Every finding on record at Aliya of Homewood

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that required fall prevention interventions were on the care plan, failed to implement fall prevention interventions, failed to ensure that risk assessments were accurate, failed to ensure that staff were aware of resident falls/injury, failed to ensure that staff were aware of resident transfer requirements, and/or failed to provide supervision to four of four residents (R2, R3, R4, R5) reviewed for falls. These failures resulted in the following serious injuries; R5's (3/16/26) fall with sustained head laceration - requiring staple repair and R4's (2/6/26) fall with sustained eyelid laceration. The facility also failed to ensure that physical assessments (post fall) were accurate.Findings include:The (1/23/26-3/23/26) Facility Falls Incident log affirms that 42 falls occurred - within 2 months.The Falls Incident log affirms that R5 fell on 3/13/26 and 3/16/26. R5's diagnoses include anxiety, restlessness, agitation, hemiplegia and hemiparesis. R5's (3/19/26) functional assessment affirms resident requires substantial/maximal assistance with rolling left and right and sitting on side of bed. Chair/bed to chair transfer was not attempted due to medical condition or safety concerns. R5's (3/13/26) fall risk assessment determined a score of 24 (high risk). R5's (3/13/26) incident report states 10:44am, CNA (Certified Nursing Assistant) observed patient on the floor, when entering the room writer observed patient on the floor next to the bed sitting upright on the right, leaning on right hip. Resident states that he was trying to go to the bathroom. No injuries observed at time of incident. Predisposing factors confused, gait imbalance, incontinent. Interventions: received a winged mattress to recognize parameters of bed. [Witnesses are excluded]. R5's (3/16/26) incident report states 11:50am, writer was notified by one of the CNAs that resident was on the floor in his room. Resident was observed laying on his right side out of the floor mats facing the nightstand. He was awake, verbally responsive with no change in level of consciousness noted but was observed to have some bleeding on the right side of head (parietal area). Area was assessed and a laceration was noted. When resident was asked what happened, he stated I just felt like it, so I rolled out of bed and hit my head. Predisposing situation factors: resident always attempting to get out of bed [Witnesses are excluded].R5's (3/13/26) care plan states the resident is at high risk for falls, interventions: (3/13/26) wing mattress. (3/16/26) ultra-low bed, ultra-low floor mat while resident is in bed [provide supervision is excluded]. On 3/23/26 at 1:24pm, R5 was observed in the therapy gym sitting (upright) in a specialty wheelchair and unattended by staff. V7 (Occupational Therapist Assistant) was present, however her (V7) back was facing R5 - while accessing the computer. Surveyor inquired about R5's fall prevention interventions. V7 stated, We (staff) have him (R5) at a max assist for ADL (Activities of Daily Living) transfer, he (R5) stands up with us (therapy staff). I (V7) think he (R5) has floor mats in his room. Surveyor inquired about R5's fall prevention interventions while in the therapy gym. V7 responded, Just us supervising him. Surveyor inquired why R5 was unattended by staff in the therapy gym. V7 replied, It's just line of sight, I (V7) was just checking a note really quick. Surveyor inquired if V7 was aware that R5 fell twice this month. V7 stated, I was not aware of that. Surveyor inquired how resident falls are communicated to staff. V7 responded, Typically through nursing. R5's (3/19/26) BIMS (Brief Interview Mental Status) determined a score of 4 (severe impairment).On 3/23/26 at 1:28pm, surveyor inquired if R5 recently fell. R5 stated, I think so. Surveyor inquired if R5 was injured when he fell. R5 responded, On my head and pointed towards the right side. Four (4) staples were noted to R5's right (parietal) head. On 3/23/26 at 1:33pm, V8 (LPN/Licensed Practical Nurse) affirmed that she's (V8) assigned to R5. Surveyor inquired about R5's fall prevention interventions. V8 stated, We (staff) make sure we put him in a chair with staff monitoring him. Surveyor inquired if R5 recently fell. V8 responded, I'm (V8) aware that he (R5) fell last week, I (V8) got a report that he has a head injury. Surveyor inquired about R5's head injury. V8 replied, There's um they did a suture. Surveyor inquired if R5's laceration required a suture or staple(s) repair. V8 stated, Suture. Surveyor inquired if V8 assessed R5 today. V8 responded, I did however staples (not sutures) were observed on R5's head. On 3/26/26 at 1:27pm, surveyor inquired about R5's functional status. V23 (CNA) stated, He (R2) cannot walk and cannot stand. We (staff) have to have his (R5) bed in the lowest position, and he has to have mats on the side of his bed. He can't ambulate at all. Surveyor inquired about R5's (3/16/26) fall. V23 responded, I (V23) was walking past his room, and he was on the floor, so I told the Nurse. Surveyor inquired if floor mats were in use when R5 fell (on 3/16/26). V23 replied, Yes, when I saw him, he was lying on the floor where there wasn't any mat and his head was by the nightstand.On 3/26/26 at 1:44pm, surveyor asked if R5 can transfer himself and/or walk. V22 (RN/Registered Nurse) responded, No, he (R5) cannot walk, and I (V22) don't think he can transfer himself without assistance. Surveyor inquired about R5's (3/16/26) fall. V22 replied, The CNA came to me (V22) and said that the resident (R2) was on the floor. I immediately went in there and he was on the floor lying on his right side. The floor mat is in place, but his body was not inside the mat. Surveyor inquired how could R5 roll out of bed if a winged mattress was in use? V22 responded, He always tries to put 2 legs outside of the bed hanging, we (staff) always have to reposition him. Surveyor inquired how R5 injured his head. V22 replied, Theres a nightstand near where he fell so he might have hit his head on the nightstand.___The Facility Falls Incident log affirms that R4 fell on 1/27/26, 1/31/26, and 2/6/26. R4's diagnoses include seizures, lack of coordination, muscle wasting/atrophy and history of falling. R4's (1/7/26) functional assessment affirms the resident is dependent on staff for sit to stand and chair/bed to chair transfers. R4's (1/2/26) post fall risk assessment determined a score of 7 however history of falls and/or fracture in the past 6 months - include the current fall incident was not selected (as warranted) - this selection adds 10 additional points [Indicating high fall risk]. R4's (1/27/26) incident report states 2:00pm, incident location: Nursing Station. Resident had a seizure; resident was sitting in a wheelchair at the nurse's station. Resident fell out of wheelchair onto the floor and hit the left side of her temple. Bleeding noted to left side of head. Notes: laceration noted to left side of head with moderate bleeding. R4's (1/27/26) hospital history & physical affirms abrasion (not laceration) to left upper forehead and 2x2 centimeter hematoma were noted. R4's (1/31/26) incident report states 9:00pm, CNA reported that the patient was lying on the floor. Observed patient laying on right side of the floor mat next to her bed. Patient stated that she was getting up to go to another room. No apparent injury. [Witnesses are excluded].R4's (2/6/26) incident report states 5:00pm, incident location: Nursing Station. Observed that the patient was on the floor face down in front of her wheelchair. There was a small skin tear noted to the right eye lid under her eyebrow, there was a small amount of blood. The patient has a small skin laceration to the right upper eye lid. The resident stated that she was getting up to go to another room. Injuries observed at time of incident: Laceration, face [Witnesses are excluded].R4's (2/7/26) history & physical affirms she (R4) had a small laceration under her left eyebrow which is incongruent with the right side - which was documented. R4's (1/2/26) care plan states the resident is at high risk for falls related to reduced mobility, recent falls and poor safety awareness, interventions: staff to assist as needed. Perform frequent rounding and provide prompt assist for change in position/toileting.On 3/23/26 at 1:56pm, V10 (LPN) affirmed that she's (V10) assigned to R4. Surveyor inquired about R4's fall prevention interventions. V10 stated, She (R4) has the floor mats, keep the bed in lowest position, in the morning we get her (R4) up, make sure she has the soft helmet on and call light within reach [frequent rounding was excluded]. Surveyor inquired how R4 transfers from the bed to wheelchair. V10 responded, As far as transferring her, I'm (V10) not 100% sure, you (surveyor) would have to ask the aide. R4's (1/7/26) BIMS determined a score of 13 (cognition intact).On 3/23/26 at 1:59pm, R4 stated I (R4) did fall when I was in my room. I lost my balance, I was trying to reach for something, and I fell. Surveyor inquired about facility call light response time. R4 responded, Sometimes I have to wait until they're (staff) finished with another person. Surveyor inquired if R4 was over medicated while in the facility. R4 replied, He (Physician) changed it (medication) because it was a little too strong, so I'm (R4) doing better now. On 3/26/26 at 3:05pm, surveyor inquired about R4's (2/6/26) fall /injury. V24 (RN) stated, She (R4) was sitting in the chair (at the nurse's station) I (V24) looked up and she was face down on the floor. When we (staff) got her up and sat her back down, I know she had a laceration on her right eye. Surveyor inquired about R4's fall prevention interventions. V24 responded, Low bed and the mats [frequent rounding was excluded].___ On 3/7/26, IDPH (Illinois Department of Public Health) received allegations that R2 needed help on 2/17/26 and no one came. R2 attempted to get out of bed - to reach for the urinal and fell. R2 was on the floor for about 15 minutes.On 3/23/26 at 8:17am, V3 (Family) stated that (R2) fell at home (prior to admission) broke his hip and was non-weight bearing. He (R2) was at the facility for 3 nights; he fell and was sent to (hospital). R2 did not return to the facility. R2's diagnoses include Parkinson's disease with dyskinesia, muscle wasting/atrophy, cognitive communication deficit, type II diabetes mellitus, chronic kidney disease, hypertension, benign prostatic hyperplasia, history of falling, and (2/14/26) fracture of superior rim of right pubis.R2's (2/17/26) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact).R2's (2/17/26) functional assessment affirms impairment in range of motion on both upper extremities and one lower extremity. Resident requires partial/moderate assistance with toileting and substantial/maximal assistance with chair/bed to chair transfer. Walking was not attempted due to medical condition or safety concerns. R2's (2/17/26) fall risk assessment determined a score of 24 (high risk).R2's (2/14/26) Physician Order Sheets include non-weight bearing to right leg for right pelvic fracture. R2's (2/15/26) care plan states resident is at high risk for falls related to reduced mobility and poor safety awareness [fractured right pubis is excluded]. Interventions include bed in lowest position, keep frequently used items within reach, placement of call light within reach and staff to assist as needed [non-weight bearing is excluded].R2's progress notes state (2/14/26) Patient was admitted , diagnosis status/post fall right pelvic fracture. (2/17/26) Writer went to answer call light and observed resident on the floor sitting on the side of bed toward the end of the bed on his buttocks. Resident stated he fell trying to get to the washroom. Writer assessed resident from head to toe, observed medium size knot with redness to top left head. Resident stated he hit his head. New orders to send resident to ER. (2/18/26) Writer reviewed hospital paperwork and resident was admitted for fall and non-acute pelvic fracture. R2's (2/17/26) incident report states writer went to answer call light and observed resident on the floor sitting on the side of the bed toward the end of the bed on his buttocks. Resident stated he fell trying to get to the washroom. [Witnesses are excluded].On 3/23/26 at 11:28am, surveyor inquired about R2's plan of care V2 (Director of Nursing) reviewed R2's care plan and stated, Resident is at high risk for falls due to reduced mobility and poor safety awareness. Surveyor inquired about R2's fall prevention interventions. V2 responded, Bed in lowest position, keep frequently used items within reach [R2's urinal was not within reach]. Surveyor inquired if R2 was supposed to be getting up out of bed with a fractured pelvis. V2 replied, That would depend on his (R2) weight bearing status based upon his ortho recommendation prior to coming to us (facility). V2 reviewed R2's hospital records and stated, Weight bearing says non-weight bearing right leg. Surveyor inquired if non-weight bearing (right leg) was on R2's care plan. V2 reviewed R2's care plan and stated, I don't see that in here.On 3/26/26 at 10:49am, surveyor inquired about R2's functional status. V18 (Physical Therapy) stated, During the evaluation (2/16/26) his (R2) bed mobility is like partial/moderate assistance 25-50% assistance. With the sit to stand I understand he is non-weight bearing and need a lot of assistance - maximal assistance 75% with the caregiver. On 3/26/26 at 11:38am, surveyor inquired about R2's functional status. V5 (Registered Nurse) stated, The CNA transferred him (R2) with one person assist. Surveyor inquired if R2 was non-weight bearing. V5 responded, I (V5) would have to look and see and affirmed she (V5) was unsure. Surveyor inquired about R2's fall prevention interventions. V5 replied, I would have to look in the system to see what his fall precautions are. Surveyor inquired about R2's (2/17/26) fall. V5 stated, He (R2) told me (V5) that he was trying to get to the washroom, and he fell. He had like a knot on his head and redness, so I asked him if he hit his head. He said yeah. Surveyor inquired if R2 had a fracture diagnosis - prior to falling. V5 responded, No, I can't really recall.___R3's diagnoses include legal blindness, multiple sclerosis, weakness, restlessness and agitation. R3's (10/30/25) BIMS determined a score of 9 (moderate impairment).R3's (1/30/26) functional assessment affirms resident requires substantial/maximal assistance with rolling left and right. Transfers were not attempted due to medical condition or safety concerns. R3's (1/30/26) fall risk assessment determined a score of 14 (high risk). R3's (2/19/24) care plan states the resident is at high risk for falls related to generalized weakness, potential medication side effects, multiple sclerosis, legally blind, muscle weakness, and failure to thrive, interventions: floor mats while in bed. On 3/23/26 at 2:05pm, R3 was lying asleep in bed. A floor mat was adjacent to R3's bed (near the wall) however the floor mat (between the beds) was folded and angled away from - the foot of bed. The over-bed table (placed beneath the bed) was impeding ability to place the floor mat near R3's bed. On 3/23/26 at 2:08pm, surveyor inquired about R3's fall prevention interventions. V11 (LPN) responded, The mat and I (V11) usually stay here (in the hallway) from time to time. I got 30 patients, but I try to keep an eye on. Surveyor inquired about the location of R3's floor mat (between the beds). V11 subsequently entered the room and replied, It should be bedside, uh next to the bed and affirmed that it was not. Surveyor inquired if R3 rolled out of bed right now (between the beds) where would she (R3) land? V11 stated, If she rolls out? she would be on the floor. On 3/23/26 at 2:10pm, V12 (Assistant Director of Nursing) entered R3's room, unfolded the floor mat, and placed it near R3's bed after V11 moved R3's over-bed table out of the way. On 3/26/26 at 12:52pm, surveyor inquired about potential harm to a resident that falls. V21 (Medical Director) stated, It depends, they (residents) can have injuries; fractures, laceration, bleeds or other medical conditions if they're on a blood thinner.The fall prevention and management policy (reviewed 3/2026) states 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 preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. A fall risk evaluation will be completed on admission, readmission, and quarterly, significant change and after each fall. Residents at risk for falls will have fall risk identified on the interim plan of care with interventions implemented to minimize fall risk.

Based on interview and record review the facility failed to follow policy procedures, failed to ensure that resident risk assessments were completed, and failed to ensure that a risk assessment was accurate for one of four residents (R4) reviewed for falls. Findings include:R4's (1/2/26) post fall risk assessment determined a score of 7 (at risk) however section G: Falls, Accidents, Fractures; was not answered (the responses were blank) therefore incomplete. History of falls and/or fracture in the past 6 months? include the current fall incident (was not selected). The assessment was conducted post fall therefore this response should have been selected. This selection adds 10 additional points to the score [Scoring a 10 or higher makes resident High Risk for falls]. On 3/25/26 at 12:51pm, surveyor inquired about concerns with R4's (1/2/26) post fall risk assessment. V2 (Director of Nursing) stated, Letter G is not checked, it's gonna throw the score off. Surveyor inquired what the score should have been if accurately assessed. V2 responded, It would be 17.The fall prevention and management policy (reviewed 3/2026) states the facility will identify and evaluate those residents at risk for falls. A fall risk evaluation will be completed on admission, readmission, and quarterly, significant change and after each fall.

Based on interview and record review, the facility failed to follow policy procedures and failed to ensure that required diagnoses/interventions were included in the baseline care plan for one of four residents (R2) reviewed for falls.Findings include:R2 was admitted to the facility on [DATE] with diagnoses including history of falling and fracture of right pubis. R2 fell at the facility on 2/17/26.R2's (2/14/26) Physician Order Sheets include non-weight bearing to right leg for right pelvic fracture. R2's (2/15/26) care plan states resident is high risk for falls related to reduced mobility and poor safety awareness [right pelvic fracture is excluded]. Interventions include bed in lowest position, keeping frequently used items within reach, placement of call light within reach and staff to assist as needed [non-weight bearing and transfer requirements are excluded].On 3/23/26 at 11:28am, surveyor inquired about R2's fall plan of care. V2 (Director of Nursing) reviewed R2's baseline care plan and responded, Resident is at high risk for falls due to reduced mobility and poor safety awareness. Surveyor inquired about R2's fall prevention interventions. V2 replied, Bed in lowest position. Keep frequently used items within reach. Staff to assist as needed. Promote placement of call light within reach and assess resident ability to use. Surveyor inquired if R2 was supposed to be getting out of bed - with pelvic fracture. V2 responded, That would depend on his (R2) weight bearing status based upon his ortho recommendation prior to coming to us (facility). V2 subsequently reviewed R2's hospital records (received prior to admission) and stated, Weight bearing, says non-weight bearing right leg. Surveyor inquired if non-weight bearing right leg or pelvic fracture were included in R2's baseline care plan. V2 responded, I (V2) don't see that in here.The baseline care plan policy (revised 3/17/26) states the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care. 2.) The baseline care plan will be developed within 48 hours of a resident's admission into the facility. 3.) The baseline care plan will include at a minimum the following necessary information to properly care for a resident. B.) Fall risk.

Based on observation, interview, and record review, the facility failed to notify the physician and registered dietitian of a resident's poor appetite and decreased oral intake, which resulted in significant weight loss, and failed to implement timely interventions to prevent further decline. This affected one of three residents (R9) reviewed for nutritional status in a sample of 44 residents. This failure resulted in R9 experiencing a significant unplanned weight loss of 13.3% over a three-month period.Findings include: On 2/17/26 at 12:47 PM, R9 received lunch meal tray. R9's head of bed was at 45 degrees. At 1:10 PM, R9 was observed eating one piece of canned fruit. R9 was observed coughing while eating. By 1:25 PM, R9 had consumed two pieces of canned fruit and drank 100 ml (milliliters) juice. V20 CNA (certified nurse aide) removed R9's tray from room.On 2/18/26 at 1:12 PM, R9's lunch tray was set up and head of bed 45 degrees. By 1:36 PM, R9 had not eaten anything. By 2:15 PM, R9 ate one bite of cornbread. R9 was observed coughing while eating. V20 CNA removed R9's tray from room. On 2/18/26 at 12:20 PM, V21 CNA stated that she lets the nurse know if resident does not eat or eats very little.On 2/18/26 at 3:50 PM, V28 (attending physician) stated that he was not made aware of R9's poor appetite or R9's weight loss. V28 stated that he just spoke with R9's nurse who informed him that R9 was fine, no concerns with eating. V28 stated that he expects the nurse to notify him when a resident has a weight change of +/- 5 pounds in a month. V28 stated that he expects the nurse to notify him if resident eats very little or refuses a meal. On 2/19/26 at 10:25 AM, R9's meal intake for the past 30 days was reviewed with V7 RD (registered dietitian). V7 stated that she was not made aware of the frequency that R9 was consuming 0-50% and refusing meals. V7 stated that she would have made recommendations for supplements if staff had notified her.R9's medical record notes the following weights:On 2/19/26, R9 weighed 130.5 pounds.On 2/6/26, R9 weighed 132 pounds.On 1/6/26, R9 weighed 130 pounds.On 12/3/25, R9 weighed 150 pounds.There is no weight documented for November 2025.On 10/7/25, R9 weighed 151.5 pounds.On 8/4/25 R9 weighed 153.5 pounds.On 2/19/26, This surveyor observed V26 (restorative aide) and V27 (restorative aide) weigh R9 using a mechanical lift device. R9 weighed 130.5 pounds. R9 had a 14.98% weight loss in six months and 13% weight loss since 12/3/25.On 2/20/26 at 1:45 PM, V25 ST (speech therapist) stated that she just completed an evaluation on R9. V25 stated that R9 did not exhibit any coughing while eating. When questioned if the coughing this surveyor observed while R9 was eating could be related to R9 lying in bed with head of bed raised only 45 degrees, V25 responded that there is a direct relationship of coughing when head of bed is not at 90 degrees. V25 stated that V25 is always informing the staff to make sure residents are sitting upright during the meal and for 30 minutes after. V25 stated that swallow strategies she recommends for R9 include 1:1 feeding assistance, alternating liquids and solids, upright posture during meals and for 30 minutes after meal, soft and bite sized food.On 2/20/26 at 3:35 PM, V31 (regional nurse consultant) stated that R9 had a lot of edema (swelling) documented in R9's medical record in December and January to account for R9's significant weight loss.R9's medical record, dated 12/2/25-1/6/26 notes the following documentation regarding R9's edema:On 12/2, the nurse practitioner noted R9's extremities normal, no edema.On 12/3, pulmonary nurse practitioner noted R9's lungs clear to auscultation; trace edema resolving.On 12/4, the nurse practitioner noted no edema.On 12/9, the nurse practitioner noted R9's extremities normal, no edema.On 12/12, the nurse practitioner noted R9's extremities normal, no edema.On 12/23, nephrology nurse practitioner noted R9 euvolemic (normal healthy volume of blood and body fluids).On 12/30, the nurse practitioner noted R9's extremities normal, no edema.On 1/6/26, nephrology nurse practitioner noted R9 euvolemic. No edema noted.On 2/20/26 at 3:51 PM, V31 stated that R9's weight loss was due to R9 having Covid-19 in December.R9's medical record, dated 12/3/25 notes R9 tested positive for Covid-19. On 12/4, the nurse practitioner noted R9 being seen for follow-up on Covid-19. R9 had a routine Covid-19 test, which was positive. R9 is asymptomatic. R9's POC (point of care) charting, dated 12/1-12/31, notes documentation of R9's meal consumption for 88 out of 93 meal opportunities. R9 consumed 0-25% of meal served 13 times; 26-50% of meal served 23 times; and refused the meal 6 times. R9 was unavailable for one meal.R9's POC (point of care) charting, dated 1/1-1/30, notes documentation of R9's meal consumption for 92 out of 93 meal opportunities. R9 consumed 0-25% of meal served 21 times; 26-50% of meal served 22 times; and refused the meal 4 times.R9's POC (point of care) charting, dated 2/1-2/19, notes documentation of R9's meal consumption for 56 out of 57 meal opportunities. R9 consumed 0-25% of meal served 13 times; 26-50% of meal served 18 times; and refused the meal 5 times.There is no documentation found in R9's medical record noting V28 was notified each time R9 consumed 0-25% or refused the meal.There is no documentation found in R9's medical record that R9's weight loss is medically unavoidable.The facility's weight change policy, dated 05/2025, notes this facility will monitor the nutritional status of all residents, including all significant or trending patterns of weight change. It also notes in part review weights for significant weight change. Notify dietitian, physician, and resident representative. Dietitian will review and provide recommendations.

Based on observation, interview, and record review, the facility failed to ensure that residents who were at risk for malnutrition and dependent on enteral feedings received nutrition as ordered to maintain adequate nutritional status and prevent weight loss. The facility also failed to ensure staff demonstrated competency in the administration and management of enteral nutrition and care. This affected 2 of 3 residents (R82 and R89) reviewed for enteral nutrition in a sample of 44 residents. As a result, R82 experienced a significant weight loss of 14.1% between July 2025 and February 2026, and R89 experienced a weight loss of 4.4% within eight weeks of admission. Findings include: On 2/17/26, intermittent observations were made from 12:20 PM until 4:00 PM, R82 was observed self-propelling wheelchair in halls and attending activities; R82 was not connected to enteral feeding pump.On 2/18/26 at 3:36 PM, R82's enteral feeding container shows R82 received 600ml since it was started on 2/17/26 at 10:09 PM. Continuous observations were made on R82's nursing unit from 11:55 AM until 4:00 PM; R82 was not observed receiving enteral feeding during this time.On 2/17/26 at 10:15 AM, R89 was observed lying in bed. R89's enteral feeding pump was turned off. Intermittent observations were made from 12:20 PM until 4:00 PM, R89 was in wheelchair at nurses' station not receiving enteral feeding.On 2/18/26 at 9:30 AM, R89 was observed in wheelchair at nurses' station, not receiving enteral feeding. At 2:00 PM, R89 was observed in room with family; R89 was not receiving enteral feeding.On 2/18/26 at 3:44 PM, R89 was observed sitting in wheelchair in room, not receiving enteral feeding. Enteral feeding container shows R89 received 150ml since it was started at 5:45 AM at 80 ml/hour. On 2/19/26 at 3:30 PM, V29 (activity director) stated that R82 is in wheelchair participating in activities or self-propelling in halls all day every day.On 2/19/26 at 10:32 AM, V24 (nurse) stated that R89's enteral feeding was started at 5:50 AM. When questioned how it is communicated to oncoming nurses the amount of feeding delivered and/or amount left, V24 did not respond. When questioned how does V24 know when the resident has received the total amount of feeding per 24 hours, V24 responded the pump will shut off. When questioned how to check pump settings and amount fed, V24 did not respond and left R89's room.On 2/19/26 at 10:35 AM, V7 RD (registered dietitian) stated that enteral feedings are ordered to deliver feeding over 20 hours daily to ensure the resident is receiving adequate nutrition. V7 stated that the total volume of feeding is based on the resident's caloric needs. V7 stated that residents should not lose weight if receiving nutrition as prescribed. V7 stated that she reviews the total volume fed on the feeding pump. V7 stated that she has increased R89's feeding by 5ml/hour each month since December because he was not receiving the prescribed daily total volume. V7 stated that she did this hoping R89 would receive the nutrition he needs. V7 stated that R89 should receive 1680 ml (milliliters) total feeding and 1050 total water per 24 hours. V7 reviewed on R89's enteral feeding pump the amount of feeding R89 received in the past 24 hours and 48 hours. V7 stated that the pump shows R89 received 1080 ml of feeding and 715 ml of water flush in 24 hours and 2264 ml feeding and 1240 ml water flush in the past 48 hours. V7 stated that R89 is not receiving adequate nutrition. V7 stated that these residents are discussed at the NARS (nutrition at risk) meetings and she voices her concerns.On 2/19/26 at 10:50 AM, V7 RD stated that R82 should be receiving 1500 ml total feeding and 1800 ml water flush per 24 hours. V7 stated that R82's feeding pump shows R82 received 1021 ml of feeding and zero water flush in 24 hours and 1852 ml feeding and zero water flush in the past 48 hours. V7 stated that R82 is not receiving adequate nutrition.On 2/19/26 at 11:15 AM, V2 DON (director of nursing) stated that the nurses received an in-service on the enteral feeding pump one year ago. V2 stated that the nurses were not competencied on the feeding pump. V2 stated that the nurse is expected to ask V2 or the nurse manager for assistance if the nurse does not know how to use the enteral feeding pump or has any questions. V2 stated that nurses that started working at this facility after 1/27/25, received 1:1 training on the enteral feeding pump during orientation.The facility provided a list noting there are 47 current licensed nurses working at this facility. Of these 47 nurses, 21 started after 1/27/25.On 2/20/26 V2 DON presented the facility's enteral feeding pump in-service documentation dated 1/27/2025. Six of the 47 licensed nurses were in-serviced. The facility was unable to provide documentation that the 21 nurses that started after 1/27/25 received training during orientation. The facility was unable to provide any documentation that the 41 nurses that did not attend the in-service on 1/27/25 received any education on the feeding pump. The facility was unable to provide any documentation that all nurses are competent in using the feeding pump.R82's weight documentation:On 7/2/25, R82 weighed 195.5 pounds.On 10/7/25, R82 weighed 168 pounds.On 1/6/26, R82 weighed 171.5 pounds.On 2/19/26, R82 weighed 167.8 pounds.R89's weight documentation:On 12/26/25, R89's admission weight was 147.5 pounds.On 1/23/26, R89 weighed 145.6 pounds.On 2/19/26, R89 weighed 141 pounds.The facility's tube feeding policy, dated 01/2024, notes in part, the health care provider should be notified if tube feeding amount not infused as ordered. Feeding pump: pump should be cleared at the end of each shift. Document tube feeding delivered. Alert health care provider of any issues or concerns.

