 12:25pm. Z2, (Family Member) stated, "(R2) has fallen forward out of his wheel chair, several times, in the past couple of years. It was the last time, in October 2011, that put us over the edge. He had so many stitches and black eyes. It seems every time I go there, (R2) has fallen and has lacerations or bruising to his face. He doesn't walk and falls forward out of his wheel chair." Fall Risk Assessments from 8-27-2010 through 10-5-2011 document (R2) is "High Risk for falls and has a history of falls. On 11-1-2011 at 12:35pm. E2, (DON) stated, "(R2) lacks lower motor strength and cannot stand, transfer, or ambulate independently." For each of the nine above identified falls R2's interventions to prevent further falls on the Incident/Skin Tear/Bruise Investigation Forms included "Instructed (R2) on safe transfer techniques and use of call light." Care Plan of 8-27-2010 includes "Problem: Falls. Interventions: Encourage (R2) to ask for assistance. Instruct (R2) in use of adaptive equipment. Anticipate fall times. Chair alarm when up in chair. Bed alarm when in bed. Assist with ambulating, toileting, transferring. Do not leave unattended when toileting. Low bed. Call light within reach. Arrange bedside for safety, put most needed items closest to bed. When anticipating room move keep resident as close to the nurses station as possible for safety." The same variation of these interventions were in place without new approaches to prevent R2 from recurrent falls and injury until 10-5-2011. R2's Care Plan for Falls was updated 10-5-2011 with the Intervention of an adult recliner, to replace R2's wheel chair. On 10-26-2011 at 2:15pm. E3, (MDS/Care Plan Coordinator) stated, "I've been the MDS/Care Plan Coordinator for approximately two and a half years. I went back and reviewed (R2's) Care Plan and added, just now the (adult recliner) that was implemented after the (10-5-2011) incident investigation. The Restorative Nurse did not feel (R2) could release a seat belt. In the daily Morning Meeting we, all Department Heads, talk about falls. We do an update. We all discuss Interventions and decide the next step. If we agree on an Intervention or next step, I add this to that resident's Care Plan. Initiated Interventions are after team agreement. (R2's) falls were varied. In the last year, (R2's) Care Plan, I think we have reinforced Interventions, and the Interventions for staff. (R2) had such varying falls, we did try approaches. (R2) isn't teachable. The teaching is a reminder to staff. We've tried a lot with (R2). We've had several Physical Therapy evaluations and Restorative evaluations for him." E1, (Administrator) and E2, (DON) on 10-26-2011 at approximately 3:15pm., during Daily Status, verbalized R2 did not have a pattern of falls and they would need to review R2's 8-27-2010 through 10-5-2011 fall history before they could provide information on what Interventions were put in place to prevent future falls and prevent injury. E2, (DON) on 11-1-2011 at 12:35pm. stated, "I provided an In-service to nursing personnel on 10-28-2011, 10-29-2011, and 10-30-2011. Nursing personnel misunderstood that Interventions for falls were needed. Nursing thought Interventions were for injury only. So Nursing understands there will always be Interventions. We make Interventions for preventing injuries, we can't prevent falls." On 11-1-2011 at approximately 1:15pm. E2, (DON) provided a time line of R2's falls with Immediate Interventions and Care Plan and/or Staff Interventions from 10-25-2010 through 10-12-2011. E1, (Administrator) and E2, (DON) on 11-1-2011 at approximately 2:00pm. verbalized new Interventions, (documented on R2's time line of falls), to prevent R2 from falling were on 12-14-2011 to "hook bed alarm on bed frame, out of sight, 3-28-2011 (R2) will have shoes or non-slip slippers when up in chair. On 10-5-2011 an adult chair was employed to replace R2's wheel chair and a restraint assessment was completed." E1 and E2 affirmed R2 did not have the ability to stand, transfer, or ambulate independently. On 11-1-2011 at 2:00pm. E1, (Administrator) stated, "There is time between (R2's) falls and some falls without injury, so we felt the Interventions we employed were working. There wasn't a pattern."