Based on observations, interviews, and record reviews, this facility failed to follow its call light response policy and ensure the call light cord was within reach for 4 residents (R60, R91, R114, and R126) out of 4 residents reviewed for call light accessibility in a sample of 44. Findings include:On 2/17/26 at 10:05 AM, R60 was observed sitting in a wheelchair across from bed. R60's call light cord was observed on the floor under R60's bed, not within reach.On 2/17/26 at 12:20 PM, R126 was observed lying in bed. R126's call light cord was observed on floor under bed, not within reach.On 2/18/26 at 11:00 AM, R91 was observed sitting in a reclining chair next to the foot of her bed. R91's call light cord was observed on R91's nightstand at the head of the bed, not within reach.On 2/18/26 at 11:50 AM, R114 was observed lying in bed. R114's call light cord was observed dangling behind R114's nightstand, not within reach.On 2/17/26 at 10:06 AM, V24 (nurse) stated that the resident's call light cord should definitely be within the resident's reach.The facility's call light response policy, dated 5/1/25, notes ensure the call light is always within the resident's reach. When the resident is in bed, provide the call light within easy reach of the resident.

Based on observation, interview, and record review, the facility failed to ensure residents received timely incontinence care, hygiene, and skin care services at least every two hours to maintain cleanliness, prevent skin breakdown, and promote comfort. This affected five of six residents (R126, R9, R89, R44, and R11) reviewed for activities of daily living (ADL) care, incontinence care, and hygiene/skin care in a sample of 44 residents. On 2/17/26 at 12:45 PM, V20 CNA (certified nurse aide) stated that R126 was last changed at 6:30 AM when V20 started her shift today. On 2/20/26 at 11:15 AM, V2 DON (director of nursing) stated that staff are expected to provide incontinence care to their assigned residents every two hours and as needed. R126: On 2/17/26 at 12:20 PM, R126 stated that R126 needs brief changed. R126 stated that he is able to activate the call light for assistance but does not know where his call light cord is. R126's call light cord observed under R126's bed. On 2/17/26 at 12:26 PM, V24 (nurse) came into R126's room and placed his call light cord within his reach. R126 stated that he needed his brief changed. V24 stated that she would let R126's CNA (certified nurse aide) know and V24 left R126's room. On 2/17/26 at 12:37 PM, V20 CNA entered R126's room to provide incontinence care. R126's brief was saturated with urine. R126's bed linen was wet with a brown discoloration outlining the wet area. R126's MDS (minimum data set), dated 1/2/2026, notes R126's BIMS (brief interview of mental status) score is 15 out of 15. R126 is cognitively intact. R126 is dependent on staff for incontinence care. R126's ADL care plan, initiated 7/29/23, notes R126 requires assist with daily care needs related to stroke. It notes to keep R126 clean and dry as an intervention. R126's care plan for bowel and bladder incontinence, initiated 2/8/24, notes provide incontinence care at routine timely intervals. R9: On 2/18/26 at 11:55 AM, R9 was observed lying in bed. This surveyor noted a strong foul odor when standing next to R9's bed. On 2/18/26 at 12:20 PM, V21 CNA (certified nurse aide) was observed entering R9's room and moved R9's bedside table closer to R9 then left R9's room. On 2/18/26 at 12:47 PM, R9's lunch meal tray was delivered and R9's head of bed was raised to 45 degrees. On 2/18/26 at 1:35 PM, V21 CNA was observed encouraging R9 to eat meal. On 2/18/26 at 1:50 PM, V21 was observed with her coat on and stated that she was leaving. On 2/18/26 at 2:15 PM, V20 CNA was observed picking up R9's meal tray. On 2/18/26 at 3:15 PM, V37 CNA entered R9's room to provide incontinence care. R9's brief was saturated. R9's incontinence care plan, initiated 5/23/22, notes R9 has bowel and bladder incontinence related to impaired mobility and cognition. Interventions in part note apply skin moisturizers/barrier creams as needed and provide incontinence care as needed. R89: On 2/19/26 at 9:30 AM, R89's was observed lying in bed. When R89 was turned onto his left side for wound care treatment, R89's brief was observed to be saturated with urine. R89's MDS, dated [DATE], notes R89's BIMS score is 10 out of 15. R89 has moderate cognitive impairment. R89 is dependent on staff for incontinence care. The facility's incontinence care policy, dated 05/2025, notes in part incontinence care is provided to keep residents as dry, comfortable and odor free as possible. R44: R44 MDS (minimum data set) for functional abilities dated 1/23/2026 shows R44 requires supervision or touching for toileting and personal hygiene. On 2/17/26 at 11:41am R44 was observed resting in bed, there was an odorous smell of urine. R44 said she was wet, and the aide had not come in to change her. R44 said she needed to be changed. R44 agreeable that surveyor can make observation of her care. Nurse and V18(CNA) were made aware of R44 concerns. 2/17/26 11:46am V18 (CNA) said the last time she checked R44 was at 7:30am. V18 she did not check on R44 because she was busy getting other residents up for the morning. R44 observed with no brief on, the bed sheet and white folded blanket were soiled. V18 said maybe R44 took off her brief because it was soiled. V18 said she should be completing care rounds every two hours to provide incontinent care for R44. R44's care plan with initiated date 3/12/2018 shows R44 has ADL (activity of daily living) self-care deficit r/t (related to) decreased functional mobility and strength, decline in cognition and DX (diagnosis) dementia and CHF (congestive heart failure) and bipolar disorder. Interventions are to assist with daily hygiene, grooming, dressing, oral care and eating as needed. R11: R11 MDS dated [DATE] shows R11 is dependent of staff for functional activities of shower/bathing, and personal hygiene. 2/19/26 at 12:15pm R11 observed resting in bed, R11 awake able to mouth words. R11 bilateral feet were observed with severe flaky skin, some of the flaky skin was the size of a dime, R11's socks had an abundance of dry skin flakes inside the socks, able to be poured out. Observed by V30 (LPN). R11 said she wanted her feet washed, and moisturized. V30 (LPN) said the aides should be washing R11's feet and applying lotion to her feet on her shower days and as needed. 2/20/26 at 9:37am V6 (Wound care Nurse) said R11 receives skin checks daily, V6 said R11's feet did not become severely dry like that since the last skin check. V6 said she has to address foot care with the staff. R11's care plan has ADL (activity of daily living) Self-care deficit related to decreased functional mobility and strength, decline in cognitive and Dx (diagnosis) cerebral infraction with hemiparesis and dysphagia, chronic diastolic, heart failure and dementia. Interventions are to assist to bathe/shower as needed, assist with daily hygiene, grooming, dressing, oral care and eating as needed. 2/20/26 at 11:42am V2 (Director of Nursing) said the aides should be completing rounds on residents every two hours or as needed, to provide care. V2 said her expectation is that on shower days and or as needed the resident's feet should be washed and moisturized. Facility policy for foot care dated 1/2023 shows foot care is given to promote cleanliness, prevent infection, control odor, provide comfort, monitor for skin breakdown and promote healing. Foot care is provided routinely with the bath and PRN (as needed) it may also be done more frequently with a physician or nurse practitioner order. During the bath examine the feet for any open areas, redness bruises odor or color change. Dry feet carefully with a towel, making sure to dry between toes. If necessary, moisturize feet. Facility policy for bathing dated 1/1/2023 shows all residents are offered a bath and shower at least once per week. More frequent bathing or showering is given as needed or requested. Bed/ bath- wash thighs, legs, and feet. Report any skin issues to the Charge nurse or skin coordinator. Skin care prevention dated 1/2023 shows in-part treat dry skin with moisturizer as needed.

Based on observation, interview, and record review, the facility failed to ensure medications were labeled and stored in accordance with facility policy and accepted standards of practice. Specifically, opened and used medications located on the medication cart were not dated upon opening. This affected four of four residents (R 39, R140, R82, and R58) reviewed for medication storage. Finding Includes:On [DATE] at 3:59pm, during a medication cart audit with V14 (nurse), R39 was observed with an Latanoprost eye drops opened and not dated. V14 said, R39's eye drops are open, used and not dated. V14 said, R39's eye drops should have been dated upon opening. Dating the medication is to ensure its not administered past the expiration date.R39 was diagnosed with Glaucoma. R39's physician order sheet documents Xalatan Ophthalmic Solution. Instill one drop in both eyes in the evening for glaucoma. Pharmacy recommended expiration dates documents: Xalatan-expiration six (6) weeks.On [DATE] at 4:04pm, during a medication cart audit with V15 (nurse), R140 was observed with prednisolone eye drops opened and not dated. V15 said, R140's eye drops were opened, used and not dated. V15 said, prednisolone eye drops are good for twenty-eight days after opening. V15 said, R140's eye drop should have been dated after opened to ensure we don't administer expired medication.R140's physician order sheet documents: Prednisolone acetate ophthalmic solution. Instill one drop in left eye four times a day.On [DATE] at 4:31pm, during a medication cart audit with V12 (nurse), R82 and R58 were both observed with insulin lispro opened and not dated. V12 said, R82's and R58's insulin is open and used. Insulin should have a written date on the bottle when it's opened to include the expiration date. The date is to ensure expired medication is not administrated. V12 said, insulin is good for twenty-eight or thirty days depending on the type of insulin.R82 was diagnosed with type two Diabetes Mellitus. R82 's physician order sheet documents: Insulin Lispro Solution. R58 was diagnosed with type two Diabetes Mellitus with Hyperglycemia. R58's physician order sheet documents: Insulin Glargine Subcutaneous Solution (Insulin Glargine). Pharmacy recommended expiration dates documents: Insulin products vial/pen expiration-twenty-eight (28) days.Medication Storage in the Facility dated 5/2025 Policy documents: Medications and biologicals are stored safely, securely and properly following the manufacture or supplier recommendation.

Based on interview and record review, the facility failed to obtain consent for psychotropic medications prior to administration for two of two residents (R3 and R113) reviewed for resident's rights in a total sample of 44 residents.Findings include:R3 was admitted to the facility on [DATE] with a diagnosis of schizophrenia, seizures, and traumatic subdural hemorrhage.R3's physician order sheet documents: Seroquel 50mg two tablets at bedtime order and start date 1/21/26, duloxetine 30mg one tablet daily with order date of 1/19/26 and start date of 1/20/26 and mirtazapine 30mg one tablet at bedtime with order date of 1/19/26 and start date of 1/20/26.R3's consent for psychotropic medication dated 1/21/26 documents under medications Seroquel, duloxetine and mirtazapine, under family it documents verbal consent received on 2/1/26 at 5:30PM by V38 (family member). Under facility representative V2 signature dated 2/4/26. The signing date of the assessment documents 2/19/26. V38 interview attempted but unsuccessful during the survey.R3's pharmacy medication review on admission dated 1/22/26 documents: There is no informed consent for the following psychotropic medications: duloxetine, mirtazapine and Seroquel.On 2/20/26 at 11:14AM, V2(Director of nursing) said consents are obtained upon admission, with new order or if medication is increased. The consent can be found in progress notes under miscellaneous or an assessment for consent will be completed. Consent should be obtained prior to starting the medications. V2 confirmed that R3's consent was not done prior to starting the medications and should have been before R3 was administered medications.R113 was admitted to the facility on [DATE] with a diagnosis of bipolar disorder and depression.R113 order details dated 1/12/26 documents: Depakote 250mg one tablet twice a day for bipolar disorder.R113 sertraline order history documents: sertraline 50mg with start date of 8/19/23 and end date of 3/20/24; sertraline 100mg start date 3/21/24 with end date of 9/9/24; sertraline 150mg start date of 9/10/24 with end date11/4/25; sertraline 200mg with start date 12/25/24 and end date of 4/2/25; sertraline 100 mg with a start date of 4/3/25 and no stop date.On 2/20/26 at 11:14AM, V2(Director of nursing) said consents are obtained upon admission, with new order or if medication is increased. The consent can be found in progress notes under miscellaneous or an assessment for consent will be completed. Consent should be obtained prior to starting the medications. On 2/20/26 at 1:46PM, V2 confirmed there was no consents for R113 Depakote or sertraline increase in the medical record.Facility policy Psychotropic Medication Program reviewed 1/2026 documents: the purpose is to promote the safe and effective use of psychotropic mediations. To ensure the lowest dose of mediation is used for the shortest timeframe. To guarantee a resident's quality of life is enhanced by the medication usage. The second purpose of this process is to ensure the resident is evaluated and the indication for the medications is documents within the medication record including but not limited to the nursing staff, social services, activities and the physician. Also, resident and resident representative are aware of the potential side effects and the facility obtains an informed consent for the use of psychotropic medication. If a new order for psychotropic medication is obtained the resident, resident representative or power of attorney (POA) must be informed of the risks and benefits of the medication. The family must obtain informed consent. If the family or representative is not able to sign the consent at time of the order, verbal consent will be obtained by the nurse and documented on a psychotropic consent form until written consent can be obtained. This form will be part of the medical record. Once consent is obtained, the order will be entered into the medical record and the diagnosis will be added to the diagnosis list.

Based on interview and record review, the facility failed to follow their Psychotropic Medication Program by not conducting psychotropic medication assessments as indicated, not conducting Abnormal involuntary movement scale assessments as indicated and failing to develop individualized nonpharmacological interventions for two of five residents (R104 and R113) reviewed for unnecessary medications in a total sample of 44.Findings include:R104 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease, psychosis, vascular disease and anxiety.R104' s psychiatrist note dated 2/10/26 documents; R104 currently treated with mirtazapine 15 mg at bedtime, sertraline 12.5 mg daily and Seroquel 25 mg twice a day.R104's care plan dated 3/10/24 revised 6/8/24 documents: R104 requires the use of psychotropic medication for diagnosis of psychosis and antidepressant medication for poor appetite. Interventions include administrator medication as ordered dated 3/10/24; antidepressant side effects: constipation, dry mouth, difficult urination, blurred vision, sedation, excitation, insomnia, confusion, hypotension, tachycardia. Notify MD of abnormal findings dated 3/10/24; antipsychotic side effects: constipation, dry mouth, difficult urination, blurred vision, sedation, excitation, confusion, tremors, rigidity, restlessness, muscle spasms, involuntary facial movements, shuffling gait, drooling, hypotension, hypotension, tachycardia Notify MD of abnormal findings dated 6/8/24; monitor for safety risk and potential fall risk dated 3/10/24; notify physician of recent status change dated 3/10/24;physician evaluation to set time period for reduction dated 6/8/24; psych evaluation as needed dated 6/8/24; refer resident to social services for additional support when needed dated 6/8/24.R104 medical record did not document any AIMS assessments or psychotropic medication assessments.On 2/20/26 at 1:46PM, V2 (director of nursing) confirmed that there was no AIMS assessments or psychotropic medication assessments for R104. On 2/20/26 at 2:52PM, V2 (director of nursing) said there were no other plan of care for 104 to document any individualized nonpharmacological interventions. V2 was unable to present any of requested missing assessments or documents during the survey.R113 was admitted to the facility on [DATE] with a diagnosis of bipolar disorder and depression.R113 order details dated 1/12/26 documents: Depakote 250mg one tablet twice a day for bipolar disorder.R113 medical record documents sertraline 100 mg daily with a start date of 4/3/25.R113's Abnormal involuntary movement scale (AIMS) dated 8/24/25 documents low risk. R113 had AIMS assessment dated [DATE] and 7/14/24 with no other AIMS assessments documented.R113's plan of care documents: R113 requires the use of psychotropic medications sertraline to assist with managing mood and behavior related to antidepressant dated 5/5/25. Interventions include administer medication as ordered dated 5/5/25; assess any behaviors/mood changes dated 5/5/25; notify the physician of resident status change dated 5/5/25.R113's psychotropic medication assessment form dated 9/15/25 documents initial assessment that is not completed or signed by staff for completion. Documents under status in progress. There was no other psychotropic medication assessments listed or documented in the medical record.On 2/20/26 at 1:46PM, V2 (director of nursing) confirmed that there was no other AIMS assessments or psychotropic medication assessments for R113. On 2/20/26 at 2:52PM, V2 (director of nursing) said there were no other plan of care for R113 to document any individualized nonpharmacological interventions. V2 was unable to present any of requested missing assessments or documents during the survey.Facility policy Psychotropic Medication Program reviewed 1/2026 documents: the purpose is to promote the safe and effective use of psychotropic mediations. To ensure the lowest dose of mediation is used for the shortest timeframe. To guarantee a resident's quality of life is enhanced by the mediation usage. The second purpose of this process is to ensure the resident is evaluated and the indication for the medications is documents within the mediation record including but not limited to the nursing staff, social services, activities and the physician. Also, resident and resident representative are aware of the potential side effects and the facility obtains an informed consent for the use of psychotropic medication. The third purpose of this guideline is once a resident is placed on a psychotropic medication the facility monitors the resident for side effects and adverse reactions, addresses the use of the medications in a comprehensive plan of care, and assesses the residents for gradual dose reduction. Upon admission and quarterly each resident will have a psychotropic medication reviewed utilizing the psychotropic medication assessment for initiated by the program designee. This form will identity the time period the resident has been taking the medication, the diagnosis for the mediation, behavior associated with the need for the medication and non-pharmacological interventions. Nonpharmacological interventions are defined as interventions to assist with deescalating behaviors without the use of medications. These interventions will be personalized for the resident and will be obtained through resident/family interview, social service and activity assessments and staff interaction with resident. A baseline Abnormal involuntary movement scale (AIMS) test will be done by the psychotropic nurse or designee prior to starting any new anti-psychotic medication and at least every 6 months thereafter. Care planning: once the resident is placed on a psychotropic medication, the team will review and revise the plan of care. The care plan will be developed with input from the resident's family or resident's representative and include participation from the interdisciplinary team. The care plan will be initiated upon start of the psychotropic medication and be reviewed at least quarterly. The care plan will include current psychotropic medication regime, diagnosis for medication use, targeted symptoms/behaviors, individualized nonpharmacological interventions along with additional monitoring interventions.

Based on observation, interview, and record review, the facility failed to ensure that wound care treatments and pressure ulcer prevention interventions, including repositioning and turning, were implemented as ordered. This affected one of eight residents (R11) reviewed for pressure ulcers in a sample of 44 residents R11's face sheet shows diagnosis of hemiplegia, hemiparesis following cerebral infraction affecting left non dominate side, type two diabetes. R11's wound assessment dated [DATE] shows coccyx wound, type; pressure, source; facility acquired, clinical stage;3, date identified 2/28/2023, care goal; decrease ulcer area, approach; off-loading, optimizing moist wound healing. On 2/19/26 at 9:51am during continuous observations from 9:51am to 12:00pm R11 was observed resting on her back in supine position at 45 degrees (position confirmed by V30-LPN). The facility staff did not turn and reposition R11 during this continuous observation. Staff were observed standing at R11's room doorway at 10:30am, 11:00am, 11:41am. One staff member dressed in purple entered the room and immediately came out. At 12:00pm request was made to observe R11's skin, V30 assisted. R11's feet (bilateral) were observed with severe dry skin, flaking and falling off, able to be poured out the sock. R11 was agreeable for observation of wound treatment dressing to sacrum, R11 did not have a wound treatment dressing applied. V30 said R11's sacral wound should be covered, V30 said she was not made aware that the wound treatment dressing was not on.2/19/26 12:16pm V36 (CNA) was identified as R11's nursing aide. V36 said the last time she changed R11 was at 9:30am, and that was the last time she turned R11 also. V36 said the wound treatment dressing was not in place at the time of care. V36 said she did not inform the wound care Nurse, nor did she inform V30 (LPN). V36 said she did not inform anyone that R11's sacral wound dressing was not on. V36 said she received training on notifying the nurse immediately when the wound treatment dressing is not on and she should have notified the Nurse and or the wound care Nurse. V36 said she doesn't know why it's important for R11's wound treatment to be on and in place. V36 said R11 should be turned every two hours to prevent pressure sores from developing, it helps with circulation.2/20/26 at 9:37am V6 (wound care Nurse) said she was not made aware on 2/19/26 at 9:30am that R11's wound treatment was not on and or in place. V6 said her expectation is that V36 inform her or the floor Nurse. V6 said the floor Nurse could have put a wound treatment dressing in place until she (V6) was available to apply the treatment as ordered. V6 said R11 has a facility acquired wound and her goal is to heal R11's wound. V6 said not repositioning R11 and not having the wound treatment in place can contribute to R11's wound not healing. V6 said turning promotes blood circulation. V6 said R11 has calcium alginate in place to breakdown the bioburden, calcium alginate is a form of debriding. V6 said R11 wound treatment was changed today. V6 said R11's Braden score is 12, and R11 is at risk for skin breakdown.2/20/26 at 11:46am V2 (Director of Nursing) said her expectation is that staff complete rounds, providing incontinent care, turn/reposition every two hours or as needed, the staff should be providing whatever care that the residents may need. R11's physician order sheet dated 12/23/25, shows orders for coccyx: cleanse with saline; pat dry; apply betadine to peri wound; apply iodosorb gel and calcium alginate to wound bed; cover with dry dressing daily and PRN (as needed). R11's care plan shows R11 has a pressure ulcer coccyx area, administer treatment per physician orders, low air loss mattress in place to help promote wound healing and reduce risk of wound deterioration, use pillows and/or positioning devices as needed, administer analgesia per physician orders. R11 is at risk for alteration in skin integrity related to: impaired mobility, b/b incontinence, weight loss, presence of G tube and h/o pressure ulcer, dx of DM (diabetes). R11 has self-care deficits related to decreased functional mobility and strength, decline in cognition and DX (diagnosis) cerebral infraction with left hemiparesis and dysphagia, chronic diastolic heart failure and dementia, bed mobility with assist x2. Facility policy titled skin care prevention, dated 1/2023 shows all residents will receive appropriate care to decrease the risk of skin breakdown. The nursing department will review all new admissions readmissions to put a plan in place for prevention based on the resident's activity level, comorbidities, mental status, risk assessment and other pertinent information. All resident that are unable to reposition themselves will be repositioned as needed based on a person-centered care approach (minimum of every two hours).

Based on observation, interview, and record review, the facility failed to ensure licensed nurses demonstrated the competencies and skills necessary to safely manage and monitor residents receiving enteral nutrition via feeding pump, in accordance with professional standards of practice, placing residents at risk for complications related to improper administration and monitoring of enteral feedings. This affected three of three residents (R4, R82, R89) who were receiving enteral nutrition in a sample of 44 residents.Findings include:On 2/17/26 at 10:30 AM, R82 was observed in room. Intermittent observations were made from 12:30 PM until 4:00 PM, R82 was observed self-propelling wheelchair in halls and attending activities; R82 was not connected to enteral feeding pump.On 2/17/26 at 10:15 AM, R89 was observed lying in bed. R89's enteral feeding pump was turned off. Intermittent observations were made from 12:30 PM until 4:00 PM, R89 was in wheelchair at nurses' station not receiving enteral feeding.On 2/19/26 at 3:30 PM, V29 (activity director) stated that R82 is in wheelchair participating in activities or self-propelling in halls all day every day.On 2/19/26 at 10:32 AM, V24 (nurse) stated that R89's enteral feeding was started at 5:50 AM. When questioned how it is communicated to oncoming nurses the amount of feeding delivered and/or amount left, V24 did not respond. When questioned if V24 clears the feeding pump of volume infused at the end of V24's shift, V24 responded the night shift nurse clears the pump. When questioned how does V24 know when the resident has received the total amount of feeding per 24 hours, V24 responded the pump will shut off. When questioned how to check pump settings and amount fed, V24 did not respond and left R89's room.On 2/19/26 at 10:35 AM, V7 RD (registered dietitian) stated that enteral feedings are ordered to deliver feeding over 20 hours daily to ensure the resident is receiving adequate nutrition. V7 stated that R89 should receive 1680 ml (milliliters) total feeding and 1050 total water per 24 hours. V7 reviewed on R89's enteral feeding pump the amount of feeding R89 received in the past 24 hours and 48 hours. V7 stated that the pump shows R89 received 1080 ml of feeding and 715 ml of water flush in 24 hours and 2264 ml feeding and 1240 ml water flush in the past 48 hours. V7 stated that R89 is not receiving adequate nutrition.On 2/19/26 at 10:50 AM, V7 RD stated that R82 should be receiving 1500 ml total feeding and 1800 ml water flush per 24 hours. V7 stated that R82's feeding pump shows R82 received 1021 ml of feeding and zero water flush in 24 hours and 1852 ml feeding and zero water flush in the past 48 hours. V7 stated that R82 is not receiving adequate nutrition.On 2/19/26 at 11:00 AM, V7 RD stated that R4 should be receiving 1500 ml total feeding in the past 24 hours. V7 stated that R4's pump shows she has received 1561 ml so far and the pump is still running.On 2/19/26 at 11:15 AM, V2 DON (director of nursing) stated that the nurses received an in-service on the enteral feeding pump one year ago. V2 stated that the nurses were not competencied on the feeding pump. V2 stated that if the nurse is expected to ask V2 or the nurse manager for assistance if the nurse does not know how to use the enteral feeding pump or has any questions. V2 stated that nurses that started working at this facility after 1/27/25, received 1:1 training on the enteral feeding pump during orientation.The facility provided a list noting there are 47 current licensed nurses working at this facility. Of these 47 nurses, 21 started after 1/27/25.On 2/20/26 V2 DON presented the facility's enteral feeding pump in-service documentation dated 1/27/2025. Six of the 47 licensed nurses were in-serviced. The facility was unable to provide documentation that the 21 nurses that started after 1/27/25 received training during orientation. The facility was unable to provide any documentation that the 41 nurses that did not attend the in-service on 1/27/25 received any education on the feeding pump. The facility was unable to provide any documentation that all nurses are competent in using the feeding pump.The facility's tube feeding policy, dated 01/2024, notes in part, the health care provider should be notified if tube feeding amount not infused as ordered. Feeding pump: pump should be cleared at the end of each shift. Document tube feeding delivered. Alert health care provider of any issues or concerns.

Based on observations, interviews, and record reviews, the facility failed to follow its infection prevention and control policy and don appropriate PPE (personal protective equipment) prior to entering resident rooms with enhanced barrier precautions and providing direct resident care. The facility also failed to place a resident with a gastrostomy tube in enhanced barrier precautions. These failures affected three residents (R78, R82, and R89) out of 6 residents reviewed for infection control in a sample of 44.Findings include:On 2/17/26 at 11:35 AM, V22 CNA was observed bringing clean linen into R78's room; V22 had gloves on. V22 did not don a gown prior to entering R78's room to provide direct resident care. There was signage noted on R78's door for EBP and a bin with PPE located next to R78's door. At 11:51 AM, V22 exited R78's room carrying soiled linens.On 2/17/26 at 12:20 PM, this surveyor observed an enteral feeding pump at R89's bedside. There was no signage for enhanced barrier precautions (EBP) noted on or near R89's door. There was no bin with PPE outside of R89's room.On 2/19/26 at 11:50 AM, V26 (restorative aide) and V27 (restorative aide) were observed using a mechanical lift device to obtain R82's weight. V26 and V27 did not don appropriate PPE prior to entering R82's EBP room.On 2/19/26 at 1:40 PM, V3 (infection prevention nurse) stated that residents with colonized multidrug resistant organisms are placed in EBP. V3 stated that residents with indwelling catheters, wounds, intravenous access devices, gastrostomy tubes, and receiving dialysis are also placed in EBP. V3 stated that staff are expected to don gowns and gloves when providing direct resident care to residents in EBP.The facility's infection prevention and control policy, dated 07/2025, notes in part enhanced barrier precautions involves the use of gloves and gowns during high contact resident care activities infected or colonized with multidrug resistant organisms as well as residents with wounds and/or indwelling medical devices.

Based on interviews and record review, the facility failed to prevent an injury of unknown origin which occurred for one resident. This affected one of three residents (R1) reviewed for injury of unknown origin. This failure resulted in R1 sustaining an undetermined injury of an acute left humeral neck with displaced transverse fracture.Findings Include:R1's referral package dated 8/17/22 documents: past medical history of falls, osteoporosis and closed hip fracture. R1 was admitted with the diagnosis of Age-Related Osteoporosis without current pathological fracture. Minimal data set section C (Brief interview for mental status) dated 6/3/25 document a score of four (4) which indicates severe cognitive impairment. Section GG (functional abilities) documents: R1 required substantial/maximal assistance with upper body dressing, the ability to dress and undress above the waist: including fasteners, if applicable. Event report dated 6/29/25 documents: At approximately 4:00pm on 6/29/25, the assigned V6 (CNA) reported to V8 (nurse) that following taking R1's blood pressure with the vital machine there was a discoloration to her left arm. V8 and another nurse went to assess and noted a mild discoloration to R1 left arm where the cuff was applied. Action taken: range of motion within normal limits, R1 denied pain, MD notified of temporary discoloration that appears to have resolved. R1's X-ray requisition dated 7/1/25 documents reason: unable to move left arm. Radiology report dated 7/1/25 document: Impression: Left humerus (long bone in the upper arm neck extending from the shoulder to the elbow) with complete transverse fracture with displacement. V8's witness statement dated 7/2/25 documents: continues to monitor R1 with no worsening and it seemed to resolve.On 7/15/25 at 9:35am, V9 (nurse) said on Sunday June 29th at the end of her day shift, and the beginning of V8's (nurse) shift which was the evening shift (3pm-11pm), V8 asked V9 to look at R1. V9 said, R1 was observed with bruised area to the left upper arm. V6 reported taking R1's vitals, V9 said V8 was asking R1 questions about her left arm. V9 said, R1 was unable to report how she got the bruise or an incident. V9 denies knowledge of incident/abuse involving R1. On 7/15/25 at 10:07am, V6 (CNA) said, when he did his rounds and passed water to R1 around 2:30pm -3:00pm, R1 was relaxing perfectly fine in bed. V6 said, about an hour later he took R1's vitals. V6 said, R1 made a face when he took off the blood pressure cuff off her arm. V6 said, he informed the nurse who instructed V6 to update him if R1's bruise got worst. V6 said, R1's bruise was a little red. V6 said, R1's bruise did not get worst. V6 said, he asked R1 what happened, R1 denied fall or abuse. Vital report dated 6/28/25 and 6/29/25 taken by V6 (CNA) documents lying/r/arm. On 7/18/25 at 2:15pm, V2 said, r indicates Right arm.On 7/15/25 at 12:08pm, V1 (administrator) said R1's bruise was not an injury of unknown origin R1's left arm fracture was. V1 said, she does not know when R1's fracture occurred. V1 said, staff saw the discoloration to R1's arm after V6 (CNA) removed the blood pressure cuff. Then an x-ray was ordered which resulted in a fracture. V1 said, R1 did not have a traumatic event. V13 (nurse practitioner) said, R1's fracture was pathological. R1 had a diagnosis of osteoporosis and osteopenia. On 7/15/25 at 1:11pm, V16 (orthopedic specialist) said, R1's fracture was due to either a fall on the ground landing on her left arm or someone moved R1 attempting the wrong way, lifting by R1's arm instead of R1's core. Pathological fractures are due to underlying conditions associated with cancers/tumor. V16 said, a blood pressure cuff did not cause R1's fracture. R1 is not a healthy person but none of her current diagnosis would be associated with her fracture. V16 said, bruising/blood takes three to five days to come out of the bone, travel through the muscle and appear on the skin. On 7/15/25 at 1:29pm, V13 said, staff called him to report R1's bruise. Staff reported R1 had a routine blood pressure and when the cuff was removed, she had a bruised area where the cuff had been placed. V13 said he asked what happened, staff denied pain initially, fall or trauma. R1 had osteoporosis. R1's bruising increased. R1 complained of mild pain. R1 had swelling noted to her left upper arm. V13 said, he ordered an x-ray which resulted in a transverse fracture. V13 said, R1 was discharged to the hospital for further evaluation. No surgery was indicated. R1's fracture could be from osteoporosis or from normal activities of living (ADL) i.e. R1 could have been moving and the bone just snapped or with ADL care when staff was helping resident. R1 was on prednisone which can demineralized the bones. V13 said, he did not review the x-ray result, speak with any of the hospital doctors or the orthopedic doctor in order to determine the root cause of R1's fracture. V13 said, he cannot differentiate the cause of R1's fracture. V13 said, he relied on staff's information. V13's practitioner note dated 7/7/25 documents: Member (R1) with significant past medical history of osteoporosis, hypothyroidism, severe calories malnutrition and based on review of hospital note, her (R1) acute displaced fracture to left humerus is mostly due to pathological fracture. Per staff, on 6/30/25 evening, R1's blood pressure taken and they noted to have bruises to the left upper arm where blood pressure cuff was placed. In the morning, staff noted that the bruising worsened, with swelling, complaint of pain with limited movement of her left arm.On 7/15/25 at 3:52pm, V2 (Director of Nursing) said, R1's fracture was perceived to be from the blood pressure cuff compression. V2 said, she was not sure why R1's arm did not bruise with the other daily blood pressures that were taken prior to the bruised area being found. V2 said, R1's body was changing and at that time the blood pressure was taken, it could have been a change in R1's body resulting in a bruised arm after the blood pressure cuff was removed.Hospital paperwork dated 7/2/25 documents: R1 with past medical history of age-related osteoporosis and functional quadriplegia who presented from nursing facility for evaluation of left upper extremity bruising, Unknown if R1 had a fall or when R1 incurred injury to left arm. Per emergency room physician discussion with primary care provider, there were no documented fall at skill nursing facility but patient (R1) was being lifted from bed to wheelchair and back to bed with a mechanical lift during which injury may have been possible. X-ray note acute displaced fracture of left proximal humerus.

Based on interview and record review, the facility failed to monitor a resident (R2) sitting on the side of the bed when preparing R2 for a transfer when R2 reached for an item on the ground causing R2 to fall off the bed for one out of three residents reviewed for falls in a total sample of eight. The failure resulted in R2 needing to be hospitalized after suffering a laceration to the head and a subarachnoid hemorrhage. Findings Include: R2 is an [AGE] year old with the following diagnosis: traumatic subdural hemorrhage, aphasia, hemiplegia affecting the left side, glaucoma, and cognitive communication deficit. Nursing note dated 4/5/25 documents the CNA reported to the nurse that as the CNA was turning to grab R2's wheelchair, R2 fell forward from a sitting position on the side of the bed. R2 struck R2's head on the nightstand before landing on the floor on the left side. The nurse assessed R2 and noted a small laceration to the left side of the forehead with moderate bleeding. A pressure dressing was applied by the wound nurse. 911 was called and took R2 to the hospital for an evaluation. R2 was admitted to the hospital. Nursing note dated 4/5/25 at 11:50 PM documents R2 was transferred to a different hospital with a diagnosis of left subdural hematoma. The Hospital Transfer Form dated 4/5/25 documents the reason for transfer was fall. A laceration was noted to the left side of the head. R2 was documented as being a high fall risk. The Emergency Department Records dated 4/5/25 document R2 presented to the emergency room for a witnessed fall. R2 has no recollection of the fall and does not know why R2 was sent to the emergency department. Per the facility, R2 fell while being transferred from the bed to the wheelchair. R2 was not a reliable historian. Upon physical examination, there was a concern for a forehead laceration. A CT of the head was completed and showed a small subdural hematoma along the left cerebral convexity, and a small hemorrhagic contusion to the left frontal lobe. The x-ray of the pelvis showed an irregularity along the lesser trochanter of the femur, which could be concern for fracture. R2 had a laceration repair at 11:59 AM. The laceration was about 3 cm in length and repaired with steri-strips. R2 was then transferred to another hospital as a trauma patient. A follow up CT scan was completed at this hospital, which showed a decrease in size of the frontal lobe contusion since yesterday. There is small residual hyperdense focus. No new hemorrhage was identified. The subarachnoid hemorrhage has resolved. The MRI of the left hip did not show any evidence of a left hip or proximal femur fracture. There is mild subcutaneous edema within the left lateral hip. The Facility Incident Report dated 4/11/25 documents the CNA assisted R2 with ADL care. The CNA reached to position the wheelchair for transfer when R2 reached for eyeglasses on the floor and fell forward, landing on the left side before the CNA could assist R2. The CNA immediately alerted staff for assistance. A body assessment was completed and an open area to the left side of the forehead was noted. First aid was administered and a dry dressing was applied. When interviewed, R2 said, I was reaching. Prior to the incident, R2 was sitting comfortably with the bed in the lowest position. New orders were received to send R2 to the emergency room for further evaluation. R2 was transferred to a different hospital and admitted with a small left subdural hematoma. Repeat CT scan revealed this small hematoma resolved and did not require any surgical intervention. On 5/13/25 at 2:06PM, V2 (CNA) stated V2 was doing morning care and was getting R2 dressed and washed up. V2 sat R2 on the side of the bed and R2 was sitting up. V2 reported R2 reached down on the side of the floor and fell out of the bed. V2 stated V2 always has to coach R2 when V2 is with R2 because R2 has a habit of reaching. V2 reported R2 wasn't a high fall risk at the time of the fall and is a one assist with transfer and walking. V2 stated V2 was facing R2 when R2 was reaching but V2 was setting up the wheelchair so V2 didn't see R2 begin to fall. V2 reported V2 was maybe a foot or two away from R2 when the fall occurred. V2 stated V2 set the wheelchair down right in front of R2 so the wheelchair was in between V2 and R2. V2 reported V2 usually sets up the wheelchair in the way because R2 has never had a problem with falling forward before. V2 stated R2 had a cut to R2's head. V2 was unaware if R2 was in physical therapy at the time of the fall. On 5/14/25 at 11:50AM, R2 was sitting at the dining room table waiting for lunch. R2 stated R2 was comfortable speaking in the dining room. R2 reported having a fall about a month ago. R2 was not able to remember what caused the fall. R2 stated R2 couldn't remember anything until R2 was at the hospital and hospital staff told R2 that R2 fell. R2 pointed to R2's left side of the top of the head and told the surveyor that this is where R2 hit R2's head during the fall. There is a healed scar about 1.5 inches long. R2 was not able to remember if R2 had any other injuries. R2 could not remember who was in the room with R2 during the fall. R2 stated R2 now has a reacher to grab things so R2 won't bend down anymore. R2's mental status was assessed. R2 knew R2's name, birthday, and that R2 was in a nursing facility in Chicago. R2 was unable to state the date or the name of the town. On 5/14/25 at 11:59AM, V4 (Nurse) stated V2 informed V4 that R2 was on the floor so V4 went to assess R2. V4 reported R2 had bleeding coming from the left side of the top of the head and a dry dressing was put on it after the wound nurse looked at it. V4 stated R2 was sent out via 911 per the physician's orders. V4 knew R2 couldn't move one side of the body due to stroke but V4 couldn't remember what side. V4 reported R2 is not a high fall risk and is not confused. V4 stated V2 told V4 that R2 was leaning forward out of the bed and was trying to grab something and fell. V4 was not aware of R2 having that behavior. On 5/14/25 at 1:02PM, V6 (Therapy Director) stated when R2 was in therapy before the fall, R2 was moderate assist with transfers. V6 reported transfers were rough for R2 so R2 was referred to therapy for that reason. V6 stated R2 had fairly good trunk control. V6 reported R2 can follow directions and knows who you are but won't remember what day it is. On 5/14/25 at 1:45PM, V10 (Medical Director) stated a radiologist will report any kind of bleed even if the bleed is small in the brain. V10 reported if there is an area the radiologist sees that is hyperdense focus it means that area of the brain on the scan was brighter than it should have been, but it is usually a really tiny area only millimeters long. V10 stated the hyperdense focus could be from a bleed that has a large sized hematoma to accompany it which would be caused by trauma. V10 reported if a resident has a certain behavior that puts them at risk of being harmed then it is the responsibility of the facility to prevent any harm from that behavior as best as possible by putting in interventions that address the behavior. On 5/14/25 at 2:07PM, V9 (DON) stated V9 does all the reportable investigations for falls with injury. V9 reported R2 had a witnessed fall with a laceration to the head. V9 stated V2 told V9 that V2 turned to get the wheelchair for R2 when R2 leaned forward and fell before V2 could react. V9 denied R2 remembering the fall. V9 reported R2 was admitted to the hospital so they could rule out a subarachnoid bleed in the brain. V9 stated the subarachnoid bleed was ruled out but R2 needed to stay in the hospital about three to four days for monitoring. V9 was not able to answer if the brain bleed was ruled out then why was it added to R2's diagnoses on the face sheet? V9 said, That is a question for MDS. V9 reported R2 also had a laceration repair of the forehead while at the hospital which has now healed. V9 stated a reacher was put in place after the fall to prevent any additional falls from happening in this manner. V9 reported R2 is a fall risk but not a high fall risk because R2 is not confused. V9 stated R2 does have a history of a stroke with weakness or paralysis to one side. On 5/14/25 at 2:53PM. V13 (MDS Nurse) stated V13 reviews the most recent assessment and plan from the physician in the hospital records upon a resident's return to the facility. V13 reported V13 uses active diagnoses to update the resident's face sheet. V13 stated R2 had a follow up with neurosurgery to see if R2 was able to restart the anti-platelet medication after having the brain bleed. The Fall Report dated 4/5/25 documents the CNA was providing R2 morning ADL care. The CNA just changed R2's clothing and sat R2 on the side of the bed to get R2 into the wheelchair. The CNA reported turning to retrieve the wheelchair when R2 leaned forward from a sitting position at the side of the bed, causing R2 to destabilize and fall forward. R2 struck R2's head on the nightstand before landing on the left side. R2 said, I fell onto the floor. I am OK but my head hurts. R2 denied any other pain or discomfort. R2 is noted with a small laceration to the left forehead with moderate bleeding. 911 was called to take R2 to the hospital for further evaluation. The Hospital Records dated 4/7/25 document R2 has a history of cerebral vascular accident with residual left sided hemiparesis. R2 presented as a trauma transfer for mechanical fall R2 was being transferred from the wheelchair when R2 became lightheaded and fell forward, hitting R2's head but did not lose consciousness. The initial CT scan of the head showed a small subdural hematoma with serial CT scans showing the hematoma was stable. Per neurosurgery, no surgical interventions are recommended, but will continue to hold the anti-platelet medication until follow up. An MRI of the left femur revealed there was no evidence of acute fracture. Assessment and plan documents a mechanical fall with a subdural hematoma. This is the documentation that V13 referenced and showed the surveyor for the diagnosis of subdural hematoma that was entered on R2's face sheet upon return to the facility. The Physical Therapy progress report dated 3/7/25 through 4/2/25 documents R2 is a fall precaution with aphasia and left sided weakness. R2 needs partial/moderate assistance from going from a sitting to standing position and transfers. R2 needs supervision or touching assistance with walking. Picking objects up off the floor is documented as not applicable. Continue therapy is recommended to increase lower extremity range of motion and strength, minimize falls, and promote safety awareness. The note dated 4/2/25 documents skilled interventions focused on instruction in scooting techniques to facilitate upright posture and proper positioning in wheelchair and training and safe sit to stand/stand to sit mobility. The After Visit Summary dated 4/30/25 documents R2 had a follow up with neurosurgery and was cleared to resume the anti-platelet medication. This was a follow up due to the subdural hematoma and fall. The Fall Risk Evaluation dated 11/2/23 documents a score of 15 indicating R2 is at high risk for falls. This assessment was completed post fall. R2 has decreased mobility, is confused/has impaired memory or judgment, is incontinent, and above 75. No other fall risk evaluations were completed again until 4/5/25. This fall risk evaluation document a score of four indicating R2 is not at risk for high fall. A score of 10 or higher makes a resident high risk for falls. When looking at the assessment, it is incorrectly coded, giving R2 a lower score. If the assessment was properly charted, R2 would have a score higher than 10 making R2 a high fall risk. The Functional Abilities and Goals dated 2/7/25 document R2 needs substantial/maximal assistance with bed mobility, going from a sitting to standing position, and transfers. Picking up an object from the floor was not attempted due to medical condition or safety concerns. The Care Plan dated 11/3/23 documents R2 is at high risk for falls related to impaired mobility and strength, decline in cognition, potential medication side effects, unsteady gait, and diagnosis of cerebral infarct with left hemiplegia. Interventions put in place after the fall on 4/5/25 include educate R2 on the importance of complying with safety measures and document understanding of education and instances of noncompliance, encourage use of and provide a reacher as needed to assist R2 with getting items from hard reach areas, and encourage appropriate use of the walker and wheelchair. The Care Plan dated 11/8/23 documents R2 is memory, impaired, and has difficult with decision-making, insight, logic, planning, and organization of thoughts. The Care Plan dated 11/9/23 documents R2 is on antiplatelet therapy and is it risk for adverse side effects. The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental status score at 11 (moderate cognitive impairment). Section GG of the MDS indicates R2 has an upper extremity impairment to one side. R2 needs substantial/maximal assistance with bed mobility and transfers. The policy titled, Fall Prevention and Management, dated 2/2025 documents, General: This facility is committed to maximizing each resident's physical, mental, and social well-being. While preventing falls is not possible, the facility will identify and evaluate those residents at risk or fall, plan preventative strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed.

Based on observation, interview, and record review the facility failed to ensure the antibiotic prescribed include duration, care plan, and documentation of long term used. This deficiency has the potential to affect 1 of 2 residents (R103) reviewed for antibiotic use in a sample of 23. Findings Include: On 11/12/2024 at 12:31PM, R103 on Enhanced Barrier Precaution (EBP). R103 said he takes medication for infection. On 11/14/2024 at 01:02PM, R103 said he knows he is on antibiotic medication for infection but does not know the name and has been taking it since he came to facility in September 2024. On 11/14/2024 at 10:35AM, V4 (Infection Control Nurse) said R103 is prescribed antibiotic, Metronidazole, should include a start and stop date along with indication for use. V4 said as part of Antibiotic Stewardship program, V4 review all antibiotic prescribed within a day or two of admission and communicate to the doctor if the duration is not indicated and document on resident medical records. V4 said the antibiotic prescribed for R103 on September admission should have a stop date. On 11/14/2024 at 10:58AM, V2 (Director of Nursing/DON) said all antibiotic should have a start and stop date along with indication for use. Doctor should be informed if duration is not indicated. R103 Metronidazole antibiotic should have a stop date and not indicated for long term used. On 11/14/2024 at 01:05PM, V14 (Licensed Practical Nurse/LPN) said she is a regular on the unit where R103 resides but do not give antibiotic to R103 on her shift. V14 reviewed physician order with Surveyor which include the Metronidazole antibiotic. V14 said there should have been a stop date for the antibiotic. Admission Record: Diagnosis Information: Sepsis, Unspecified Organism Order Summary Report: Metronidazole Oral Tablet 500 MG (Metronidazole) Give 1 tablet by mouth every 12 hours for Bacterial Infection, Order date - 9/25/2024, Start date - 9/26/2024, no End date. Care Plan (Created on 11/14/2024) Focus: R103 is on Antibiotic Therapy r/t bacterial infection. Policy: Guideline: Antibiotic Stewardship Review Date: 2/2024 Policy: It is the policy of . to maintain an Antibiotic Stewardship Program with the mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. Components of the policy were developed by using evidence-based practice guidelines and are aligned with the Core Elements of Antibiotic Stewardship for Nursing homes, published by Centers for Disease Control and Prevention (CDC)(1), and State Operations Manual (Appendix PP): Guidance to Surveyor of Long Term Care Facilities, published by CMS (2). Prescribing record keeping: Dose, duration, route, and indication of every antibiotic prescription MUST be documented in the medical record for every resident. Records will be reviewed monthly to assess compliance with this requirement, as well as prescription appropriateness for the individual resident.

Based on observation, interview, and record review the facility failed to implement ongoing monitoring of antibiotics. This deficiency affects one (R103) of three residents in the sample of 23 reviewed for Antibiotic Stewardship Program. Findings include: On 11/14/2024 at 10:36AM, V4 (Infection Preventionist) said that she reviews the antibiotic medications prescribed weekly and an infection assessment evaluation is done prior to the start of antibiotic use for the purpose of monitoring for the antibiotic stewardship program. V4 said that R103 is currently on Metronidazole 500mg every 12hours for bacterial infection with no stop date. V4 said she is unable to locate R103's infection assessment evaluation record upon start of antibiotic. On 11/14/24 at 1:58PM, V2 (Director of Nursing) said that her expectations for the antibiotic stewardship program should be an ongoing monitoring of antibiotics. R013 admitted on [DATE] with diagnosis listed in part but not limited to sepsis unspecified organism, periprosthetic fracture around internal prosthetic left knee joint, subsequent encounter. Active physician order sheet indicates: Metronidazole tablet 500 MG every 12 hours for bacterial infection started on 9/26/24. Facility's policy on Antibiotic Stewardship Program indicates: Reviewed 2/2024. It is the policy of . to maintain an Antibiotic Stewardship Program with the mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. Components of the policy were developed by using evidence-based practice guidelines and are aligned with the Core Elements of Antibiotic Stewardship for Nursing Homes, published by Centers for Disease Control and Prevention (CDC) (1), and the State Operations Manual (Appendix PP): Guidance to Surveyors of Long-Term Care Facilities, published by CMS (2). Actions Prescribing and record keeping. -Dose, duration, route, and indication of every antibiotic prescription MUST be documented in the medical record for every resident, regardless of prior prescriptions or documentation elsewhere (e.g., in medical record of a discharging facility). Notation of this information should be made on the day that an in-house prescription is written or on the day that a resident returns to the facility on an antibiotic prescribed elsewhere. -When a new antibiotic is prescribed, the receiving nurse will open a new case in the PCC Infection Control module and an Antibiotic therapy form in PCC. -Records will be reviewed monthly to assess compliance with this requirement, as well as prescription appropriateness for the individual resident, site, and type of infection. -Assessment of residents suspected of having an infection. Providers will utilize the McGeer's Criteria or the Loeb Criteria for initiating Antibiotic usage.

A. Based on interview and record review, the facility failed to follow physician orders by not obtaining a urinalysis and culture for one resident who was identified as being incontinent of urine with a new onset of lethargy. This affected one of three residents (R4) reviewed for physician orders. This failure resulted in R4 being sent to the hospital with a diagnosis of urinary tract infection and sepsis. B. Based on interview and record review, the facility conduct a comprehensive body assessment on a resident observed with his left leg/knee contorted under his wheelchair, facial grimacing and yelling out with movement. This affected one of three residents (R3) reviewed for quality of nursing and assessment. This failure resulted in R3 waiting twenty hours for an x-ray order which resulted in a diagnosis of a new acute transcervical left femoral neck fracture with marked impaction and varus angulation. Findings include: A. R4 was admitted to the facility on [DATE] with a diagnosis of hemiplegia, abnormalities of gait, weakness, depression, hypertension, functional quadriplegia, and compression of the brain. R4'as physician order dated 6/4/24 at 8:05PM documents: STAT chest x-ray, STAT CBC, CMP and Urinalysis with culture and sensitivity. On 7/26/24 at 12:26pm, V14(Lab Tech) said they did not receive any notification from the facility for any urine collection pick ups and did not receive any urine specimens from the facility for R4. On 7/31/24 at 11:32AM, V19(Nurse Consultant) said the facility practice on obtaining a urinalysis from an incontinent patient, would be to get an order for urine straight cath from the doctor and family consent. Staff should let the doctor know if unable to obtain urine specimen. The staff will usually get the sample during night shift or earlier because the lab will pick up specimens in the morning. V19 said the lab comes every morning to the facility. On 7/31/24 at 9:17AM, V36(NP) said if R4 had an order for urinalysis, she would expect staff to have collected specimen prior to hospitalization . Staff should have called to obtain order for straight cath if no urine was able to be obtained especially in an incontinent resident within first day. V36 denies receiving any calls related to R4 needing a straight cath order. V36 said she does not recall receiving any calls related to a change in mental status for R4 and said if she did, she would have sent R4 to the hospital immediately because she was a new admit and a change in her condition. R4's hospital record dated 6/6/24 documents: R4 presents from facility with altered mental status. R4 opens eyes to name but unable to answer questions or follow commands. R4's white blood count was 12.6 high (normal range 4.2-11.0). Clinical impression documents sepsis, tachycardia and acute urinary tract infection. R4s urinalysis dated 6/6/24 documents urine color orange; appearance turbid; occult blood large (normal is negative); leukocytes large (normal result negative), bacteria moderate (normal result none); Mucous present. Urine culture collected 6/6/24 and completed 6/9/24 documents greater than 100,000 Escherichia coli. Blood culture collected 6/6/24 and completed 6/9/24 documents Escherichia coli. R4's Minimum Data Set, dated dated dated [DATE] documents under section H bowel and bladder under urinary continence documents always incontinent. 41758 B. On 7/25/24 at 3:13PM V10 (Nurse) said, R3 was wheelchair bound, very weak and could not articulate well. V10 said, V13 (CNA) updated her that R3 was yelling when she touched his left leg. R3 had a history of left knee pain. V10 said, R3 allowed her to move his left leg. R3 was in pain. V10 said, R3 had a facial grimace when she attempted to reposition R3's leg while he was in the wheelchair. V10 said, she lifted R3's leg up and down while R3 sat in his wheelchair. V10 demonstrated lifting her leg by gathering both hands underneath her posterior thigh just behind her bent knee and lifted her leg up, with her foot coming off the floor a few inches while she sat in the chair. V10 did this motion once as an example of how she assessed R3 while he was sitting in his wheelchair. V10 said, she administered, R3's scheduled muscle rub to the knee and gave an acetaminophen. V10 said, she was not sure what happen after that because she ended her shift earlier than scheduled. V10 said, R3 was sent to the hospital the following day. R3 was diagnosis with a fracture. V10 said, she thought R3 was having knee pain. On 7/25/24 at 3:30PM, V13 (CNA) said, she was passing dinner trays, R3 was in his room sitting by the closet which was odd. Normally, R3 was in the hallway, self-propelling in his wheelchair using his feet and the handrail to go back and forth in the hallway. R3 normally ate in the dining room. V13 said, she placed R3's dinner tray on his bedside table. V13 said, she noticed R3's left leg was bent completely back up under his wheelchair. V13 demonstrated how R3 was sitting in his wheelchair by scooting towards the edge of her seat and placing her leg, with a bent knee behind her completely under her chair. V13 said, she tried to move R3's leg. R3 was in so much pain. R3 was unable to report what happen. V13 said, she informed V10. On 7/26/24 at 1:33PM, V18 (PAN Nurse) said, R3 was observed in the bed moaning and groaning in pain. The nurse should have assessed R3's pain by completing a comprehensive head to toe assessment which includes vitals, range of motion to limbs, extending and flexing extremities, asking the resident if something happen, notified MD/family and followed given orders. R3 required staff assistance for transfers. R3 was able to self- propel with feet once in wheelchair. On 7/30/24 at 3:55pm, V32 (Nurse) said, R3's words and actions contradicted each other. R3 will say he is not in pain while guarding or holding on to a body part. On 7/31/24 at 12:58pm, V33 (Medical Doctor) said, she was not notified of R3's change of condition on 6/13/24. Severe osteoporosis/osteopenia can contribute to a fracture but whatever trauma happen to R3's leg that caused his leg to be bent completely under his wheelchair was the cause of his hip fracture. V33 said, she was notified about R3's fracture after he returned from the hospital. V33 said, she would expect the nurse to lay R3 down on his bed and complete a full body exam to include range of motion of the extremities after R3 was groaning with facial grimacing and yelling out in pain. R3 would have had severe pain with a hip fracture. V33 said, she would have ordered a stat x-ray had she been informed of R3's change of condition. Most hip fractures are caused by a traumatic event. V33 said, she does not know exactly how R3 fractured his hip. R3 has a diagnosis of prostate cancer but there was no documentation that R3's cancer metastasized to his bones in R3's medical record therefore it cannot be considered as a factor. Nursing note dated 6/13/24 written by V10 at 18:36 (6:36pm) documents: Prior to dinner CNA (V13) attempted to reposition resident's (R3) left foot to bring side table towards him. Resident (R3) voiced vulgar language and told the V13 to get away from him and also grimaced. Nurse observed R3, R3 grimaced, when moving left leg but not right leg. R3 voiced he was not in pain but did mumble something incoherent. R3 was sitting in wheelchair at time of assessment and refused to go in bed. Resident was observed in room, ambulating in wheelchair but resident did not leave the room during the evening. PRN acetaminophen administered and pain ointment was administered. Left hip was touched, no abnormal reaction to touching site. Knee was assessed as resident refused care, no signs of dislocation fracture or bruising to site. Medication appeared effective. No signs of pain assessed prior to leaving. Witness stated written by V10 documents at approximately 18:15 (6:15pm) on 6/13/24: C.N.A (V13) requested she observe R3. While sitting in his wheelchair R3 was observed with resistance to moving his left lower extremity (LLE) and would not move his left foot. R3 exhibited grimacing and stated leave me alone when the C.N.A (V13) attempted to assist with mobility. V10 assessed R3's left ankle and LLE for any signs of injury. NO sign or symptoms of injury were observed. Witness stated written by V25 dated 6/14/24 documents: during the shift change, second shift CNA stated, she noticed something with his (R3) leg when [NAME] was putting him to bed the night before, V25 then squeezed his (R3) knee again, got no reaction but when I tried to move his leg, he reacted in pain. Telehealth evaluation dated 6/14/24 documents: R3 started to have left leg pain, therefore he had x-ray left hip, knee and left ankle. Left hip revealed impacted fracture of left femoral neck. R3 complained of pain with movement of hip and leg. This is an acute new problem. R3 condition is worsening pain. Transfer to emergency department. Diagnostic Order dated 6/14/24 at 15:29 (3:29pm) documents: left knee, three view, left hip, unilateral with pelvis. Facility radiology result report dated 6/14/24 at 20:55 (8:55pm) documents: impression pelvis: impacted transcervical fracture of the left lower neck with varus deformity. Hospital paperwork dated 6/14/24 documents: He (R3) has been complaining of severe left hip pain which prompted them (facility) to get an x-ray. R3 was able to answer yes and no to questions. Musculoskeletal: Left lower extremity is shortened. Cat scan (CT) pelvis without contrast dated 6/15/24 document: New acute transcervical left femoral neck fracture with marked impaction and varus angulation demonstrated. No dislocation. Diagnosis: Closed hip fracture.

Based on observation, interview and record review, the facility failed to implement effective individualized fall interventions to include supervision/monitoring and reduce the risk of multiple falls. This affected two of three residents (R2, R8) reviewed for falls prevention interventions. This failure resulted in R2, who had a diagnosis of Dementia and Alzheimer's disease and identified as high fall risk sustaining a second unwitnessed fall from bed requiring hospitalization for an acute comminuted displaced fracture of the bilateral nasal bones and one centimeter lip laceration. In addition, the facility left R8 unsupervised on the floor for 13 minutes following an unwitnessed. Findings include: R2 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease, weakness, and dementia. Resident's brief interview for mental status score dated [DATE] documents a score of ,d+[DATE] which indicates severe cognitive impairment. R2's fall risk assessment dated [DATE] documents a score of 21 which indicates a high fall risk. R2's incident report dated [DATE] documents: Certified nursing aide reported to nurse that R2 was on the floor. Observed patient lying on her back on the floor at the base of the bed. Resident stated that she fell . The patient was unable to say why she got up but did say that she hit her head when she fell . Under mental status documents oriented to person. Under predisposing physiological factors: confused, hypotensive, gait imbalance and impaired memory. R2's fall management meeting form documents under root cause observed in a prone position on the floor in her room apparent roll from bed. Intervention placed floor mats while in bed. R2's incident report dated [DATE] documents: Nurse informed by staff patient is on the floor. Nurse entered room and observed patient lying on the floor on the right side with blood noted on the left side of the face and on the floor. Bed observed in low position with floor mats on both sides of the bed. Resident said I was looking for friends. Under injury, skin tear to left knee and face. Under mental status documents oriented to person. Under predisposing physiological factors: confused, hypotensive, gait imbalance and impaired memory. Under predisposing situation factors ambulating without assist. R2's fall management meeting form documents under root cause observed on the floor mat in her room Resident said she was looking for friends; confusion contribute to attempt to self transfer and get up. Intervention placed room change closer to nursing station. R2's facility state report dated [DATE] documents: R2 fall resulted from confusion related to dementia leading to either roll from bed or R2 attempting to get up without assistance per staff resulting in mechanical fall. On [DATE] at 2:58PM V13 (Restorative Nurse) said R2 was admitted with standard fall precautions in place: Document signs and symptoms of adverse effects of medication on resident; Encourage resident to keep room free of obstacles/ clutter; Keep bed in lowest position; Keep frequently used items within reach; Monitor labs/ notify MD of abnormal findings; Notify MD and family of any new fall; Skilled therapy as ordered; Staff to assist as needed. After the fall on [DATE] the interventions added were Floor mats while in bed and rounding for prompt assist for change in position, toileting, offer fluids, and ensure resident is warm and dry. V13 was asked was there individualized preventive fall interventions implemented for R2 after the first fall and V13 said No. V13 said floor mats are not a preventive fall intervention. Floor mats are utilized to minimize injury to the resident. V13 was asked were floor mats an effective intervention if R2 sustained a nasal fracture for the fall on [DATE]. V13 said the floor mats do not prevent someone from falling. V13 was asked about the intervention (rounding for prompt assist for change in position, toileting, offer fluids, and ensure resident is warm and dry) and asked how often rounding would occur. V13 said rounding would be done every 2 hours unless otherwise specified. V13 said all residents are rounded on every two hours and that is in place for all residents. R2's care plan Date Initiated: [DATE] Created on: [DATE] documents the following interventions: Document signs and symptoms of adverse effects of medication on resident; Encourage resident to keep room free of obstacles/ clutter; Keep bed in lowest position; Keep frequently used items within reach; Monitor labs/ notify MD of abnormal findings; Notify MD and family of any new fall; Skilled therapy as ordered; Staff to assist as needed. Floor mats while in bed Date Initiated: [DATE] Created on: [DATE]. Rounding for prompt assist for change in position, toileting, offer fluids, and ensure resident is warm and dry Date Initiated: [DATE] Created on: [DATE]. Falling Star Program Date; Move resident to room with optimal visual access from the nurse's station; Orient resident to surroundings frequently, including location of bathroom, dining room, bedroom and activity locations; Provide proper, well maintained footwear; wing mattress Initiated: [DATE]. On [DATE] at 1:00pm, V16(Therapy Director) said R2 was seen by occupational therapy on [DATE]. At that time R2 required moderate assistance which means 50% help by one person to complete transfers and bed mobility. R2 required frequent cueing during therapy due to cognition. R2's therapy evaluation dated [DATE] documents under fall risk does patient feel unsteady when standing documents an answer of yes; does patient feel unsteady when walking documents an answer of yes; Under balance patient stands without upper extremity support with assistive device as needed x ten seconds? Documents no. Under reason for therapy: Patient presents with impairments in balance, dexterity, fine motor coordination, gross motor coordination, mobility, strength, attention, follow through, planning problem solving, self modification, self monitoring, interpersonal routines/behavior, and use of coping strategies resulting in limitations and /or participation restrictions in the areas of self care, mobility, and general tasks and demand which requires skilled OT services. R2'a hospital record dated [DATE] documents under physical exam: Small laceration to bridge of nose approximately one centimeter. Additional small laceration upper lip, approximately 1.5 cm in length and small interior upper lip laceration. Under laceration upper exterior lip 1 cm length and 0.5cm depth, repair method tissue adhesive. Under CT facial bones impression documents: mildly comminuted displaced acute fractures of the bilateral nasal bones. Facility fall prevention and management policy reviewed ,d+[DATE] documents: The 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. All resident falls shall be reviewed, and resident existing plan of care shall be evaluated and modified as needed. Resident at risk for falls will have fall risk identified on interim plan of care with interventions implemented to minimize fall risk. A fall risk evaluation Is completed by the nurse, a score of ten or greater indicates the resident is high risk for falls. Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence. 41156 R8 admitted in the facility on [DATE] under hospice care and expired in the facility on [DATE]. R8 has diagnoses of Metabolic Encephalopathy, Malignant Neoplasm, Anemia, Type 2 Diabetes, Pain in Right Hip, and Convulsion. R8 has a BIMS of 3 (Severe Cognitive Impairment). R8 had 2 fall incidents in the facility. Fall incidents dated [DATE] and [DATE]. R8 has care plan for high risk for fall with an initial date of [DATE]. R8 has care plan for high risk for falls related to impaired mobility and history of seizure with a created date of [DATE] and revised date of [DATE]. R8's [DATE] fall incident reads in part: R8 was observed on the floor, during final rounds laying on the right side, using right arm to support his head. When R8 was asked what happened. R8 was unable to explain what happened, but when asked if he was trying to turn, R8 said yes. R8 fall care plan updated after the first fall on [DATE] and intervention added was provide perimeter pillows dated [DATE]. R8's [DATE] fall incident reads in part: Nurse was called and notified by R8's family member who was visiting R8 that R8 was on the floor mat. Upon entering the room, writer observed R8 on the floor mat. R8 was rounded on 10 minutes before the incident. R8 was in bed sleeping and bed in low position. No injury. Assisted back to bed with 2 staff. R8 fall care plan updated after the second fall on [DATE] and interventions added were bed bolsters for perimeter awareness and rounding for prompt assist for change in position, toileting, offer fluids, and ensure resident is warm and dry dated [DATE]. On [DATE] at 2PM, V31 (Complainant) stated that another family member came in before her and saw R8 on the floor next to his bed. V31 stated that this family member recorded the time that the nurse was made aware of the fall. V31 stated her family member stopped recording when V31 arrived on the scene. V31 observed R8 on the floor, no staff with the resident just the other family member. V31 reported that 2 female staff members entered the room and assisted in placing back R8 into his bed. They waited 13 minutes with no staff watching R8 and R8 was left on the floor. Review of family's attached video with this complaint. Video shows V28 (Nurse) walking in the room. R8 on the floor, laying on floor mat with pillow on his head. Nurse left the room. Video ended. On [DATE] at 2:40PM, V7 (IP Nurse, covering DON) stated that for any fall incident, the team will meet and discuss the root cause analysis. Based on the fall, they will add interventions appropriate for the resident. For R8's fall incident on [DATE], the team doesn't know how R8 really fell , might be due to R8 was restless and maybe repositioning himself in bed. We added perimeter pillows after the first fall. Floor mats were in place the morning of [DATE], before his 2nd fall. Due to the fall of [DATE], pillows were used to tuck on his side that will give awareness to R8 that he is close to the edge of the bed. Somedays R8 was more alert than other days, the intervention added would be helpful on the days R8 was more alert. V7 stated that after R8's second fall the team added interventions of monitoring and bolster small foam, which is a little more solid than a pillow. During R8's health decline, that was when the falls happened. In general, CNAs or staff that found the patient on the floor, has to call or yell out for help or push the call light; but stay in the room because we don't want the resident to move until they are assessed by a nurse.They need to assess the resident before moving and placing the resident back to bed. The nurse has to give an okay in order for them to move the resident. Our expectation is for the staff to keep an eye on the patient to prevent anything else that could happen with the patient. Expectation to call for assistance immediately, we have plenty of people around to help. Fall Prevention and Management Policy with a revised date of ,d+[DATE], reads in part: 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. All resident falls shall be reviewed, and the resident existing plan of care shall be evaluated and modified as needed. A fall risk evaluation will be completed on admission, readmission, and quarterly, significant change and after each fall. Care plan to be updated with new interventions based on the root cause analysis after each fall occurrence.

Based on interview and record review, the facility failed to notify their physician of an acute change in condition as noted in their change in condition policy. This failure affected one of three residents (R3) reviewed for change in condition. The failure contributed to a delay in treatment orders for R3 of over 24 hours. Findings Include: On 7/25/24 at 3:13PM, V10 (Nurse) said, V13 (CNA) updated her that R3 was yelling when V13 touched his left leg. R3 had a history of left knee pain. V10 said, R3 allowed her to move his left leg. R3 was in pain, and grimaced when she attempted to reposition R3 in the wheelchair. V10 said, she is not sure what happen after that because she ended her shift earlier than scheduled. V10 said, R3 was sent to the hospital the following day. V10 said, she thought R3 was having knee pain. On 7/25/24 at 3:30pm, V13 said, she was passing dinner trays. R3 was in his room sitting by the closet which was odd. R3 was normally in the hallway, self-propelling, using his feet and the handrail to go up and down the hallway. V13 said, she placed R3's dinner tray on his bedside table. V13 said, she noticed R3's left leg was bent completely back up under his wheelchair. V13 demonstrated how R3 was sitting in his wheelchair by scooting towards the edge of her seat and placing her leg, with a bent knee behind her completely under the chair. V13 said, she tried to move R3's leg but R3 was in so much pain. R3 was unable to report what happen. On 7/31/24 at 12:58pm, V33 (Medical Doctor) said, she was not notified of R3's injury until after his hospitalization . V33 said, had she been notified, she would have ordered a stat x-ray. On 7/31/24 at 10:30am, V37 (R3's emergency 1st contact) said, she was not notified about R3's leg until 7/14/24. On 7/31/24 at 3:27pm, V10 said, if the doctor was notified it would be charted in the resident's electronic record in a note or an assessment. V10 said, she did not call R3's doctor on 6/13/24. Nursing note dated 6/13/24 written by V10 at 18:36 (6:36pm) documents: Prior to dinner CNA (V13) attempted to reposition resident's (R3) left foot to bring side table towards him. Resident (R3) voiced vulgar language and told the CNA (V13) to get away from him and also grimaced. Nurse observed R3, R3 grimaced, when moving left leg but not right leg. R3 voiced he was not in pain but did mumble something incoherent. Witness statement written by V10 documents at approximately 18:15 (6:15pm) on 6/13/24: C.N.A (V13) requested she observe R3. While sitting in his wheelchair R3 was observed with resistance to moving his left lower extremity (LLE) and would not move his left foot. R3 exhibited grimacing and stated leave me alone when the C.N.A (V13) attempted to assist with mobility. R3's medical record did not document doctor or family/emergency contact notification on 6/13/24. Facility radiology result report dated 6/14/24 at 20:55 (8:55pm) documents: impression pelvis: impacted transcervical fracture of the left lower neck with varus deformity. Nursing note dated 6/14/24 at 22:18 (10:18pm) documents: writer has notified third eye(sic) doctor on call physician of x-ray results; he has given instruction to send R3 to emergency department for evaluation. Nursing note dated 6/14/24 at 22:25 (10:25pm) documents: V37 was made aware of x-ray results and doctor's recommendation to transfer R3 to emergency department for evaluation. Change in resident condition policy dated 1/2023 document: 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 change in condition. Nurse will notify the resident's physician or nurse practitioner when: the resident is involved in an accident or incident. There is a significant change in the resident's physical, mental or emotional status.

Based on interview and record review, the facility failed to have effective fall interventions in place for a resident assessed to be at risk for falls and failed to provide two staff assist when providing assistance with Activities of Daily Living (ADL) per the resident's plan of care. This failure applied to one (R3) of three residents reviewed for falls and resulted in R3 sustaining a fall while being provided with care from one staff and resulted in R3 being transferred to the hospital and diagnosed with a subdural hematoma measuring 2mm. R3 subsequently returned to the facility with a neck collar and gastrostomy feeding tube (G-Tube). Findings include: R3 is an [AGE] year-old female who has resided at the facility since 2022, with past medical history including, but not limited to Chronic obstructive pulmonary disease, dementia, heart failure, hypertension, hypothyroidism, etc. Fall risk assessment dated [DATE] and 4/22/2023 score R3 as a 13, indicating that resident is at risk for falls. Facility minimum data set (MDS) assessment dated [DATE] section C (Cognitive) documented a BIMS score of 7 for R3, section G (functional) of the same assessment coded R3 as requiring extensive assistance with two-person physical assist for all ADLs. Fall care plan initiated 1/29/2022 states the following: Resident is a high fall risk due to decreased mobility and strength, potential medication side effects, history of falls, etc. Interventions include: encourage to transfer and change positions slowly, provide assist to transfer and ambulate as needed, provide two persons assist during bed turning for hygiene, Bed in low position, etc. Progress note dated 1/3/2024, documented by V21 (LPN) states: Certified Nurse Assistant (CNA) informed writer that resident rolled out of bed while lying on right side during care. Resident was reaching toward dresser then stated I'm falling CNA could not catch her. Upon assessment writer noticed raised area to top of head on left side. Hospital record dated 1/3/2024 states in part, [AGE] year-old female with history of COPD, Dementia, history of heart failure . Presenting to hospital after falling out of bed in her nursing home. Patient was found to be more altered, and CT of the head was notable for a small traumatic subdural hematoma measuring 2mm. On 1/19/2024, V16 (RN) documented the following: readmitted [AGE] year-old . from hospital via ambulance and two paramedics, resident arrived wearing a cervical collar that must remain in place for 6 to 8 weeks, g-tube placed 01/17, resident is NPO. On 2/29/2024 at 2:45PM, V16 (RN) said that R3 was a very sweet lady, she was bedridden but makes her needs known to staff, she will always ask staff to open her candy and place them on her bedside table, R3 cannot reach further than her bedside table, she cannot reach her drawer, always ask staff to get the candy from her drawer and open them. Prior to the fall R3 does not move and was dependent on staff for ADLs, staff always need assistance to turn and hold her, will say that R3 requires 2-person assistance for ADLs to be on the safe side. R3 came back from the hospital with a G-Tube, a cervical collar and was not doing good, just went downhill. On 2/29/2023 at 1:43PM, V13 (LPN) said that she recalls R3, she was alert and oriented x2, incontinent of bowl & bladder, and non-ambulatory. Resident did not have a G-Tube before the fall, she cannot do much for herself, staff must feed her, resident cannot use her hands and cannot reach to her drawer to get anything. V13 said she would use 2-person assist with R3 for ADLs due to her weight, it depends on the CNA but most of them ask for help. On 2/29/2024 at 1:55PM, V14 (Restorative CNA) said that R3 requires mechanical lift for transfers, she does not get out of bed, she needed 2 people to help her turn, V14 came to work after the resident was sent out to the hospital after she fell . V14 has done range of motion exercises with resident, she came back from the hospital with a neck brace and a G-tube. V14 stated that R3 requires two people to turn her, and she has assisted other CNAs in providing ADL care to R3. R3 did not have any floor mat prior to her fall. On 3/4/2024 at 11:55AM, V19 (LPN/Restorative) said that she oversees fall care plans, the initial fall assessment is done upon admission, quarterly and when there is a fall. R3 requires extensive assistance with ADLs, she was a high fall risk and had interventions like low bed, resident does not have a floor mat before the fall, and there were no additional interventions after the fall. On 3/4/2024 at 4:13PM, V22 (LPN) said that R3 was alert x 1 to 2, she can tell you what she wants and can refuse some stuff sometimes. V22 was not present but was told that staff rolled resident away from her, resident started to reach to her drawer for candy and staff could not pull her back. V22 stated that she in-serviced the CNA about compliance to resident's care plan. R3 was a two-person assist at that time as indicated in her care plan. CNA stated that she was not aware, but resident's level of care is also listed in the Kardex patient information sheet that is available to the CNAs and it is their responsibility to know the type of care a resident requires. On 3/4/2024 at 3:24PM, V21 (LPN) said that she recalls R3, she was a total care. V21 is not sure if R3 is a fall risk, resident returned from the hospital with a G-tube after the fall, R3 does not get out of bed and did not have any interventions before the fall, resident did not have a floor mat before the fall. On 3/4/2024 at 1:58PM, V20 (CNA) said that she recalls R3, she was a total care, incontinent of bowel and bladder and she has always taken care of her by herself, never called anyone to assist her with the resident. V20 said that she was taking care of R3 the day she fell , she was in the middle of changing resident when she started asking for a candy that the family brings for her. V20 said she had gloves on and told resident to wait for her to finish, resident started reaching to her drawer for the candy and V20 could not reach her to pull her back on the bed. V20 said that she was told that R3 was a two person assist and that it was in her care plan but at the time she was not aware of that. V20 stated that she was in-serviced after the fall on getting another staff for assistance and resident fall risk. On 3/5/2024 at 12:53PM, V26 (Attending Physician) said that R3 came back from the hospital with a G-tube and cervical collar, resident was alert to self prior to the fall and denies pain, compliant with medications and dependent on staff for ADLs. V26 was asked if R3 declined after the fall and he said, definitely, with a cervical collar and subdural hematoma, resident declined. Fall prevention and management policy revised 1/2024 states in general that the 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 preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing care plan shall be evaluated and modified as needed. Under guidelines, the policy states in part: 1. A fall risk evaluation will be completed on admission, readmission, and quarterly, significant change and after each fall. 2. Residents at risk for falls will have fall risks identified on the interim plan of care with interventions implemented to minimize fall risk.

Based on interview and record review, the facility failed to supervise and implement effective interventions to prevent or reduce the risk of falling for cognitively impaired residents. This affected 2 of 3 residents (R2, R5) both reviewed for falls and fall prevention. This failure resulted in R2 being sent to the local hospital post fall. R2 was assessed with a subdural hematoma. R5 has been involved in at least 5 unwitnessed fall incidents. Findings include: R2 was admitted to the facility on [DATE] with a diagnosis of dysphagia, hypertension, venous insufficiency, pleural effusion, acute respiratory failure, and Alzheimer's. R2's brief interview for mental status dated 11/21/22 s score 1/15 which indicates severe cognitive impairment. R2 section G dated 11/21/22 documents one person assists for bed mobility, transfer, walk in room, dressing eating, toilet use and personal hygiene R2 progress note dated 11/16/22 documents: resident observed climbing out of bed, making unsafe transfer. Redirected but not successful, assisted to wheelchair brought to hallway for close monitoring. R2's progress note dated 11/17/22 at 1:30 documents: Resident observed climbing out of bed, making unsafe transfer. Redirected but not successful. Assisted to wheelchair and brought to hallway for monitoring. R2's progress note dated 11/17/22 at 5:29 documents: Resident requested to get back onto bed. Assisted back to bed by CNA. Bed in low position and locked, call light within reach. R2's progress note dated 11/17/22 at 5:40 documents: Resident observed sitting on the floor, next to her bed. Bed in low position. Resident brought to the hallway for close monitoring. Resident educated on the use of call light and waiting for help. R2's incident report dated 11/17/22 documents under investigation report: R2 is alert and oriented x1, requires staff assist with most activities and activities of daily. She has poor safety awareness. Resident noted sitting on the floor next to the bed after several attempts to stand due to dementia. R2 progress note dated 11/23/22 by V18 (Nurse) documents: resident had witnessed fall in bedroom without injury. MD notified with no new orders. R2 fall assessment dated [DATE] documents time of fall 11/23/22 at 17:20. Under physical limitations: impaired balance; musculoskeletal problem; gait problem. Under disease and conditions: impulsivity or poor safety awareness. On 3/1/23 at 420PM, V3 Assistant Director of Nursing (ADON) and V29 (Unit Manager) said R2's fall interventions were effective because R2 could use a call light. When asked if R2 was able to understand the need of when to push the call light and not just being physically able to push the call light, V29 said at times she knows and other times she does not know. When asked about the resident cognition, V29 said R2's brief interview score for mental status indicate severe impairment but that could vary on day and time. When asked how reenforce need to call for assistance is an effective intervention for a resident with cognitively impairment? V3 said she did not fall again. On 3/2/23 at 4:38PM, V2 Director of Nursing (DON) said R2 needed one to one supervision to prevent falls. Staff would take turns monitoring her, but we do not provide one to one and depends on staffing. R2's progress note dated 12/7/23 documents transfer to the hospital due to change in condition and lethargy. R2's plan of care dated 11/15/22 documents at risk for falls due to impaired balance. Interventions dated 11/15/22 document: provide assist to transfer and ambulate as needed; refer to therapy plan of treatment; therapy evaluation and treatment. Interventions dated 11/17/22 document: bed in low position; diagnostic labs; evaluate medications if patient demonstrates changes in mental status, Activities of daily living function, appetite, neurologic status; scoop mattress. Interventions dated 11/24/22 documents reenforce need to call for assistance. Local hospital record dated 12/7/22 documents: new right parietal convexity 8mm thickness subdural hematoma with layering hyperdensity posteriorly concerning for ongoing bleeding, no midline shift or herniation. R2 progress note dated 11/23/22 by V18 (Nurse) documents: resident had witnessed fall in bedroom without injury. MD notified with no new orders. R2 fall assessment dated [DATE] documents time of fall 11/23/22 at 17:20. Under physical limitations: impaired balance; musculoskeletal problem; gait problem. Under disease and conditions: impulsivity or poor safety awareness. On 3/1/23 at 5:49PM, V18 said she did not witness R2's fall and unable to recall who or any other details from R2's fall. R2 progress note dated 11/28/22 documents: patient with increased anxiety and restlessness. Seen by Nurse practitioner, new orders noted. On 3/2/23 at 4:38PM, V2 said the facility is unable to provide any incident or other documents related to R2's fall on 11/23/22. V2 said they are unable to determine who witnessed R2 fall, or any other information related to the fall except for what was written in the nursing note. There is no documentation if resident hit her head, just that there were no visible injuries. If it's a witnessed fall staff are expected to conduct a head-to-toe assessment, which is documented in the incident report. It is the policy of the facility if they hit their head they are sent to the hospital for evaluation. Facility post fall evaluation dated 11/21 documents: Falls are a common source of patient injury. Identifying fall risk factors is an important nursing evaluation process that occurs throughout a patients stay. In the event of that a patient does experience a fall, a comprehensive clinical evaluation by the nurse supervisor is important to determine the extent of the injury and need for additional intervention. The licensed nurse's evaluation of the patient condition after a fall, identification of changes in condition and recognition of emergent situations is critical to achieving positive outcomes. The licensed nurse is responsible for completing this evaluation and reporting changes in condition to the attending physician whenever any symptom, sign or apparent discomfort is sudden in onset, a marked change in relation to usual symptoms or unrelieved by initial interventions. Documentation of change in condition is completed using the SBAR process. R2's admission hospital record dated 10/29/22 documents under CT scan of head documents: No acute intra cranial hemorrhage, acute transcortical infarct or mass effect. On 3/2/23 at 3:01PM, V32 (MD) said a subdural hematoma is usually caused by a fall. V32 said the subdural hematoma could possibly be from the fall on 11/23/22. On 2/28/23 at 2:26pm, V14 (CNA)said R2 was a fall risk. R2 was confused and tried to get up all the time. We would redirect her. She had a scoop mattress but that did not stop her, and she could still get out of bed. R2 had a lot of falls on the second shift. R2 had more than 2 falls. Local hospital record dated 12/7/22 documents: new right parietal convexity 8mm thickness subdural hematoma with layering hyperdensity posteriorly concerning for ongoing bleeding, no midline shift or herniation. Local hospital record dated 12/19/22 documents: patient likely has multifactorial encephalopathy related to infectious and metabolic etiologies. Since she has risk factors, I will rule out acute neurologic event like stroke or subclinical seizures. According to Medline plus, a subdural hematoma is a collection of blood between the covering of the brain (dura) and the surface of the brain. Under causes: a subdural hematoma is most often the result of a severe head injury. This type of subdural hematoma is among the deadliest of all head injuries. This often results in brain injury and may lead to death. Subdural hematomas can also occur after a minor head injury. The amount of bleeding is smaller and occurs more slowly. This type of subdural hematoma is often seen in older adults. These may go unnoticed for many days to weeks and are called chronic subdural hematomas. Some subdural hematomas occur without cause. 41758 R5 was admitted with Vascular Dementia, Metabolic Encephalopathy, Hypertension and a history of falls. Brief interview for mental status dated 10/6/22 documents a score of seven which indicates severely impaired. Section G (functional status) documents: R5 requires extensive assistance with one person physical assist with bed mobility and toilet use, extensive assistance with two person assist with transfers and walking in room/corridor did not occur. Balance during transition and walking documents: R5 was not steady, only able to stabilize with staff assistance moving from seated to standing position. R5 had lower extremity (hip, knee, ankle, foot) impairment on both sides. Care plan intervention dated 10/1/22 documents: Encourage to transfer and change position slowly, reinforce need to call for assistance, therapy evaluation and treatment per orders. On 3/1/23 at 4:45pm, V3 (ADON) said, R5 had a fall trying to ambulate to the bathroom. R5 had a history of being on the edge of the bed trying to get up. I would inform the staff to assist R5 with transfers. R5 was an extensive one person assist with transfers. The intervention to provide assist to transfer and ambulate as needed was not effective due to R5 being provided extensive assistance with two person assist with transfers upon admission. Progress note dated 10/3/2022 documents: Informed by CNA, patient (R5) was on the floor. Observed R5 sitting on the end of bed next to bathroom door. Brief saturated. Fall report dated 10/03/22, physical performance limitation documents: R5 had difficulty maintaining sitting balance and was incontinence. Care plan initiated 10/1/22 documents: R5 was at risk for fall due to impaired mobility. Interventions dated 10/3/22 and 10/4/22 documents: Bed in lowest position, staff to toilet before bed, provide assist to transfer and ambulate as needed. Investigation report dated 10/4/22 documents: towards end of shift, CNA rounding, seen R5 in the room on the floor. R5 displayed poor safety awareness, Witness statement dated 10/3/22 documents: R5 said, she was trying to use the bathroom. On 3/1/23 at 4:45pm, V3 (ADON) said, R5 had a fall on 10/8/22, there was not any interventions implemented for that fall. Progress Note 10/8/2022 documents: R5 noted sitting on her buttocks facing the wall next to the window, alert and oriented times 1-2. R5 was asked where she was trying to go, she stated she did not know. Physician note dated 10/8/22 documents: R5 was discovered between her bed and the wall mostly on her buttock. Fall report dated 10/8/22, physical performance limitation documents: R5 had difficulty maintain sitting/standing balance with gait and musculoskeletal problems. Care plan initiated 10/1/22 did not document any intervention for R5's fall dated 10/8/22. Investigation report dated 10/10/22 documents: R5 displayed poor safety awareness. On 3/1/23 at 4:45pm, V3 (ADON) said, R5 had a fall on 10/19/22, the intervention was a low bed. R5 had a low bed on 10/13/22. The intervention for 10/19/22 may have not been the most effective due to R5 already having a low bed. Maybe we should have given R5 scoop mattress to help prevent falls from the bed. Progress noted dated 10/13/22 and 10/19/22 documents: R5 in low bed. Notified by CNA that R5 was observed sitting on floor next to bed in the dark. R5 stated I don't know when asked how she got onto floor. Fall report dated 10/19 documents: R5 difficult maintaining sitting/standing, need to rock body or push off on arms chair when standing up from chair and impaired balance during transitions. Disease and conditions: loss of arm or leg movement, declines in function status, incontinence, chronic or acute condition resulting in instability, muscle weakness, impulsivity or poor safety. Care plan intervention dated 10/19/22 documents low bed. On 3/1/23 at 4:45pm, V3 (ADON) said, the scoop/perimeter mattress should have been given prior to this fall. Progress note dated 11/2/2022 documents: R5 observed lying on the floor pulling out clothes in her night stand next to her bed. Resident unable to tell staff how she got on floor. Care plan intervention dated 11/2/22 documents scoop/perimeter mattress. On 3/1/23 at 4:45pm, V3 (ADON) said, R5 had a fall on 11/6/23. It was determined that nothing was on the floor. R5 was not trying to pick up anything up from the floor. We implemented to keep common items within reach. V3 was asked, how keeping common items within reach was an effective intervention when R5 wasn't reaching for any items on the floor. V3 said, R5 didn't have any more falls after 11/6/22. Progress note dated 11/6/2022 documents: R5 was observed on the floor next to her bed. Roommate stated that patient was trying to get something off the floor. Resident unable to tell staff what happen. Care plan intervention dated 11/7/22 documents: have commonly used articles within easy reach.

Based on interview and record review, the facility failed to effectively monitor and ensure adequate hydration was provided to prevent dehydration. This affected 2 of 3 (R5 and R1) residents reviewed for dehydration. This failure resulted in R5 being found tachypneic, tachycardic and with tongue hanging to the side of her face. R5 was sent to the local hospital and diagnosed with dehydration and hypernatremia. R1 was sent to the local hospital and diagnosed with hypernatremia. Findings Include: R5 had the diagnosis of Vascular Dementia, Chronic Kidney Disease, Metabolic Encephalopathy, Hypercalcemia and Hypertension. Brief interview for mental status dated 10/6/22 documents a score of seven which indicates severely impaired. Section G (functional status) documents: R5 requires extensive assistance with one person physical assist with eating. Physician order sheet dated 12/01/22 documents: Pureed diet and nutritional shake. On 3/2/23 at 12:34pm, V22 (Medical Doctor) said, R5's fluid volume was down. Dehydration can cause no urine based on low volume intake. On 3/2/23 at 3:10pm, V32 (Medical Doctor) said, R5 was on furosemide which usually keeps sodium levels down. Dehydration is caused by not enough fluids. R5 was not on dialysis. Nutrition note dated 10/5/22 documents: R5 averages only ~ 50% meal consumption since admission. Lab results dated 12/19/22 at (1621/4:21pm) documents: Sodium 149 High (H) - (normal range 138-147). Progress note dated 12/20/22 at (2106/9:06pm) documents: lab reviewed, new order intravenous (IV) fluid times one liter, contact pharmacy for fluid and (IV) pump. EMAR and skilled nursing note dated 12/21/22 at (0611/6:11am) awaiting arrival from pharmacy. R5 to start IV fluids when arrives from pharmacy (0618/6:18am). Medication Administration record dated 12/21/22 documents one liter of sodium chloride was given at (2050/8:50pm). Lab results dated 12/23/22 documents: Sodium 151 High (H) - (normal range 138-147). R5 electronic record dated 12/23/22 did not document any interventions. Physician order sheets dated 12/1/22 did not document any ordered related to the sodium level. Medication Administration record dated 12/23/22 did not documents any interventions related to the 12/23/22 sodium level. Physician note dated 12/30/2022 documents: Seen R5 after nurse stated she did not seem like herself. Assessed patient (R5) was lethargic, not responding. R5 was visibly tachypneic although saturating well, and tachycardic. R5 was in bed, tongue was hanging to the side of her face, and she was not opening eyes not responding to voice, or touch. Hospital paperwork dated 12/30/22 documents: Sodium 160 High (H) - (normal range 135-145). Intervention altered mental status since 12/28/22 subdual non-verbal (off baseline), hypernatremia, electrolyte abnormalities, dehydration, very dry mucous membranes treated with bolus of 0.9 normal saline. Hydration Management Guidelines dated 1/22 did not apply. R1 had the diagnosis of Dementia and failure to thrive. Section G functional status dated 1/24/23 documents: R1 requires extensive assistance with one person physical assist with eating. Physician order sheet dated 2/1/23 enhanced pureed diet with house shakes three times a day. On 3/1/23 at 2:22pm, V22 (Medical Doctor) said, staff should have to give R1 water to prevent the dehydration. On 3/1/23 at 5:30pm, V30 (Nurse) said, R1 was dehydrated from not drinking a lot. On 3/2/23 at 11:30am, V2 (DON) said, I am not able to provide reports from R1 speech session. On 3/2/23 at 12:34pm, V22 (Medical Doctor) said, dehydration can cause no urine based on low volume intake. Surveillance note date 1/26/23 document: Appetite poor, family states R1 did not urinate today. R5 states burning with urination. CNA reports, R5 did urinate. Bladder scan 23ml seen in bladder at this time. Service Log dated 2/6/23 documents: R1 was seen by speech on 1/20/23, 1/22/23, 1/27/23 and 1/28/23. Lab report dated 1/30/23, 1/31/23 document sodium 150 (normal range 138- 147) note dated 1/30/23 documents: Sodium 150, oral fluids encouraged. BMP will be repeated. Lab report dated 2/1/23 document sodium 152. Progress note dated 2/1/23 documents: D5 1 liter infusing. Lab report dated 2/3/23 document sodium 150. No intervention documented. Run sheet dated 2/4/22 documents: services were called for R1 for abnormal labs indication sodium level of 150. Nurse reports R1 has not been eating or drinking since admitted [DATE]. Sodium levels have stayed in 150 for the past four days, attempted saline bag with no change in condition. Hospital paperwork dated 2/4/23 documents: Chief complaint: abnormal lab. Hypernatremia. Hydration Management Guidelines dated 1/22 did not apply. Hydration policy dated 2/2023 documents: This policy allows for each resident to be provided with sufficient fluid intake to maintain proper hydration and health.

Based on interview and record review, the facility failed to develop a plan to prevent or reduce the risk of falling for a high risk fall resident also assessed to have bilateral lower extremity weakness. This affected 1 of 3 residents (R1) reviewed for fall prevention. This failure resulted in R1 having 2 falls in three days subsequently sustaining a left hip fracture. Findings Include: R1 is a [AGE] year old with the following diagnosis: vascular dementia, cognitive communication deficit, and reduced mobility. R1 admitted to the facility on [DATE] and discharged on [DATE]. The Incident Report dated 11/25/22 documents R1 was observed sitting in the wheelchair near the nurse's station and the next time R1 was seen again, R1 was sitting on the floor in the hallway. R1 was admitted from the hospital for weakness after a UTI. R1 also has dementia and impaired safety awareness. R1 does not remember what R1 was trying to do prior to the fall. R1 kept on attempting to stand without an assist and fell to the ground. A Nursing note dated 11/28/22 documents R1 was placed in the wheelchair in position at the nurse's station for supervision while the assigned CNA passed out dinner trays to the rest of the residents. R1 is confused and has a diagnosis of vascular dementia. R1 has a history of being a wanderer and a history of falls. During that shift, R1 stated multiple times to the nurse that R1 wanted to leave the facility and wanted to be taken home. Several attempts were made by staff to redirect R1 and to keep R1 occupied while attempting to do other duties. After dinner, the CNA washed R1 and put R1 to bed. The bed was in the lowest position. The call light was put within reach. R1 was made comfortable, and the TV was turned on for entertainment. The nurse and the CNA took turns rounding on R1. Around 7:21 PM, the nurse was informed by another CNA that R1 was lying in the floor in the hallway. This was an unwitnessed fall. R1 reported pain to the left hip and refused to allow staff to move R1. Transportation was arranged to take R1 to the hospital. R1's family and the doctor were notified. A Physician note dated 11/28/22 documents R1 is a wanderer and has been getting out of bed. Unfortunately, staff doesn't have the coverage to watch R1, and R1 was found at the end of the hall on the floor. It was an unwitnessed fall. R1 is complaining of left hip pain and was transferred to the hospital for further evaluation. The Incident Report dated 11/28/22 documents the nurse was answering call lights on the 200 hall when a CNA came and informed the nurse that R1 was down in the hallway of the 100 hall. R1 reported having pain in the left hip. R1 had to be redirected multiple times by staff. R1 reported wanting to leave the facility that evening. R1 was washed and put to bed. R1 was checked on multiple times and appeared to be relaxing in bed without incident. The CNA and nurse were attending to other residents at the time of the unwitnessed fall. R1 was sent to the hospital for evaluation. R1 is alert and oriented to person only with periods of confusion. R1 has poor safety awareness, requiring frequent supervision. The Hospital Records dated 11/28/22 document R1 presented to the emergency room after having a fall and landing on a hard surface. R1 has a history of dementia and is not a reliable historian. R1's only complaint is left hip pain. R1 is able to wiggle toes and flex and extend the ankle on the left foot. There is no movement of the left hip secondary to pain. An X-ray of the left hip shows a left femoral neck fracture. R1 will be admitted to the hospital for medical clearance and then surgical procedure. On 12/15/22 at 3:47PM, V6 (Physical Therapist) stated, We were working on balance and strength with R1. We were also working on getting in and out of bed and walking. I would say R1 had moderate to severe cognitive deficits. Nursing does the interventions, but we will communicate with them things that we find during our therapy sessions. R1 was a high fall risk due to R1's cognition, and not having a steady gait without an assistive device. We educate the staff on our concerns with what R1 has during therapy and told them that R1 needed supervision because she was not steady. R1 also had an issue with R1's knees giving out when R1 would walk. That is why we were working on strengthening and balance with R1. On 12/15/22 at 4:02PM, V7 (CNA) stated, I had R1 for the first fall. R1 was sitting in the geri chair at the nurse's station before dinner. R1 got up and started walking alone and just fell . R1 fell a couple feet from the nurse's station. I saw R1 go down. R1 didn't trip over anything; R1 just couldn't walk anymore and fell down. I was coming out of another patient room, and I was about 20 feet from R1. I was providing patient care for about 15 to 20 minutes and no one else was at the nurse's station. R1 is very active and has a wiggly gate. We try to keep eyes on her as much as possible, but we do have other residents we need to care for. I don't know what intervention was put in place after that for R1. We will try to just keep an eye on R1 and trade off with the other nurses and CNAs on the floors with who is watching R1. I don't think R1 was a high fall risk because I don't remember R1 having a yellow band on. R1 was able to do everything on R1's own. R1 just was a little wobbly. On 12/16/22 at 11:38AM, V8 (CNA) stated, I was in another room doing patient care when R1 fell . I didn't see or hear the fall. I heard another staff member say R1 was on the ground in the hallway. R1 stays in the room [ROOM NUMBER]XX which is right next to the nurse's station, and R1 ended up walking all the way down to room [ROOM NUMBER]XX before R1 fell . That is in the middle of the hall. R1 got out of bed and walked down the hall after being put to bed around 7:30PM. I would say the fall was probably 30 or 45 minutes after that. Before that, R1 was sitting in a chair at the nurse's station. R1 is a busybody. We kind of just keep an eye out for R1 but we can't watch R1 and do patient care at the same time. R1 was just antsy. I'm not sure if R1 was a high fall risk. I don't remember it saying that in the chart. I was never told that R1 had any other falls. The nurse would tell us if R1 had other falls in report. R1 was only steady on R1's feet for a couple steps then it would seem like R1 wants to go down. I think R1 was just weak. The nurse will tell you about the new interventions that are put in. I don't know what was put in after this fall or if R1 had any others. On 12/16/22 at 12:46PM, V12 (Nurse) stated, I got report from the dayshift nurse, and she told me that the R1 normally has a sitter but that day the sitter did not show up. R1 was at the nurse's station when I got there, and I sat with R1 for a while the CNAs did their care and passed the dinner trays. After R1 was finished eating, the CNA went to lay R1 down in bed to put R1 to sleep for the night. We try to keep tabs on R1 and do the best we can. I had to start passing my medication on the other wing so I will check on R1 as I walked by. When I was on the other wing, passing my medication and another CNA came by and told me that they saw R1 on the floor. I immediately went to go assess R1 and she told me she was fine but when R1 tried to move, R1 had hip pain. R1 did have a history of falls and had a fall a couple days before. We were still doing neuro checks on R1 from the previous fall. I know R1 has dementia and goes in and out of confusion. I had to go finish passing my medication, and the CNAs had to go finish up with patient care for the other residents. R1's fall was not witnessed. I was not told how R1 walks. This was my first time with R1. I would say R1 was put down around 630 and probably just before 730, I was told R1 was on the ground. R1 made it all the way down to the middle of the hallway before falling down. We just look in the chart to see what (interventions) someone should have in place. I don't remember being told anything that R1 was weak, but I knew R1 was a high fall risk because R1 already had another fall. On 12/20/22 at 11:04AM, V14 (Primary Physician) stated, R1 is only alert and oriented times one. Physical therapy will eval the residents and help make suggestions on what is best for them. That is up to nursing and rehab to put in the interventions to help prevent the falls. On 12/20/22 at 11:18AM, V2 (DON) stated, For this fall, R1 was found down in the hallway. When I interviewed the CNA, she said she put the bed in the low position, gave R1 the call light, and put the TV on to give her a little bit of light and background noise in the room. The CNA left the room and went to go collect the other trays and take care of the other residents. The nurse went to pass medication to other residents. A different CNA found R1 on the floor. For her the interventions were a low bed, monitor for assist to transfer and ambulate, reinforced need to call for assistance, report, any pain or new bruises that would suggest a fall, and physical therapy to evaluate and treat. Some of the interventions are put in at the admission time, others are put in after the physical therapy evaluation, and then other interventions are put in after a fall. Yeah, R1 was a high fall risk from admission. We consider anyone with dementia, unsteady gait, and needing more attention a high fall risk. Interventions are put in based on what type of fall occurred to prevent it from happening again. On 12/20/22 at 12:33PM, V3 (Nurse Manager) stated, R1 has dementia, and is very impulsive. R1 has no regards to safety. The initial intervention for the fall is put in by the nurse. We make the interventions based off of what their diagnosis is along with the fall that occurred to make it appropriate to prevent further fall. The Physical Therapy Evaluation and Plan of Treatment dated 11/16/22 documents R1 needs partial to moderate assistance with walking secondary to knees giving out. R1 exhibits uneven, step length, decreased accuracy of movements, and in adequate knee extension any instability. R1 has impaired right and left lower extremity strength. The Physical Therapy note dated 11/25/22 documents the right lower extremity has tendency to buckle down during ambulation. The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score as a 7 (severe cognitive impairment). Section G of the MDS dated [DATE] documents R1 needs an extensive one person, physical assist with bed mobility and locomotion on unit. An extensive two person physical assist with transferring and walking in the room is needed for R1. When moving from a seated to a standing position and when walking R1 is not steady and is only able to stabilize with staff assistance. The Care Plan dated 11/15/22 documents R1 is at risk for falls due to unsteady gait. The following interventions are documented on 11/15/22: provide assist to transfer in ambulate as needed, reinforce need to call for assistance, therapy, evaluation and treatment for orders, report development of bruises/pain/change in mental status/ADL function/appetite/neurological status per facility guidelines post fall. The following interventions are documented on 11/18/22: bed in low position. The following interventions are documented on 11/28/22: monitor for unassisted transfers. There are no documented interventions regarding R1's weak lower extremities or R1's knees giving out while ambulating. The policy titled, Falls Practice Guide, dated 11/2020 documents, The purpose of the falls practice guide is to describe the process steps for identification of patient. Fall risk factors, and interventions and systems that may be used to manage falls . Upon admission, review hospital, discharge records, transfer sheets or other data regarding the patient's history of, or risk factors for, experiencing a fall. Interview the patient and family or responsible party about the patient's history of falls, possible causes of those falls in interventions that did, or did not work to prevent further falls. Complete the patient admission/re-admission screen, answering the specific questions regarding the patient's history of actual falls and ongoing risk for falls. Some risk factors or conditions that may predispose a patient to a fall may include, but are not limited to: musculoskeletal conditions, that impair strength, history of falls, orthostatic, hypotension, depression, urinary or fecal urgency, visual, or hearing impairments, peripheral neuropathy's, history of vestibular, disease, unsteady gait, muscle weakness, syncope, stroke, transient, ischemic, attack, age, greater than [AGE] years, cognitive impairment, dementia, use of assistive devices, physical restraints, medication's, and physical environment .Based on the findings of the MDS and the CAAs, following review of risk factors, environmental factors in other clinical conditions, the patient's initial care plan is updated or a comprehensive care plan is developed to include individualized patient interventions that focus on the patient's risk factors . Interventions are clear, specific, and individualized for the patient's needs . The care plan is revised as clinically indicated to meet the patient's current needs.

Based on observation, interview and record review the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R1 developing a urinary infection requiring antibiotic treatment. Findings include: R1 plan of care shows R1 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 MDS (Minimum Data Set) dated 11/23/21 shows R1 has a BIMS score of 14 (cognitively intact). On 11/27/21 at 12:22p.m R1 was observed resting in bed, alert and orient, R1 said lately her suprapubic site has not been getting cleaned and she has been waiting since around November 11, 2021 for the nurse to put an anchor in place to secure the suprapubic catheter, R1 also said her suprapubic catheter was not changed on October 23, and the nurse told her that she had an appointment, and the catheter will be looked at, at that time. At 1:00p.m during a care observation with R1 permission, R1 was noted to have a tannish colored suprapubic catheter in place attached to a clear tubing that's attached to a clear and white urinary drainage bag, there was a clear piece of tape noted wrapped around the clear tubing of the urinary drainage bag, the tape was not observed attached to R1 body part. V1 removed the old dressing, dry blood was observed on the dressing, V1 cleaned the site using a gauze, the gauze was noted to be soiled (not blood), V1 cleaned the site with a new gauze until the gauzed was no longer visibly soiled, and V1 cleaned the suprapubic catheter, and placed a clean dressing with date to the suprapubic site. V1 was observed with a catheter securing device but V1 did not attached the device on R1 but did place it on R1 nightstand. During the catheter care observation, R1 was heard telling V1 not to pull the catheter out twice. On 11/28/21 at 9:36a.m V3 (Nurse) said she only changed R1 urinary drainage bag on 10/23/21, V3 said she was not aware that she could change the suprapubic catheter. V3 said she has read the order, but she was not aware that she could change the suprapubic catheter, V3 said she has not asked the DON is it okay to change a suprapubic catheter. On 11/28/21 at 10:35a.m V4 (Nurse Practitioner) said R1 is alert and orient and R1 informed her that her catheter is not been getting changed. V4 said R1 catheter should be changed monthly to prevent infections. V4 said she prescribed R1 the antibiotics because when she saw R1 for an office visit in November, R1 suprapubic catheter was removed and the tip was black, the urine was mild odorous and there was a lot of debris observed in the urinary drainage bag. V4 said R1 was prescribed the antibiotics based on her assessment and when she sent R1 urine for culture it was positive for proteus and [MEDICATION(S)] was an appropriate medication for that organism. V4 said R1 catheter is not being changed as ordered. V4 said it is her expectation that the nurses follow the orders for changing the suprapubic catheter. On 11/18/21 at 2:39p.m V1 (DON- Director of Nursing) said the nurse should follow physician orders, and if they need clarification on an order, they should contact the physician, herself or a manager, V1 said it is her expectation that the nurse follow physician orders. R1 progress notes dated 11/11/21 shows resident out to see urologist, return with new order for [MEDICATION(S)] 500mg p.o. (by mouth) b.i.d. (twice a day) for 10 days for infected suprapubic site, catheter changed at urology appointment. Resident alert times 3 and aware of order for [MEDICATION(S)]. R1 TAR (treatment Administration Record) for October 2021 shows in-part initials for 10/23/21 for V3. On 11/28/21 at 9:36a.m V3 (Nurse) said she only changed R1 urinary drainage bag on 10/23/21, V3 said she was not aware that she could change the suprapubic catheter. V3 said she has read the order, but she was not aware that she could change the suprapubic catheter, V3 said she has not asked the DON is it okay to change a suprapubic catheter. R1 POS- Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] Tablet 500 MG ([MEDICATION(S)] HCl) give 1 tablet by mouth every 12 hours for infection to suprapubic site per Urologist for 10 days with start date of 11/11/2021. Suprapubic catheter care every shift, every shift for suprapubic catheter with start date of 07/13/2021. R1 plan of care dated 03/04/2021 shows in part use of suprapubic catheter needed due to [CONDITION(S)] bladder, will have no acute complications of urinary catheter use, apply dignity bag to the bed and chair at all time and change as needed, Catheter Care, Change catheter per physician order, change urinary collection bag as needed, maintain drainage bag below bladder level, Secure catheter with securement device and change every week on Tuesday PM, Report any changes in amount and color, or odor of urine, and administer medication per physician orders.

Based on observation, interview and record review the facility failed to develop and implement a plan of care to meet the care needs to include catheter changes, assess and care the catheter, and keep the catheter secured to reduce the risk of dislodgment for 1 of 1 resident (R1) reviewed for urinary catheter care. This failure resulted in R1 developing a urinary infection requiring antibiotic treatment. Findings include: R1's plan of care shows R1 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS (Minimum Data Set) dated 11/23/21 shows R1 has a BIMS score of 14 (cognitively intact). On 11/27/21 at 12:22p.m R1 was observed resting in bed, alert and orient, R1 said lately her suprapubic site has not been getting cleaned and she has been waiting since around November 11, 2021 for the nurse to put an anchor in place to secure the suprapubic catheter, R1 also said her suprapubic catheter was not changed on October 23, 2021 and the nurse told her that she had an appointment, and it will be looked at then. At 1:00p.m during a care observation with R1's permission, R1 was noted to have a tannish colored suprapubic catheter in place attached to a clear tubing that's attached to a clear and white urinary drainage bag, there was a clear piece of tape noted wrapped around the clear tubing of the urinary drainage bag, the tape was not observed attached to R1's body part. V1 (DON- Director of Nursing) removed the old dressing, dry blood was observed on the dressing, V1 cleaned the site using gauze, the gauze was noted to be soiled (not blood), V1 cleaned the site with a new gauze until the gauzed was no longer visibly soiled, and V1 cleaned the suprapubic catheter, and placed a clean dressing with date to the suprapubic site. V1 was observed with a catheter securing device but V1 did not attached the device on R1 but did place it on R1's nightstand. During the catheter care observation, R1 was heard telling V1 not to pull the catheter out twice. On 11/27/21 at 2:40p.m R1 said no one came into the room to secure the catheter. On 11/27/21 at 3:00p.m V1 (DON- Director of Nursing) said catheter care should be done at least once a day, V1 said a catheter securing device should always be in place and should be changed weekly and or when it becomes soiled or comes off. V1 said catheter care is done to maintain skin integrity and prevent infection, and the securing device is used to prevent the catheter from being pulled and dislodged. V1 said R1 did not have an infection but was treated with the antibiotic's prophylaxis. Request was made to review documentation/ paperwork from the urology visit. On 11/28/21 during a follow up interview with V1, V1 said the nurse miss placed the documentation paperwork from R1's urology visit. On 11/28/21 at 9:36a.m V3 (Nurse) said she only changed R1's urinary drainage bag on 10/23/21, V3 said she was not aware that she could change the suprapubic catheter. V3 said she has read the order, but she was not aware that she could change the suprapubic catheter, V3 said she has not asked the DON if it is okay to change a suprapubic catheter. On 11/28/21 at 10:35a.m V4 (Nurse Practitioner) said R1 is alert and orient and R1 informed her that her catheter is not been getting changed. V4 said R1's catheter should be changed monthly to prevent infections. V4 said she prescribed R1 the antibiotics because when she saw R1 for an office visit in November, R1's suprapubic catheter was removed and the tip was black, the urine was mild odorous and there was a lot of debris observed in the urinary drainage bag. V4 said R1 was prescribed the antibiotics based on her assessment and when she sent R1's urine for culture it was positive for proteus and [MEDICATION(S)] was an appropriate medication for that organism. V4 said R1's catheter is not being changed as ordered. V4 said it is her expectation that the nurses follow the orders for changing the suprapubic catheter. On 11/28/21 at 1:00p.m V1 said she did not use the securing device on R1's catheter yesterday because R1 had tape in place to secure the catheter, V1 was made aware of the observation of the tape and it was wrapped around the clear tubing that's connected to the urinary bag and not secure to anything nor was the tape observed securing the suprapubic catheter. V1 said the catheter was secure and tape or securing device is appropriate. V1 said the nurse misplaced the documentation paperwork from R1 urology visit. At 4:12p.m V1 said the nurse should document when they provide suprapubic catheter care in the TAR and progress notes as necessary. R1 POS- Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] Tablet 500 MG ([MEDICATION(S)] HCl) give 1 tablet by mouth every 12 hours for infection to suprapubic site per Urologist for 10 days with start date of 11/11/2021. Suprapubic catheter care every shift, every shift for suprapubic catheter with start date of 07/13/2021. R1 TAR (Treatment Administration Record) for October 2021 does not show initials for completing the task of suprapubic catheter care every shift for October 2nd, 3rd, 4th, 5th, 6th, 7th, 8th, 10th, 11th, 12th, 13th, 16th, 18th, 23rd, 24th, 27th, 30th and 31st. R1's plan of care dated 03/04/2021 shows in part use of suprapubic catheter needed due to [CONDITION(S)] bladder, will have no acute complications of urinary catheter use, apply dignity bag to the bed and chair at all time and change as needed, Catheter Care, Change catheter per physician order, change urinary collection bag as needed, maintain drainage bag below bladder level, Secure catheter with securement device and change every week on Tuesday PM, Report any changes in amount and color, or odor of urine, and administer medication per physician orders. Facility policy Titled Catheter suprapubic (cystostomy): Reinsertion dated 11/2011 and updated 01/021 shows in-part the purpose is to resume continuous urinary drainage via suprapubic catheter. The catheter is placed through the abdominal wall above the symphysis and into the bladder, procedure #1 shows verify medical practitioners' orders, assemble equipment, procedure #12 shows secure catheter to abdomen with catheter securement device to reduce tension on insertion site. Securement device are changed at least every 7 days and as needed, using an alcohol pad to remove device. Facility Policy Titled Catheter suprapubic (cystostomy): site care and dressing change dated 11/2011 and updated 01/021 shows in-part the purpose is to maintain skin integrity at the cystostomy tube site. Completion procedure #17 shows secure catheter to abdomen with tape or catheter securement device to reduce tension on insertion site. Securement device are changed at least every 7 days and as needed, using an alcohol pad to remove device.

Based on observations, interviews, and record reviews, this facility failed to perform a comprehensive respiratory assessment, recognize the need to implement life sustaining interventions, including providing oxygen therapy, according to professional standards of practice, the comprehensive person centered care plan, and the resident's goals and preferences for a resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], R1 exhibited abnormal vital signs, decreased oxygen saturation levels, increased heart rate, and labored breathing for 43 minutes before EMS (emergency medical services) was notified. This failure resulted in R1 expiring upon arrival to the hospital. The Immediate Jeopardy was identified from observations and interviews to start on [DATE]. The Immediate Jeopardy was called on [DATE] at 1:36pm and the Administrator was notified. The Immediate Jeopardy was removed on [DATE]. Findings include: Review of R1's medical record, notes R1 was admitted to this facility on [DATE] after being hospitalized for acute on chronic respiratory failure, and septic shock secondary to urinary tract infection. During R1's hospital stay, R1 was intubated and mechanically ventilated. R1's medical history included chronic respiratory failure and home oxygen therapy. On [DATE], R1 exhibited a change in condition with a temperature of 102.1 degrees Fahrenheit, sweating, and only responsive to painful stimuli. An outside ambulance service was contacted. Upon their arrival, the paramedics noted R1 to have increased heart rate, labored breathing, and an oxygen saturation level of 88% on room air. The paramedics applied supplemental oxygen of 15 liters per minute using a non-rebreather face mask and transported R1 to the hospital. R1 was readmitted to this facility on [DATE]. During the onsite investigation the following was observed regarding R1's care: On [DATE] at 11:26am, the emergency cart was observed being pulled into R1's room by V4 (nurse) and V6 (nurse). A rapid response emergency code was paged overhead at 11:15am for R1 exhibiting respiratory distress. R1 was observed sitting upright in bed. R1's breathing was labored. R1's breathing was audible and sounded gargled. Respirations were deep and chest was rising and falling with great effort. This surveyor did not observe an oxygen tank in R1's room or with the emergency cart. On [DATE] at 11:30am, V3 (unit manager) was observed looking for oxygen tank and supplies at R1's bedside. V4 (nurse) asked if V3 wanted V4 to call 911 EMS (emergency medical services). V3 responded yes. V3 requested oxygen tank and oxygen supplies. On [DATE] at 11:31am, V3 was observed exiting R1's room. R1 was observed lying in bed with head of bed elevated. R1's eyes are open; R1 did not respond to V4's verbal or tactile stimulation. On [DATE] at 11:33am, V3 was observed returning to R1's room with a portable oxygen tank. V4 was observed setting up the suction equipment and suction R1's mouth. V10 (nurse) was observed entering R1's room to assist with R1. On [DATE] at 11:35am, V3 stated that R1's oxygen saturation level is 82% on room air. Oxygen at 15 liters via non-rebreather mask applied to R1. On [DATE] at 11:37am, V3 asked V4 (nurse) and V10 (nurse) if 911 EMS was called. No clear answer was given. V3 exited R1's room to inquire if 911 EMS was called. On [DATE] at 11:48am, V3 was observed re-entering R1's room and stated that EMS was in route. On [DATE] at 11:51am, V3 was observed asking V4 how long R1 had been decompensating. V4 stated it's been about an hour. When I first checked on R1, I noticed something was a bit off during my first assessment. I came back 30 minutes later and R1's breathing was increased. I came back 10 minutes after that and R1 was full blown (respiratory distress). I put an oxygen sensor on R1 but could not get a reading. On [DATE] at 11:55am, EMS paramedics were observed at R1's bedside. V4 informed EMS R1 had been in distress for one hour. Nursing staff were interviewed about R1's condition and services provided on [DATE] as follows: On [DATE] at 1:35pm, V6 (nurse) stated that at 11:15am, V4 (nurse) approached V6 and informed V6 that V4 needed help. V6 stated that V4 informed V6 that the emergency cart was needed. V6 stated that V4 and V6 went to R1's room with the cart. V6 stated that the oxygen tank was not with the emergency cart and V6 was instructed by V3 (unit manager) to obtain an oxygen tank. V6 stated that V4 (nurse) went to the oxygen supply room to obtain an oxygen tank, so V6 went to the nurses' station to print forms (face sheet, medication list) for EMS paramedics. Neither V6 nor V4 were observed bringing an oxygen tank to R1's room. On [DATE] at 12:20pm, this surveyor observed V30 (director of maintenance) measure the distance between R1's room and this facility's oxygen supply room. R1's room is noted to be 289 feet from this facility's oxygen supply room. On [DATE] at 2:00pm, V4 (nurse) stated that during V4's rounds at 8:30am this morning, R1 was okay, a little rhonchi (coarse breath sounds), slight cough, V4 tried to get R1 to cough, R1 not able to effectively cough. V4 stated that V4 requested V11 (central supply room staff) to deliver a suction machine on the next delivery round. V4 stated that V4 returned at 10:30am, R1's lungs sounded a lot moister. V4 stated that V4 elevated R1's head of bed a little more and tried to get R1 to cough. V4 stated that no other assessments were done. V4 stated that V4 returned to R1's room [ROOM NUMBER] minutes later and R1 was in (respiratory) distress. At 11:00am, R1's breathing more labored becoming diaphoretic, unable to obtain accurate oxygen saturation level with pulse oximetry, fleeting reading of 86%. V4 stated that V4 informed V3 (unit manager) of situation and then asked another nurse (V6) for assistance. V4 stated that V4 did not recall what time V4 notified V6 and V3. V4 stated that V4 got the emergency cart and brought it to R1's room. V4 stated that the oxygen tank was not with the emergency cart. V4 stated that the emergency cart is checked daily by nursing. V4 stated that the suction machine, portable defibrillator, back board, and a full oxygen tank should be present with the emergency cart. V4 stated that at approximately 11:32am, V4 set up the suction machine and suctioned R1's mouth. V4 stated that V4 tried to obtain oxygen saturation level on left index finger, then applied oxygen. V4 stated that at approximately 11:34am, the highest oxygen saturation level was 86% on 15 liters of oxygen and R1's heart rate was 128 beats/minute. V4 stated that the suction machine V4 requested was not delivered prior to the onset of this event. On [DATE] at 9:20am, V2 DON (acting director of nursing) stated that when a resident exhibits a sudden change in condition, the nurse should remain at the resident's bedside and shout out for assistance as well as shout out for a rapid response or code to be called. V2 stated that each emergency cart is checked daily by the nurse. V2 stated that the nurse is expected to make sure oxygen, portable defibrillator, resuscitative bag, back board, and suction machine are present and functioning properly. V2 stated that there is a form on top of the emergency cart that the nurse signs and documents the cart's lock number. V2 stated that if a nurse takes equipment off emergency cart, the nurse is expected to replace before leaves building for day. On [DATE] at 10:35am, V11 (central supply room staff) stated that V11 is responsible for ordering and stocking supplies on nursing units. V11 stated that V11 received a call from V4 (nurse) between 11:00am and 11:15am requesting a suction machine. V11 stated that V11 brought V4 suction machine to the nurses' station, heard code paged overhead. V11 stated that V11 brought suction machine to R1's room. V11 stated that V11 was not sure which resident needed the suction machine in R1's room and therefore left the suction machine at nurses' station. On [DATE] at 9:18am, V3 RN (registered nurse/unit manager) stated that at approximately 11:15am, just prior to the rapid response emergency code called, V4 (nurse) informed V3 that R1 may have to be sent out to the hospital for respiratory distress. V3 stated that this facility's protocol is to inform the unit manager of any changes in resident's condition. The unit manager is responsible for investigating the situation and assessing the resident immediately. V3 stated that V3 expects the nurse to obtain oxygen supplies and oxygen tank when a resident initially exhibits any breathing difficulties. V3 stated that V3 expected V4 (nurse) to remain at R1's bedside, apply oxygen and continue to obtain an oxygen saturation level with the pulse oximeter, and then shout out for a rapid response to get additional staff assistance at 11:00am on [DATE]. V3 stated that on [DATE], V4 (nurse) did not inform V3 that R1 was exhibiting respiratory distress until 11:15am. V3 stated that upon entering R1's room, V3 noted R1 with audible coarse breath sounds. V3 stated that V3 did not see any oxygen supplies or an oxygen tank in R1's room. V3 stated that R1's blood pressure was low, R1 had a lot of generalized swelling, and V3 had difficulty obtaining R1's oxygen saturation level on room air. V3 stated that R1's heart rate was 94 beats/minute at that time. V3 stated that V3 knew R1 was in acute distress just by looking at R1. V3 stated that 911 EMS should have been called immediately. V3 stated that V4 brought the emergency cart to R1's room, but the oxygen tank was missing. V3 stated that V3 instructed V4 to obtain an oxygen tank. V3 stated that V3 asked for nurse to check R1's code status. V3 stated that when V3 asked if 911 EMS was called, V3 got no response from V4 or V10 in R1's room. V3 stated that V3 left R1's room to inquire. V3 stated that a nurse at the nurses' station informed V3 that EMS was in route; V3 returned to R1's bedside. V3 stated that EMS arrived about 10 minutes later and took over the care for R1. V3 stated that when bringing the emergency cart, the nurse is expected to do a quick check and ensure suction machine, oxygen tank, resuscitative bag, and defibrillator are present. On [DATE] at 3:00pm, V19 (nurse manager) stated that V19 is unable to find a policy regarding oxygen therapy. V19 stated that this facility follows a Care Path for symptoms of SOB (shortness of breath). Care path reviewed with V19. If resident exhibits difficulty or labored breathing, the nurse should obtain the resident's vital signs; if heart rate more than 100 beats/minute, oxygen saturation level less than 90%, physician should be notified. Evaluate signs/symptoms for immediate notification: cough, abnormal lung sounds, notify physician. V19 stated that the care path can be reviewed from any computer within this facility and it should be utilized when a resident is exhibiting a change in medical condition. On [DATE] at 8:15am, V2 DON presented this facility's oxygen administration policy. V2 stated that the first lines of the policy note it is appropriate for nursing to administer oxygen immediately and then notify the resident's physician for orders. On [DATE] at 9:10am, V29 NP (nurse practitioner) stated that V29 expects nursing staff to apply oxygen immediately for any resident exhibiting signs/symptoms of respiratory distress, such as difficulty breathing, labored breathing, increased respirations, decreased oxygen saturation level, and then contact V29 or the physician for further orders. Review of R1's respiratory surveillance documentation, dated [DATE] - [DATE] at 3:02am, noted R1 did not exhibit a cough or shortness of breath, and R1's lungs sounds were clear in all lobes on auscultation. There is no documentation noted in R1's medical record of R1 having a history of requiring oral suctioning via a suction machine at any time during R1's stay at this facility. Review of R1's care plan, dated [DATE], notes R1 has altered respiratory status related to chronic respiratory failure and [CONDITION(S)] (chronic obstructive pulmonary disease). Interventions identified include: monitor for changes in orientation, increased restlessness, and air hunger; monitor for signs/symptoms of respiratory distress and report to physician: increased respirations, decreased pulse oximetry, increased heart rate, diaphoresis, and accessory muscle usage; monitor/report abnormal breathing patterns to physician: increased rate, prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, and nasal flaring; position R1 with proper body alignment for optimal breathing pattern; and provide oxygen as ordered. Review of R1's altered cardiovascular status care plan, dated [DATE], notes monitor/report to physician changes in lung sounds and [CONDITION(S)]. Notify physician of any abnormal vital signs. Review of R1's progress notes, dated [DATE], notes the following: At 3:02am, noted R1's lung sounds, right and left lobes clear. At 8:46am, V4 RN (registered nurse) noted lung sounds, right and left upper lobes with rhonchi (coarse breath sounds), right and left lower lobes diminished. At 12:20pm, V4 noted at 10:30am, R1 with more rhonchi than on first assessment this morning, awake and responsive. At 12:25pm, V4 noted at 11:00am, R1's breathing more labored becoming diaphoretic, unable to obtain accurate oxygen saturation level with pulse oximetry, fleeting reading of 86%. At 12:32pm, V4 noted at 11:10am, vital signs: blood pressure ,d+[DATE], heart rate 124 beats/minute, respirations 30/minute, still unable to get accurate oxygen saturation level. Review of the EMS (emergency medical services) report, dated [DATE], noted EMS was notified at 11:44am. The EMS unit was in route to this facility at 11:45am. The EMS unit arrived on scene at 11:51am and were at R1's bedside at 11:52am. EMS assessment noted R1's breathing labored, rapid, and shallow, mental status was unresponsive. Initial vital signs taken at 11:53am: blood pressure ,d+[DATE], heart rate 106 beats/minute, respirations 36/minute, oxygen saturation level on 15 liters of oxygen was 85%. Summary noted EMS dispatched for a resident having difficulty breathing. Upon arrival, R1 was unresponsive and in respiratory distress on 15 liters/minute oxygen via non-rebreather mask. Staff stated R1 had been in current condition for approximately one hour. R1 was diaphoretic and coarse breath sounds were heard bilaterally. The local hospital was alerted to R1's critical condition. While in route to the hospital, R1 began gurgling and mouth was suctioned, no improvement in R1's overall condition. Upon arrival to the hospital, R1 stopped breathing. Hospital staff took over the care of R1. Review of the hospital records, dated [DATE], noted R1 was pronounced expired at 12:19pm on [DATE]. Change in R1's condition on [DATE]: On [DATE] at 12:00pm, V24 LPN stated that the protocol for a change in resident's condition, the nurse performs an assessment, full set of vital signs, neurological check, and notifies physician. V24's documentation on [DATE] at 2:45pm was reviewed with V24. V24 stated that upon completion of R1's assessment, V24 checked R1's code status. V24 stated that R1 was DNR (do not resuscitate) with selective treatment, but was unable to locate DNR form in R1's medical chart at the nurses' station. V24 stated that V24 paged the nurse practitioner to inform her V24 was going to send R1 out to the hospital. V24 stated that V24 called 911 EMS (emergency medical services). V24 stated that V24 stayed at R1's bedside until paramedics arrived. V24 stated that V24 obtained vital signs with V24's assessment; no further vital signs were obtained. V24 stated that V24 did not apply oxygen to R1. Review of R1's medical notes R1 was admitted to this facility on [DATE]. Review of R1's POS (physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1's POS, dated [DATE], notes R1 is DNR. Review of R1's DNR form, dated [DATE], notes R1 is DNR with selective treatment, including oxygen therapy. Review of R1's progress notes, dated [DATE], notes the following: At 10:12am, V24 LPN (licensed practical nurse) noted R1 with temperature of 101.6. Acetaminophen was given. At 1:15pm, V24 LPN noted R1's temperature went down to 99.5. At 2:45pm, V24 LPN noted R1's temperature back up to 102.1, diaphoretic, only responsive to painful stimuli. At 3:38pm, V25 NP (nurse practitioner) noted V25 received a call from V24 at 3:30pm stating R1 has mental status changes and temperature of 101.4 and V24 was sending R1 out to hospital now. V13 (attending physician) notified. At 4:24pm, V26 LPN noted R1's family made aware that R1 was transferred to the hospital per outside ambulance service to the local hospital due to increased heart rate, altered mental status, and elevated temperature. R1 admitted with fever, [CONDITION(S)], dehydration, and elevated troponin (type of protein found in the muscles of the heart; this protein is released into the blood when the heart muscle becomes damaged). There is no documentation found noting V24 called 911 EMS for R1's transport to hospital on [DATE]. Review of the outside ambulance service run sheet, dated [DATE], noted dispatch was notified on [DATE] at 3:16pm. The outside ambulance service was in route at 3:23pm and arrived at R1's bedside at 3:39pm. Initial vital signs: blood pressure ,d+[DATE], heart rate 135 beats/minute, respirations 35/minute, oxygen saturation level 88% on room air. R1's breathing noted to be labored. Paramedics placed oxygen at 15 liters/minute via non-rebreather mask. Oxygen saturation level improved to 99% with supplemental oxygen. The outside ambulance service transported R1 to the hospital at 4:11pm and arrived at 4:20pm. R1's care transferred to the hospital staff. Review of this facility's emergency management policy, revised ,d+[DATE], notes the following is documented in the resident's progress notes after a resident emergency event: resident status, time medical emergency identified and type of emergency care initiated, evaluation of resident's level of consciousness, circulation, airway, and breathing, verification of resident's code status, occurrence and time code called, time and person contacting EMS, step by step description of care provided, physician notification, response received, and orders obtained ,family notification and response received, EMS arrival and transfer of care, and time and resident status upon transfer from facility. Review of this facility's oxygen administration policy, updated ,d+[DATE], notes during a respiratory emergency, it is appropriate for nursing to administer oxygen immediately and obtain physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record in the resident's progress notes date and time oxygen was initiated, condition necessitating oxygen use, respiratory status related to oxygen use, type of delivery, device used and flow rate of oxygen and any assessments or interventions. Review of this facility's care path for symptoms of shortness of breath, dated 2014, notes symptoms of shortness of breath include: difficult or labored breathing that is out of proportion to the resident's level of physical activity; any new complaint of shortness of breath. Obtain vital signs, including: temperature, blood pressure, heart rate, respirations, and oxygen saturation level. If heart rate is greater than 100 beats/minute, respiratory rate is greater than 28/minute, oxygen saturation level is less than 90%, or accessory muscle breathing, notify physician. If resident exhibits cough with or without sputum production, abnormal lung sounds (such as rhonchi), swelling, change in mental status, cardiovascular symptoms, or other respiratory symptoms, notify the physician immediately. Review of this facility's change in condition policy, dated ,d+[DATE], notes a facility must immediately inform the resident's physician and the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status. The surveyor confirmed the following implementation of the facility's removal plan via observation, record review and interview: 1. Reviewed the Emergency Management Policy, which includes directions for crash cart maintenance and Notification of the Physician, and determine the policy provides adequate direction to staff in the event of a medical emergency. This review was conducted during the ad hoc Quality Assurance committee meeting on [DATE]. 2. The Medical Director, Dr. [NAME] [NAME], was made aware of the citation F695 on [DATE]. 3. In Response to the Abatement plan's response on [DATE], the Facility identified the Interact Car Path, Respiratory ASSESSMENT for shortness of breath, tool as an educational resource to provide as an in-service to RN/LPN Nursing staff. 4. The facility's RN/LPN nursing staff were in-serviced on the Emergency Management Policy by the facilities nurse managers. The in-services began on [DATE] and was completed that day for all RN/LPN working the evening and night shifts on [DATE]. The in-services continued on [DATE] and included all working the day shift, [DATE], and on-going forward any Licensed Nurse would receive their in-service training prior working their next scheduled shift. Currently ,d+[DATE] staff, have been in-serviced. In- service continues until 100% of current staff working receive this in-service. Newly hired nurses will receive this training during orientation, prior to working independently. This education will be repeated as needed at the direction of the QAPI committee. Any agency RN/LPN assigned to work in the facility will receive the in-service training in their orientation packet on their next scheduled shift prior to their shift assigned to the facility. The 1 remaining nurse to be educated is currently on vacation out of the country and is expected to return on [DATE] and will be educated at the beginning of her shift. 5. The facilities RN/LPN nursing staff were in-serviced on the crash cart maintenance process by the facility's nurse managers. The in-services began on [DATE] and was completed that day for all RN/LPN working the evening and night shifts on [DATE]. The in-services continued on [DATE] and included all working the day shift, [DATE], and on-going forward any Licensed Nurse would receive their in-service training prior working their next scheduled shift. Currently ,d+[DATE] staff, have been in-serviced. In- service continues until 100% of current staff working receive this in-service. Newly hired nurses will receive this training during orientation, prior to working independently. This education will be repeated as needed at the direction of the QAPI committee. Any agency RN/LPN assigned to work in the facility will receive the in-service training in their orientation packet on their next scheduled shift prior to their shift assigned to the facility. The 1 remaining nurse to be educated is currently on vacation out of the country and is expected to return on [DATE] and will be educated at the beginning of her shift. 6. On [DATE] the facility's 3 crash carts were audited for necessary supplies, both in the art and on the top of the cart (suction machine and oxygen). The crash cart will be checked daily on the night shift by the assigned nurse to the nursing unit for their designated cart. The daily checks include, ensures the lock is in place, and the items on top of or connected to the cart are present. If the cart is not locked, the contents will be identified and replaced as needed in accordance to the crash cart checklist. When the cart has been used items will be restocked and the cart will be relocked. This will be verified on a daily basis by recording the lock number on the daily crash cart form. The nurse managers will review the crash cart check during their daily rounds. A documented audit tool will be utilized daily for 2 weeks, when the nurse manager is present and reduced to 3x per week until the audit remains at 100% compliance and have been reviewed by the monthly scheduled QAPI meeting. Continued auditing will be determined at the direction of the QAPI committee. 7. The facility's RN/LPN were in-serviced on the Interact respiratory Assessment for shortness of breath tool, by the facility's nurse managers. The in-services began [DATE] and was completed for all licensed nurses working the evening and night shift on [DATE]. The in-service continued on [DATE] and then on-going forward for any licensed nurse would receive their in-service training prior to working their next scheduled shift. Currently ,d+[DATE] staff have been in-serviced. In services continue until 100% of current staff working receive this in-service. Newly hired nurses will receive this training during orientation, prior to working independently. This education will be repeated as needed at the direction of the QAPI committee. Any agency RN/LPN assigned to work in the facility will receive the in-service training in their orientation packet on their next scheduled shift or prior to their first shift assigned to the facility. The 1 remaining nurse to be educated is currently on vacation out of the country and is expected to return [DATE].2021 and will be educated at the beginning of her shift. 8. The Interact tool has been available on the Nurses desk top computer in the clinical resource HUB. An additional step was initiated on [DATE] to make a paper copy available of the Interact Care Path tool in a binder for quick reference at each Nurses station. 9. On [DATE], in response to the citation the facility's nurse, manager and respiratory therapist observed all in-house residents for any respiratory changes in condition. No resident had new onset of respiratory symptoms. All residents also had emergency oxygen available to them. This audit was continued for newly admitted residents on [DATE] and the 4 residents identified with potential for respiratory symptoms of acute respiratory distress. This audit tool will be used daily for new admissions and like residents for 2 weeks, then 3x per week for 2 weeks and then reviewed at the scheduled monthly QAPI meeting to determine need for continued audit. 10. As part response of the Covid pandemic, the facility nursing staff also perform a Respiratory Surveillance Assessment for every in-house resident on a daily basis. On [DATE] and [DATE], the facility achieved 100% compliance completing the assessments and no new symptoms were identified. The Facility Nurse Managers will oversee the completion of this assessment as a part of their routine/on call clinical oversight activities on a random weekly basis. 11. For the identified 4 residents the respiratory therapist performed a respiratory focused assessment on each resident on [DATE], no change in condition with these residents was identified. Any agency staff present during a Mock code blue drill be asked to participate in the drill and attend any education provided for emergency response/management while on duty. 12. The facility nurse managers will utilize their change in condition QA audit tool during their (M_F) clinical risk meeting when a respiratory change in condition has been identified to ensure follow up and notification to the physician occurs. 13. As part of the facility's emergency preparedness plan, the facility nurse managers will perform Mock code blue drills, one on each shift completed by the 15th of June and monthly thereafter, which is then documented on the audit tool. The result of the drills will be reviewed in the scheduled monthly QAPI meeting to determine any further educational or auditing needs. The process for the mock code blue drill is outlined in the emergency management policy.

Based on interviews and record reviews, the facility failed to assess for circulation and identify the signs of altered neurovascular status to include decrease in sensation, increase in complaints of pain and discoloration of toes, and failed to implement interventions to prevent or reduce the risk of skin breakdown for 1 of 3 residents (R5) reviewed for splint/cast neurovascular assessments. The facility also failed to follow their policy and procedures for monitoring vital signs at least every ,d+[DATE] hours for 1 of 3 residents (R12) reviewed for vital signs after admission. This failure resulted in R5 developing a gangrene wound to the top right foot area, right lateral foot and right heel requiring surgical interventions and above the knee amputation. Findings include: 1. R5: On [DATE] at 11:00am, V16 (wound care nurse) stated that the wound care team does not routinely monitor residents with a cast or posterior mold unless they are notified of a wound by the nursing staff. V16 stated that the resident's nurse is responsible for monitoring resident's skin for any changes. This surveyor reviewed a wound care photograph of R5's left heel taken on [DATE]. This photograph noted discoloration (reddened and purple areas) to R5's right toes. V16 stated that V16 was not aware of any concerns related to R5's right toes. V16 stated that wound care staff should assess and monitor any reddened areas. On [DATE] at 2:00pm, V35 (orthopedic surgeon) stated that V35 was not made aware of any changes in R5's neurovascular status to right lower leg prior to R5's appointment on [DATE]. On [DATE] at 2:15pm, V23 NP (wound care nurse practitioner) stated that any resident with a splint/cast should have the affected extremity's circulation checked on a daily basis. V23 stated that the wound care staff should be checking skin proximal and distal to splint/cast for any circulation issues. V23 stated that V23 can't see the wound care staff performing wound care to R5's right posterior knee and not assessing R5's toes for circulation. V23 does not recall observing R5's right toes during weekly wound rounds. V23 stated that all assessments should be documented in the resident's medical record. On [DATE] at 10:35am, V25 NP (nurse practitioner) stated that V25 expects the nurse to notify V25 or the physician of any changes in a resident's neurovascular status: pain, swelling, numbness, tingling, or pulses. V25 denied being informed of any changes in the color of R5's toes. On [DATE] at 4:00pm, V32 (medical director) stated that the nurse is expected to notify the physician of any changes in the resident's condition. V32 did not respond when questioned regarding this facility's cast care policy for neurovascular assessment, CMS (circulation, motion, sensation) checks. Review of the medical record notes R5 was admitted to this facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R5's admission note, dated [DATE], notes R5 admitted with redness to posterior knee; no open areas identified. Review of R5's Braden scale, dated [DATE], notes no impairments with sensory perception. R5 is noted at risk for developing pressure ulcers. On [DATE], R5's Braden scale notes a change in R5's sensory perception: slight limitation in R5's ability to respond meaningfully to pressure-related discomfort. Review of R5's medical record does not note documentation of daily head to toe skin evaluations were performed by a nurse or documented in R5's clinical record. Review of R5's MAR (medication administration record), dated [DATE], notes R5 received [MEDICATION(S)] (pain medication) 50mg (milligrams) oral on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE],,d+[DATE], ,d+[DATE], ,d+[DATE] and ,d+[DATE] for pain control. R5 also received acetaminophen 325mg two tablets oral every 6 hours for pain. R5's pain assessment, dated [DATE], notes R5 rated pain at 6 out of 10. R5 with complaints of pain frequently. R5's pain goal is 0 out of 10. Pain described as aching, throbbing, and stiffness. Pain relieving factors include repositioning and medications. Pain negatively affects R5's ADLs (activities of daily living), activities, and sleep. A photograph taken by the wound care team, dated [DATE], notes R5's left heel in the foreground and R5's right toes in the background. R5's first, second, and fourth toes are reddened and R5's third toe is observed to have purple discoloration. There is no documentation found in R5's medical record noting discoloration to R5's right toes. Review of V35's (orthopedic surgeon) follow-up appointment note, dated [DATE], noted on [DATE] R5 presented to the hospital with right ankle fracture due to fall. R5's ankle was reduced, and a well-padded splint was applied. R5 was found to be neurovascular intact with normal sensation and capillary refill less than 2 seconds post-reduction. R5 was not able to flex or extend toes before or after reduction, which apparently is R5's baseline. Right lower leg splint removed, found to be well-padded and appropriately wrapped without significant tension on elastic bandage. Posterior slab extends to 2cm (centimeters) distal to the fibular head, no exposed fiberglass material. Splint removed. There is necrosis (dead) of the skin on the top of R5's right foot, lateral foot, and heel. Pedal pulses faint to non-palpable, sensation is absent. The severity of this problem was discussed with R5 and R5's family member. R5 was transported directly from the outpatient orthopedic clinic to the hospital for further evaluation and treatment. Review of R5's hospital records, dated [DATE] - [DATE], notes R5's right foot with dusky appearance and cool to the touch. R5's right pedal pulses not palpable. Wound care physician consult note, dated [DATE], notes extensive black eschars (dead tissue) on the right foot on the top of foot, posterior heel, extending to distal shin. R5 with gangrenous skin changes of the right foot. Vascular consult, dated [DATE], noted R5 stated R5's wounds to right leg were not present prior to R5's fall. R5 had sensation in R5's right foot prior to the fall, but not since after the fall. Right foot with extensive necrotic (dead) tissue to top of foot and mottled in appearance; ischemia changes noted. On [DATE], a right above the knee amputation was performed. Photographs of 5's right foot and lower leg taken in the hospital, dated [DATE], notes discoloration to R5's right toes, swelling, and gangrenous wounds to the top of R5's right foot, right lateral foot, and right heel. Review of R5's alteration in comfort care plan, initiated [DATE], notes interventions including: provide cast care, administer pain medication per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R5's alteration in musculoskeletal status related to right ankle fracture, initiated [DATE], notes interventions including: monitor/report to physician signs/symptoms or complications related to pain, swelling, or decline in mobility. Review of R5's care plan, dated [DATE], notes R5 is at risk for complications due to musculoskeletal problems related to right ankle fracture and contractures. Review of R5's at risk for alteration in skin integrity care plan related to impaired mobility, use of cast below knee, dated [DATE], notes observe skin condition with ADL (activities of daily living) care daily, report abnormalities. Review of this facility's cast care policy, updated ,d+[DATE], notes to perform neurovascular assessment (5P's) on casted extremity every ,d+[DATE] hours for the first 24 hours. Neurovascular assessment should continue at a minimum every shift. 5P's include: pain; pallor, observe color of tissues distal to cast, no signs of circulatory compromise should be present; pulseless-ness, palpate distal pulses of casted extremity, note presence and strength of pulse, assess capillary refill; paresthesia, assess for numbness/tingling, or abnormal sensations; and paralysis, assess for ability to move toes and extremity. Notify physician of change in condition (odor, drainage, hot spots, decreased circulation, increased pain, etc.). Record in the resident's progress notes the date and time care (neurovascular assessment) was provided, condition of skin, status of circulation, and motion of distal extremity. Report unusual findings from the neurovascular assessment and document in progress note. Review of this facility's skin practice guide, dated ,d+[DATE], notes a comprehensive evaluation of a resident's skin status requires evaluations by the physician, nursing staff, registered dietitian, and rehabilitation team. The Braden scale is used to identify potential levels of risk for pressure ulcer development. Each resident is evaluated on admission or re-admission using this scale. The Braden scale is completed for 4 weeks total (at the time of admission and then weekly for the next three weeks, quarterly, with a significant change and as clinically indicated. A comprehensive skin evaluation is completed upon admission. Daily head to toe skin evaluations are completed by the nurse for any resident with a pressure ulcer and documented in the resident's clinical record. Upon completing an evaluation, the interdisciplinary team develops a resident specific care plan to include prevention and management interventions with measurable goals. For a change in resident condition, the nurse notifies the physician, wound care team, family or responsible party and documents the findings in the clinical record. The resident's care plan is updated to reflect the resident's current status and care needs. 2. R12: Review of R12's medical record notes R12 was readmitted to this facility on [DATE] after being hospitalized for urinary tract infection, weakness, and metabolic [CONDITION(S)]. On [DATE] at 2:00pm, V2 DON (acting director of nursing) stated that the nurse is expected to perform an admission/re-admission assessment, including head to toe assessment and vital signs. V2 stated that the enhanced measures protocol includes vital sign monitoring every 8 hours. On [DATE] at 2:59pm, V34 RN (registered nurse) stated that on [DATE], V34 was assisting R12 onto toilet. V34 stated that when R12 sat on toilet, R12 became unresponsive. V34 stated that V34 called out for assistance. V34 stated that another nurse was in the hallway nearby and came to assist. V34 stated that V34 tried to revive R12 while the other nurse left R12's room to page a rapid response overhead. V34 stated that more staff arrived to assist. R12 was helped into wheelchair and then placed into bed. V34 stated that R12 became responsive and was alert and oriented at baseline. V34 stated that R12 appeared to have a syncopal event. V34 stated that V34 notified R12's physician and was informed to encourage fluids and monitor vital signs. V34 denied obtaining orthostatic (blood pressure and heart rate monitoring sitting, standing, and lying flat in bed) vital signs or receiving a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V34 stated that a resident's vital signs are monitored every shift and with any change in condition. Review of R12's progress notes, dated [DATE], notes at 8:18pm R12 requested to go to bathroom, V34 RN assisted R12 to toilet, R12 become unresponsive, assisted R12 back to chair and R12 became responsive, blood pressure ,d+[DATE], heart rate 82 beats/minute, respirations 18/minute, oxygen saturation level 96% on room air, assisted back to bed and made comfortable. At 9:04pm, V34 noted R12's physician notified of R12's condition, vital signs: blood pressure ,d+[DATE], heart rate 73 beats/minute, oxygen saturation level 96% on room air, respirations 18/minute. Orders given and carried out, R12 in bed resting at present no distress at present. Review of R12's POS (physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2:30pm, notes an order for [MEDICAL RECORD OR PHYSICIAN ORDER] There is no documentation found in R12's medical record noting vital signs were ordered between re-admission to this facility on [DATE] at 4:00pm and [DATE] at 2:30pm. There is no documentation found in R12's medical record noting vital signs were obtained between [DATE] at 9:00pm and [DATE] at 10:30pm. This facility's care path for symptoms of acute mental status change, dated 2014, was reviewed. It notes for new mental status change noted, such as unresponsiveness, obtain vital signs. Evaluate resident for any other signs or symptoms and consider contacting the resident's physician for orders for further evaluation and management, such as chest x-ray, urinalysis, bloodwork, and electrocardiogram. Monitor resident's vital signs, fluid intake/urine output every ,d+[DATE] hours. Review of this facility's enhanced measures and monitoring policy, revised [DATE], notes at a minimum of every shift, obtain temperature checks and respiratory assessments on all residents. Complete respiratory surveillance evaluation in the electronic medical record at least every shift for all residents in the facility. Review of this facility's respiratory surveillance evaluation form notes to document the following: temperature; blood pressure; oxygen saturation level; cough; shortness of breath; lung sounds: right upper lobe, right lower lobe, left upper lobe, left lower lobe; sore throat; chills; congestion/runny nose; fatigue; muscle/body aches; headache; loss of taste; loss of smell; presence of nausea, vomiting, diarrhea; if on airborne respiratory isolation; and any additional notes.

Based on interviews, and record reviews, this facility failed to consistently and accurately assess and monitor a resident's clinical condition, implement interventions that are consistent with a resident's needs, goals, and professional standards of practice, evaluate the effectiveness of the interventions to prevent a pressure ulcer from developing and/or worsening for one resident (R5) in a sample of 3 reviewed for device related pressure ulcers in a sample of 22. This failure resulted in R5's redness to right posterior knee upon admission worsening to an open wound with exposed tendon requiring a right above the knee amputation. Findings include: On 5/21/2021 at 11:00am, V16 (wound care nurse) stated that R5's right leg was contracted. V16 stated that R5 developed a pressure ulcer to right posterior knee. V16 stated that these wounds were a result of R5's posterior mold splint rubbing R5's posterior leg. V16 stated that wound healing was complicated due to R5's posterior mold splint. V16 stated that a [MEDICATION(S)] dressing was applied to R5's posterior right knee wound to provide extra cushioning to this wound. V16 stated that the wound care team does not routinely monitor residents with a cast or posterior mold unless they are notified of a wound. V16 stated that the resident's nurse is responsible for monitoring resident's skin for any changes. This surveyor reviewed a wound care photograph of R5's left heel taken on 5/4/2021. This photograph noted discoloration (reddened and purple areas) to R5's right toes. V16 stated that V16 was not aware of any concerns related to R5's right toes. V16 stated that wound care staff should assess and monitor any reddened areas. On 5/21/2021 at 2:00pm, V35 (orthopedic surgeon) stated that V35 was not made aware of R5's right posterior knee wound or of any changes in R5's neurovascular status to right lower leg prior to R5's appointment on 5/18/2021. On 5/25/2021 at 2:15pm, V23 NP (wound care nurse practitioner) stated that R5's posterior mold on right lower leg rubbed against R5's posterior knee due to right leg contracture. V23 stated that V23 thinks wound care staff placed a [MEDICATION(S)] dressing over R5's posterior knee wound to provide cushioning. V23 denied notifying R5's outside orthopedic physician with concerns related to R5's splint and the pressure ulcer to R5's posterior knee. V23 stated that any resident with a splint/cast should have the affected extremity's circulation checked daily. V23 stated that the wound care staff should be checking skin proximal and distal to splint/cast for any circulation issues. V23 stated that V23 can't see wound care staff performing wound care to R5's right posterior knee and not assessing R5's toes for circulation. V23 does not recall observing R5's right toes during weekly wound rounds. All assessments should be documented in the resident's medical record. On 6/9/2021 at 4:00pm, V32 (medical director) stated that nurse practitioners have standards of care they should be following related to resident care. V32 stated that this facility's wound care staff should have notified V35 (orthopedic surgeon) that the splint was rubbing against R5's posterior knee resulting in skin breakdown. V32 stated that the wound care staff should have implemented interventions to prevent further skin breakdown due to R5's posterior mold splint. V32 stated that the nurse is expected to notify the physician of any changes in the resident's condition. Review of the medical record notes R5 was admitted to this facility on 4/29/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R5's admission note, dated 4/29/2021, notes R5 admitted with redness to posterior knee; no open areas identified. Review of R5's Braden scale, dated 4/29/2021, notes no impairments with sensory perception. R5 is noted at risk for developing pressure ulcers. On 5/6/21, R5's Braden scale notes a change in R5's sensory perception: slight limitation in R5's ability to respond meaningfully to pressure-related discomfort. Review of R5's alteration in comfort care plan, initiated 5/3/2021, notes interventions including: provide cast care, administer pain medication pre physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R5's alteration in musculoskeletal status related to right ankle fracture, initiated 4/30/2021, notes interventions including: monitor/report to physician signs/symptoms or complications related to pain, swelling, or decline in mobility. Review of R5's care plan, dated 4/30/2021, notes R5 is at risk for complications due to musculoskeletal problems related to right ankle fracture and contractures. Review of R5's at risk for alteration in skin integrity care plan related to impaired mobility, use of cast below knee, dated 4/30/2021, notes observe skin condition with ADL (activities of daily living) care daily, report abnormalities. R5's care plan, dated 5/6/2021, notes pressure ulcer to R5's right rear knee related to cast. Review of R5's POS (physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on 5/13 at 2:02pm. This same order was re-ordered on 5/13 at 2:15, but did not start until 5/15. Review of R5's MAR (medication administration record), dated May 2021, notes R5 received [MEDICATION(S)] (pain medication) 50mg (milligrams) oral on 5/5, 5/7, 5/10, 5/11,5/13, 5/14, 5/15 and 5/17 for pain control. R5 also received acetaminophen 325mg two tablets oral every 6 hours for pain. Review of R5's TAR (treatment administration record), dated May 2021, notes body audit one time a day every 7 days for skin observation. There is no documentation found noting R5's right rear knee, cleanse with normal saline, pat dry, apply medicated ointment and alginate and cover with dry dressing was performed on 5/4 or 5/12, 5/13, or 5/14. R5's pain assessment, dated 5/3/2021, notes R5 rated pain at 6 out of 10. R5 with complaints of pain frequently. R5's pain goal is 0 out of 10. Pain described as aching, throbbing, and stiffness. Pain relieving factors include repositioning and medications. Pain negatively affects R5's ADLs, activities, and sleep. Review of V35's (orthopedic surgeon) follow-up appointment note, dated 5/18/2021, noted on 4/22/2021 R5 presented to the hospital with right ankle fracture due to fall. R5's ankle was reduced, and a well-padded splint was applied. R5 was found to be neurovascularly intact with normal sensation and capillary refill less than 2 seconds post-reduction. R5 was not able to flex or extend toes before or after reduction, which apparently is R5's baseline. R5 stated that shortly after admission to this facility, staff had been regularly changing R5's dressing to R5's right posterior thigh which has become increasingly painful with every change. V35 had not been contacted regarding this dressing change. Right lower leg splint removed, found to be well-padded and appropriately wrapped without significant tension on elastic bandage. Posterior slab extends to 2cm (centimeters) distal to the fibular head, no exposed fiberglass material. Dressing over right posterior thigh removed. There is full thickness skin breakdown over the posteromedial distal thigh, approximately 3cm x 3cm in size, 2cm proximal to the posterior knee crease with surrounding redness. There is visible tendon through this wound. There is necrosis (dead) of the skin on the top of R5's right foot, lateral foot, and heel. Pedal pulses faint to non-palpable, sensation is absent. The severity of this problem was discussed with R5 and R5's family member. R5 was transported directly from the outpatient orthopedic clinic to the hospital for further evaluation and treatment. Review of R5's hospital records, dated 5/18/2021 - 5/24/2021, notes R5's right foot with dusky appearance and cool to the touch. R5's right pedal pulses not palpable. R5's right lower leg with exposed tendon to posterior thigh. Wound care physician consult notes, dated 5/20/2021, notes extensive black eschars (dead tissue) on the right foot on the top of foot, posterior heel, extending to distal shin. R5 with gangrenous skin changes of the right foot. Vascular consult, dated 5/20/2021, noted R5 stated R5's wounds to right leg were not present prior to R5's fall. R5 had sensation in R5's right foot prior to the fall, but not since after the fall. Right foot with extensive necrotic (dead) tissue to top of foot and mottled in appearance; ischemia changes noted. On 5/22/2021, a right above the knee amputation was performed. Review of this facility's cast care policy, updated 02/2017, notes to perform neurovascular assessment (5P's) on casted extremity every 1-2 hours for the first 24 hours. Neurovascular assessment should continue at a minimum every shift. 5P's include: pain; pallor, observe color of tissues distal to cast, no signs of circulatory compromise should be present; pulselessness, palpate distal pulses of casted extremity, note presence and strength of pulse, assess capillary refill; paresthesia, assess for numbness/tingling, or abnormal sensations; and paralysis, assess for ability to move toes and extremity. Notify physician of change in condition (odor, drainage, hot spots, decreased circulation, increased pain, etc.). Record in the resident's progress notes the date and time car (neurovascular assessment) was provided, condition of skin, status of circulation, and motion of distal extremity. Report unusual findings from the neurovascular assessment and document in progress note. Review of this facility's skin practice guide, dated 01/2013, notes the purpose of this guide is to describe the process steps for identification of residents at risk for the development of pressure ulcers, identify prevention techniques and interventions to assist with the management of pressure ulcers and skin alterations. A comprehensive evaluation of a resident's skin status requires evaluations by the physician, nursing staff, registered dietitian, and rehabilitation team. The Braden scale is used to identify potential levels of risk for pressure ulcer development. Each resident is evaluated on admission or re-admission using this scale. The Braden scale is completed for 4 weeks total (at the time of admission and then weekly for the next three weeks, quarterly, with a significant change and as clinically indicated. A comprehensive skin evaluation is completed upon admission. Daily head to toe skin evaluations are completed by the nurse for any resident with a pressure ulcer and documented in the resident's clinical record. Upon completing an evaluation, the interdisciplinary team develops a resident specific care plan to include prevention and management interventions with measurable goals. For a change in resident condition, the nurse notifies the physician, wound care team, family or responsible party and documents the findings in the clinical record. The resident's care plan is updated to reflect the resident's current status and care needs.

Based on observations, interviews, and record reviews, this facility failed to follow its policy and procedures and ensure the required oxygen equipment was readily available on the emergency cart when a rapid response code was called for one resident (R1) out of three reviewed for acute change in respiratory status in a sample of 22. This failure resulted in an additional 7-minute delay in R1 receiving supplemental oxygen for an oxygen saturation level of 82%. R1 expired on [DATE] at 12:19pm upon arriving at the local hospital. Findings include: On [DATE] at 11:26am, the emergency cart was observed being pulled into R1's room by V4 (nurse). A rapid response emergency code was paged overhead at 11:15am for R1 exhibiting respiratory distress. R1 was observed sitting upright in bed. R1's breathing was labored. R1's breathing was audible and sounded gargled. Respirations were deep and chest was rising and falling with great effort. This surveyor did not observe an oxygen tank in R1's room or with the emergency cart. On [DATE] at 11:30am, V3 (unit manager) was observed looking for oxygen tank and supplies at R1's bedside. V4 (nurse) asked if V3 wanted V4 to call 911 EMS (emergency medical services). V3 responded yes. V3 requested oxygen tank and oxygen supplies. On [DATE] at 11:31am, V3 was observed exiting R1's room. R1 was observed lying in bed with head of bed elevated. R1's eyes are open; R1 did not respond to V4's verbal or tactile stimulation. On [DATE] at 11:33am, V3 was observed returning to R1's room with a portable oxygen tank. On [DATE] at 11:35am, V3 stated that R1's oxygen saturation level is 82% on room air. Oxygen at 15 liters via non-rebreather mask applied to R1. On [DATE] at 1:35pm, V6 (nurse) stated that at 11:15am, V4 (nurse) approached V6 and informed V6 that V4 needed help. V6 stated that V4 informed V6 that the emergency cart was needed. V6 stated that V4 and V6 went to R1's room with the emergency cart. V6 stated that the oxygen tank was not with the emergency cart and V6 was instructed to obtain an oxygen tank. On [DATE] at 2:00pm, V6 verified V6's signature on the emergency cart check sheet and acknowledged that V6 checked the emergency cart on [DATE]. V6 stated that V6 checked the emergency cart within the first hour of starting V6's shift that day. V6 stated that by signing this form, the nurse has made sure the lock is intact and the number on the lock matches the number documented the previous day. V6 stated that V6 observed the suction machine and resuscitative bag were present. V6 stated that V6 is unsure if the oxygen tank was with the emergency cart. On [DATE] at 2:00pm, V4 RN (registered nurse) stated that the emergency cart is checked daily. V4 stated that this task is assigned on the day's assignment sheet. V4 stated that a suction machine, portable defibrillator, back board, resuscitative bag, and portable oxygen tank are stored with the emergency cart. V4 stated that the nurse is expected to make sure all of this equipment is present, the oxygen tank is full, and the lock is secured. On [DATE] at 9:20am, V2 DON (acting director of nursing) stated that there are three emergency carts; one on each nursing unit. V2 stated that the emergency cart is checked daily. V2 stated that the nurse is expected to make sure the portable oxygen tank is full, portable defibrillator, resuscitative bag, and suction machine are functioning properly. V2 stated that by signing the form on the cart, the nurse has made sure that all required equipment is present and ready for use. On [DATE] at 9:18am, V3 (unit manager) stated that on [DATE] V4 (nurse) informed V3 that R1 was exhibiting respiratory distress. V3 stated that upon entering R1's room, V3 noted R1 with audible coarse breath sounds. V3 stated that V3 did not see any oxygen supplies or an oxygen tank in R1's room. V3 stated that V4 brought the emergency cart into R1's room. V3 stated that the oxygen tank was missing from the emergency cart and V3 requested V4 obtain oxygen equipment. V3 stated that the nurse working on the night shift is expected to sign the form and ensure the required equipment is with the emergency response cart. V3 stated that if the cart is not checked on night shift, then it will be checked by the day shift nurse. V3 stated that the emergency response cart is brought to all emergent situations. V3 stated that when bringing the emergency response cart, the nurse is expected to do a quick check for portable defibrillator, full oxygen tank, suction machine, resuscitative bag, and backboard are present. On [DATE] at 12:30pm, V19 (unit manager) stated that the emergency response cart is checked by the night shift nurse after verifying all of the required equipment is present and the lock is secured. Review of this facility's emergency management policy, revised ,d+[DATE], related to emergency cart maintenance, notes the cart is secured with a numbered break-away lock. Use an emergency cart check sheet and signature log form daily to verify the contents of the cart, the licensed nurse verifies that all equipment and care items listed on the emergency cart checklist are present on the top, back, and sides of the cart; and ensures the break-away lock is intact and the number on lock is unchanged from the previous check.

Based on observation, interview, and record review the facility failed to follow the Physician Assistant's order to apply a left hand brace/splint to prevent contractures or tightening of the muscle on R5's left arm. This failure resulted in R5 developing a contracture to his left hand. This failure affected one (R5) of three residents (R5, R6, and R7) reviewed for Activities of Daily Living. Findings include: On 3/29/19 at 11:00AM surveyor met R5 in his room. R5 observed to not have splint on upper extremities. On 3/29/19 at 11:00AM V4, Certified Nursing Assistant (CNA), said she did not know if R5 should wear a splint or brace and she did not apply one. V5, CNA, was assisting V4 with R5 and said she did not apply a splint or brace on R5. On 3/29/19 at 12:38PM R5 observed feeding self lunch with left hand resting on his lap. No splint on left wrist. R5 told surveyor someone had told him over a month ago he was going to get a splint for his left wrist, but he has not received the splint. On 3/29/19 at 1:28PM R5 observed in bed without a splint on his left wrist. On 3/29/10 at 2:58PM V2, DON, accompanied surveyor to R5's room. R5 had no splint on his left wrist. No splint located in R5's room by V2. On 3/29/19 at 1:26PM V7, Nurse, said she has not seen R5 with any splint or brace on his arm, but recalls his left arm to be swollen. On 3/29/19 V8, CNA, said he sees R5 a lot in the building. V8 said he has never noticed R5 to have a splint or brace on his arm. On 3/29/19 V9, CNA, said she has been assigned to R5 regularly in the past. V9 said she had not put any splint or brace on R5, and said I don't think he has one. On 3/29/19 at 2:35PM V14, Licensed Practical Nurse (LPN), said it is be the nurses' responsibility to remove a splint or brace. On 3/29/19 at 3:09PM V2, DON, said there is not a splint or brace in R5's room. On 4/2/19 at 10:14AM, V12, Physician Assistant with Pain Management and Rehabilitation, said R5 had a [MEDICAL CONDITION], pain, and [MEDICAL CONDITION]. V12 said she ordered a splint for R5 to prevent any contracture to his left hand and digits. V12 said she ordered the splint for R5 on 1/7/19. V12 said she was just notified that the splint order had not been followed by the facility. V12 said when she was treating R5 he had weakness in the left side and was neglecting the left side from the stroke, but she did not document a contracture. V12 said the splint was ordered to prevent a contracture. V12 said R5 is alert and oriented, and reliable to say if staff was applying the splint or not. On 4/2/19 V15, Occupational Therapist, said she received an order to evaluate R5 and completed the evaluation on 4/1/19. V15 said R5 has a contracture of the left hand and digits. V15 said R5's major limitation right now is his wrist. V15 said the pain in the left wrist prevents R5 from flexing his hand. On 4/2/19 V16, Director of Rehab, said R5 was in Occupational Therapy from 12/19/18 until 1/13/19. V16 said R5 did not have a contracture on his left hand during this treatment. V16 said a stoke patient goes through the following stages during recovery, flaccid, to spastic, to normal tone. V16 said on 1/8/19 R5 still had left hand weakness.V16 said from reading the notes, the Physician Assistant (V12) placed the order for a splint, but the Interdisciplinary Team was not notified. V16 said the purpose of the splint is to prevent contractures. On 4/2/19 at 11:45AM V2, DON, said a nurse entered the order for the splint into R5's record. V2 said the nurse should have passed the order on to therapy to get the appropriate fitting device, and this part probably did not happen. V2 said the unit managers do the restorative documents for each resident. V2 said normally the Therapy Department will refer a resident to restorative program and or make recommendations. When V2 was asked to show the recommendation for R5 she said there is no restorative form for R5. On 4/2/19 at 12:10PM V17, Occupational Therapist, said she supervised R5 during his last therapy treatment (12/19/18 until 1/13/19). V17 said the goal was to restore function to R5's left hand. V17 said R5 had no contracture and was not flaccid to the left wrist or hand. V17 said, at the time, she would not recommend having a supportive device, such as a splint, as part of R5's plan of care. V17 said someone should have called the physician to clarify the order and the goal for R5. After reading the new evaluation performed by V15, V17 said R5 now has a 43 degree flexion, or tightness, in the muscle of the left lower arm/wrist area because he had not been using his muscle. V17 said R5 has 0 degree of extension in the wrist, which means R5 can move the wrist with assistance. V17 said when R5 was discharged on [DATE] he needed assistance with activities of daily living (ADLs). V17 said if R5 had a restorative program and had difficulty with the program R5 would have been referred to therapy sooner than 3/31/19. V17 said exercises from a restorative program could have prevented the muscle from tightening. V17 said there is no note that R5 was referred to a restorative program. On 4/2/19 at 2:37PM V18, Medical Director, said he always expects nurses to follow orders given.V18 said if there is a question or concern regarding an order the nurse should contact the prescriber. V18 said a [DIAGNOSES REDACTED]. V18 said a contracture can occur in an extremity from lack of use. V18 said exercise and range of motion can help prevent contractures. On 4/3/19 at 9:55AM V20, Minimum Data Set Nurse, said CNAs perform range of motion exercises while providing daily cares. V20 said if a resident is not in therapy they are assessed every quarter for range of motion. V20 said the result of the quarterly assessment is only documented when coded on the Minimum Data Set, section G0400. On 4/3/19 at 10:10AM V4, CNA, said she was assigned to R5 on 3/29/19, 4/2/19, and 4/3/19. V4 said she did not perform or assist R5 with any range of motion on 4/2/19 or 4/3/19. On 4/3/19 at 10:15AM V22, Unit Manager, said range of motion is encouraged on the unit with cares. V22 said the purpose of range of motion is to maintain function in extremities and to prevent decline or loss of function. At 10:50AM V22 said there is no documentation found in R5's record of range of motion performed. V22 said there is nothing in place for a CNA to know who to do range of motion on. On 4/3/19 at 3:15PM V22 said the check mark and initial on R5's Treatment Administration record denote the treatment was completed or carried out. Record review on 3/29/19 of R5's Physician order [REDACTED]. Review of R5's Progress Notes on 3/29/19 dated 1/7/19 written by V12 read left wrist brace ordered. On 4/3/19 R5's Treatment Administration Record (TAR) reads left hand splint every shift for left hand. The TAR for (MONTH) 2019 has several check marks and initials indicating the splint is on for every shift. On 4/3/19 Review of R5's ADL documentation on the Documentation Survey Report v2 for (MONTH) 2019 does not show documentation for range of motion performed on R5. Review of R5's care plan on 3/29/19 for ADL self care deficits does not identify the splint as an intervention. Review on 4/2/19 of R5's Occupational Therapy (OT) Discharge summary for start of care 12/20/18 denotes: LUE (Left Upper Extremity) range of motion elbow/forearm=WFL (within functional limits); wrist= WFL; hand=WFL Contracture: Functional Limitation Present d/t (due to) contracture= No Diagnoses: [REDACTED]. OT Evaluation and plan of treatment for [REDACTED]. LUE range of motion elbow/forearm= impaired; wrist= impaired; hand=impaired AROM (active range of motion)-Left wrist Flexion=43 degress; extension = 0 degrees (see above of therapist explaining these terms) Contractures: Functional limitations present d/t contracture=Yes; Functional limitations as resule of contractures: left wrist/hand/ Diagnoses: [REDACTED]. Review of R5's [DIAGNOSES REDACTED]. Facility policy on Braces/Splints reads: To maintain functional range of motion, decrease muscle contractures and provide support and alignment to weakened limbs through use of braces and/or splints. Verify medical practitioner's order. Unusual observations and/or complaints and subsequent interventions including communication with medical practitioner or rehabilitation therapist as clinically indicated.

Based on interview and record review, the facility failed to provide anti-seizure medication for 1 of 3 residents (R1), reviewed for pharmacy services. As a result of not receiving anti-seizure medication for two days, R1 had a seizure and was hospitalized . Findings include: According to the Face Sheet R1 was admitted on [DATE] with the following diagnosis; Epilepsy, rehab, [DIAGNOSES REDACTED] and dysphasia. According to the Hospital Record dated 10/27/2013 through 11/9/2013 R1 was admitted into the hospital for recurrent seizures prior to being admitted to the nursing home; R1 was stabilized on 4 different anti-seizure medications and on 11-9-2013 was discharged to the Nursing Home. Nursing Progress Note dated 11/9/2013 states, " Patient admitted . Transported from hospital via ambulance accompanied by paramedics. Orders verified and carried out. Medical Doctor states he would like to be called in the am and Controlled Substance 2 forms faxed to the doctor in the hospital, so the forms can be signed and faxed back. Patient has a [DIAGNOSES REDACTED]. Oriented family to room and call light system. Requires maximum assistance with activity of daily living. Incontinent with bowel and bladder...." Nursing Progress Notes were reviewed for 11-9-2013 through discharge of 11-10-2013. On 11-10-2013 Nursing Progress Notes document that R1 did not receive seizure medication. Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Nursing Progress Note dated 11-10-2013 at 1:33 PM states, "Family stated, R1 had a seizure for 60 seconds, vitals sign were taken, blood pressure was 119/99, pulse was 107, respiration was 16 and temperature was 98.8 oxygen saturation was 98.8% Doctor was notified and R1 was sent to the hospital. Family at bedside. Nursing Progress Note dated 11/10/2013 states, R1 has been admitted to the hospital [DIAGNOSES REDACTED]. Controlled Substance Prescription Request Form dated 11/9/2013 document that Lacosamide, Phenobarbital, Klonopin were faxed to the pharmacy. R1 had Physician Telephone Orders dated 11/9/2013 for Keppra 100 milligrams twice a day, Klonopin .5 milligrams three times a day, Lacosamide 100 milligrams twice a day and Phenobarbital 64.8 milligrams three times a day. On 11/19/2013 at 10:50 AM, E2(Director of Nursing) stated," E4(Nurse) that admitted R1 is no longer employed by the facility." On 11/19/2013 at 12:21 PM, E6(Nurse) stated, "When residents are admitted and need controlled substance drug, we have to fill up the form and notify the physician to complete and fax it back so we can fax it to the pharmacy and get the medications. That happened to me once on the weekend I needed a controlled drug for a resident and I called the physician and gave him the number to call the pharmacy and I had no problem with getting the medication." On 11-19-2013 at 12:25 PM, E7 and E8 both Nurses stated, " medications can be ordered by 2 PM for 8 PM delivery and by 2 am for 8 am delivery. But if medications are needed they can be ordered stat(right away) and the pharmacy has 2 hours to deliver it." On 11/19/2013 at 1:17 PM, E5( Nurse) stated, " I worked with R1 on 11/10/2013, I remember that R1 had 3-4 medications for seizures that were schedule 3- 4 control substances. I recall in report that the doctor was not near a fax machine and therefore could not fax the control substance form to us. I was not aware that control substances could be faxed stat neither was I aware that there is a number to give the physician to call in the orders." On 11/19/2013 at 2:00 PM, Z2(Pharmacist) stated, " The DEA requires signed authorization for schedule 2 drugs. Schedule 3-5 drugs can be telephone ordered in by the physician. It is an 800 number that is given to the physician by the nurses and if the nurses are not aware, the Director of Nursing is aware. Seizure medications are schedule 3-5." According to the Pharmacy List kept on the convenience and controlled substance box, Klonopin and Phenobarbital are class 4 controlled substances, which are kept in the controlled box. Keppra is not a controlled substance and is not stored in the convenience box. Lacosomide is a class 5 drug which is not stored in the convenience box. On 11-19-2013 at 3:30 PM, E2(DON) stated, " The nurses could have had the physician to telephone the medications in to the pharmacy and if they did not know the number they should have contacted the supervisory staff. R1 should have received the seizure medication while in the facility. R1 needed the seizure medications." On 11-19-2013 at 4:23 PM, E9(Physician) stated, "When the nurse read me the orders, I said to continue it. I never got a call from pharmacy about a problem with the medications. I sent R1 to the hospital on [DATE] because she had a seizure and there was no available medication." New Orders for Schedule III-V Controlled substances Policy revised on 01/01/2013 states, "For all Schedule III-V controlled substances medications orders, the facility must provide to the pharmacy.... An oral prescription communicated by the practitioner or the practitioner's agent to the pharmacy. If the medication is needed before the next schedule delivery, facility staff should indicate the exact time by which the medication is needed. If the Controlled substance is needed before the pharmacy can make arrangements for a timely delivery, facility must fax a request to remove a controlled substance from the Facility's Emergency Medication Supplies." Hospital Record dated 11/10/2013 through 11/15/2013 states, R1 [AGE] year old with [DIAGNOSES REDACTED]. R1 was sent to the nursing home and was unable to get her medication at the nursing home and subsequently had seizures. R1 was stabilized and discharge home with family on 11/15/2013.

Based on interview and record review the facility failed to have a protocol or physician's orders for monitoring lab values of residents receiving blood thinners for 1 of 3 residents (R1) reviewed for medications, in a sample of 18. R1's blood thinner level was not monitored during an 11 day time period during which R1 experienced a change in condition. R1 was hospitalized with abnormal lab values and [DIAGNOSES REDACTED]. Findings Include: The Face Sheet documents that R1 was admitted to the facility on [DATE] status [REDACTED]. The Physician Order Sheets (POS) dated 4/16/13 documents that R1 was started on [MEDICATION NAME] and on 4/17/13 R1 was started on [MEDICATION NAME]; both medications are blood thinners that decrease the chances of blood clot formation. R1 was prescribed 3mg of [MEDICATION NAME] on Mondays and Fridays and 6mg of [MEDICATION NAME] all other days, and 40mg of [MEDICATION NAME] to be injected subcutaneously daily. An International Normalized Ratio (INR) is a lab test used to test the clotting tendency of the blood in patients that are prescribed blood thinners. The facility lab sheet documents that a normal INR for moderate intensity therapy is 2.0 to 3.0 and for high intensity therapy the normal INR range is 2.5 to 3.5. The POS indicate orders for an INR on 4/18/13 and the INR level was 1.6. Z3 (Physician) was notified and ordered R1 to continue taking the blood thinners and to recheck the INR level in one week. The lab results dated 4/25/13 documents that R1's INR level was 1.2. Z3 was notified and ordered R1 to continue taking the blood thinners and to recheck the INR level in one week. The lab results dated 5/2/13 documents that R1's INR level was 2.7. Z3 was notified and orders were received to discontinue the [MEDICATION NAME] therapy but to continue taking the [MEDICATION NAME] as ordered, there were no new orders written to monitor R1's INR levels. The Progress Notes dated 5/14/13 at 12:55pm documents that R1 had a pale skin color, was sleeping a lot, had a change in mental status and a poor appetite. Z3 was notified and orders were received at 3:05pm for blood work and to start R1 on intravenous (IV) fluids. At 10:26pm R1 continued to have mental status changes, was started on an antibiotic and was transferred to a local hospital. Hospital Records dated 5/14/13 at 10:30pm documents that R1 was admitted to the emergency room with a urinary tract infection [MEDICAL CONDITION]. Lab work was done and R1's INR level was greater than 11.0. The sodium level was 160 and the normal range is 135 to 145. The Blood Urea Nitrogen (BUN), a test that measures how well the kidneys' are working, was 111 and the normal range is 10 to 20. The creatinine level, the level that measures the amount of waste product in the blood and urine, was 2.6 and the normal range is 0.50 to 1.30. A Computed Tomography or CT scan was done and documented that R1 had an intra-cranial hemorrhage, or bleeding of the brain that measured 3.5 by 3.0cm. R1 was admitted to the Intensive Care Unit (ICU) where 4 units of Fresh Frozen Plasma (FFP) was given, a blood component that contains coagulation factors and is given to patients with active bleeding, along with vitamin k, a vitamin that helps the blood to clot. R1 was started on IV fluids for gentle hydration and [MEDICAL CONDITION] and on 5/20/13 a feeding tube was placed due to difficulties with swallowing. On 6/27/13 at 2:20pm E9 (Nurse) stated "I did not get any orders from the physician after 5/2/13 to check INR levels. It's never ok to give [MEDICATION NAME] without monitoring the labs, but there was no physician order." On 6/27/13 at 2:10pm Z3 stated "I usually monitor the residents receiving anti-coagulants every 2 weeks once I get a therapeutic INR. My plan was to recheck R1's labs in 2weeks." On 6/28/13 at 12:30pm Z2 (Pharmacist) stated "It is recommended to check the INR level within 3 to 5 days of discontinuing the [MEDICATION NAME] injections, then to recheck the level in another 3 to 5 days. If the INR level is between 2 to 3.5 at least twice then it is recommended to check the level weekly for 4 weeks, then once every 2 weeks, and then once monthly as long as the levels remain in the therapeutic range of 2 to 3.5 to decrease the risk of bleeding." On 6/28/13 at 11:45am Z1 (Physician/Medical Director) stated "[MEDICATION NAME] monitoring is individualized for each resident but is at the discretion of the physician. I generally wait to have several therapeutic labs with INR levels between 2 to 3 before I decrease the monitoring. In this case I would not have waited 2 weeks to recheck the level." On 7/5/13 at 1:00pm E1 (Administrator) stated "Our policy was to monitor the labs based on physician orders but we have since created a new protocol for all of our residents receiving blood thinners. There will be a section on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]."