Every finding on record at Allure of Geneseo

Based on observation, interview, and record review the facility failed to ensure safety of a resident by ensuring the shower room door was closed for 1 of 3 residents (R1) reviewed for safety and supervision. This failure resulted in R1 wandering into the shower room and experiencing a slip and fall to the floor and sustaining a laceration to her head and a right femoral fracture. The findings include:R1's face sheet showed she was admitted to the facility 11/13/25 with diagnoses to include ataxia, cognitive communication deficit, macular degeneration, depression, chronic kidney disease, and protein calorie malnutrition. R1's facility assessment dated showed she has moderate cognitive impairment, required partial to moderate assistance for transfers, and uses a manual wheelchair for mobility. The facility's report to the state agency dated 3/29/26 showed, . Resident had a fall on 3/28/26, in the shower room. The CNA (Certified Nursing Assistant) was heating up the water for a resident and left the door open. [R1] entered the shower room, but due to cognitive impairment was not able to explain what she was trying to do in the room. Nurse assessed resident, vital signs stable, had a small laceration to the right temple. On 3/29/26 resident complained of pain in the right leg. Nurse notified doctor, new order received to send to the ER (emergency room) for evaluation and treatment. Resident was found to have right femoral fracture. Resident is scheduled to have surgery and will return to the facility. Resident should be in highly visible area. Intervention: All staff educated on the importance of keeping shower doors closed. Signs posted on the shower room doors to remind staff to keep closed.A copy of the sign posted on the shower room door was provided and showed, Shower room doors must stay closed for resident safety. When warming up the water, the shower room door should be closed. Please keep this door shut!!!R1's 3/28/26 Health Status Note entered at 10:54 PM showed, 8:10 PM, resident was found laying on the shower/bathroom area floor, positioned between the toilet and wheelchair. Resident was found on her right side and exhibited a laceration on the right temple area, measuring approximately 2cm x 3 cm. The bathroom/shower water was running. Clean the wound and applied sterile strips. Assess level of consciousness alert and oriented x 1. Family notified. DON (Director of Nursing) notified, and fax communication to [physician] for information. R1's 3/28/26 eMAR (electronic Medication Administration Record) Note entered at 9:54 PM showed acetaminophen given for pain. R1's 3/29/26 Health Status Note entered at 7:07 AM showed, Resident complaining of right sided leg pain post fall from last night. This nurse attempted to perform passive ROM (range of motion) and resident did not tolerate well. ST (Skin Tear) on right forehead steri strips still intact. Resident states my head is fine, it's my leg I'm worried about. Another nurse making appropriate phone calls related to concern.R1's 3/29/26 Health Status Note entered at 10:28 AM showed, Spoke to [Acute Care Nurse] at [Acute Care Hospital]. [R1] fractured her femoral neck and will be admitted . will do surgery later this week.R1's 4/3/26 Admission/readmission Note entered at 1:33 PM showed, Resident arrived at 1:21 PM via ambulance from [acute care hospital] . Alert and oriented to person per baseline. Fatigued. Right surgical hip dressing intact.R1's Care Plan showed, The resident is at risk for falls related to history of falls, osteoporosis, difficulty in walking, muscle wasting and atrophy, muscle weakness, unsteadiness on feet, other symptoms and signs involving musculoskeletal system.R1's care plan initiated 11/22/25 with a new intervention added 3/28/26 showed, The resident has had an actual fall. Intervention: . 3/28/26. Resident found lying on the floor in the shower room. Assessed by nurse, laceration noted to right temple. Resident assisted to wheelchair by staff and treatment given to head wound. 3/29/26: Resident has complaints of right-side leg pain, sent to ER (emergency room) and admitted with right femoral neck fracture. Resident will have surgery this week. Signs posted and staff educated on having shower doors closed at all times when not in use.R1's Acute Care Hospital After Visit Summary documents dated 4/3/26 showed, Closed displaced fracture of right femoral neck. admitted [DATE] through 4/3/26.On 4/19/26 at 2:03 PM, V4 CNA (Certified Nursing Assistant) said, I was just showering a different resident. I was coming out of the shower room with that resident, and I went around the corner. One of my coworkers said they had just taken [R1]to the bathroom and they put her by the nurse's cart which was near the shower room. She was in her wheelchair. I was going to put the other resident in the recliner nearby the nurse's station. [R1] went from right where she was by the nurse's cart, into the shower room, and fell. We have to keep a close eye on her because she likes to be up and down all the time. She was in the middle of the shower room when we found her on the floor. I don't know what she would have been doing. She is just very fast. I felt terrible, but I was in the middle of showering the resident I was with and taking her out. The shower door is typically closed. We even have a sign on the door that says the door has to remain shut. I left the door open because I was going to go back and clean up the towels and everything. [R1] is someone that we just really have to keep a close eye on, and everyone was so busy at the time. As soon as I finished helping the other resident into the recliner, I got the nurse right away. The nurse and another CNA went in there. The nurse looked her over, looked at her eyes was asking her questions. We hoisted her up off the floor, one on each side and put her back in her wheelchair. I remember at the time the nurse had us put her at the nurse's station and she got her vitals. I think the nurse was more worried about the bump on her head. She was bleeding from that area. She was not complaining of any pain at the time. The nurse was asking her if she was hurting anywhere. The nurse was concerned about the head wound. She said no honey I'm fine. She didn't appear to be in pain. We kept her at the nurse's station. She was across from the nurse's station in the recliner that is where she stayed overnight. She had no complaints of pain overnight. It seemed like more toward the end of the shift, around 4 AM, she was saying 'my leg hurts honey'. I told the nurse [R1] was now complaining of her leg hurting. The nurse rechecked her vitals and gave her something for pain. My shift ended at 6 AM and I think she got sent out shortly after I left. On 4/20/26 at 9:11 AM, V5 CNA said, I was working with V4, and I remember [R1] had fell in the shower room, she hit her head and was bleeding everywhere. We had to do vitals on her every 15 minutes until I left at 10. I know she gets up without permission. She just gets up. [V4] found her because she was assigned to her. What happened was [V4] walked out to get a towel or something and that is when [R1] fell. She was on the floor by the toilet when I went in there. We had to put stuff on her head to stop the bleeding. They didn't send her out to the hospital because the nurse said they didn't need to send her, but I know they were talking about it. She had a big ole bruise on the side of her head. I didn't hear her complaining of pain, she was acting like it was normal and we were all freaked out. I go there a lot in the last couple of months. I know she likes to get up throughout the night and we have to have her sit out with us. The shower room door is usually closed and has a lock on it. I think [V4] was getting the shower ready, so I think she had it propped open.On 4/20/26 at 9:48 AM, V6 LPN (Licensed Practical Nurse) said, At night [R1] has the dementia that makes her wander a lot. I think the CNA at the time took her to the bathroom and we keep her in the front near the nurse's station where the common area is. I asked 'where is [R1]' and that is how the CNA found out that she had went into the shower room and she was laying on the floor. The shower was running. The CNA was doing a shower with another lady, so she had the water running to get warm. I don't know exactly how she got in there. The door requires a code. The resident wouldn't be able to get in the shower room if the door was shut.On 4/20/26 at 10:12 AM, V2 DON (Director of Nursing) said, It was reported to me that [R1] had fallen in the shower room unattended because the door was left open. The shower room doors are usually shut. It is typically shut unless someone is in there. It should not be left open all the time. We educated the staff on ensuring the shower room doors remain closed and we placed signs on each shower room door reminding them the doors are to be shut.The facility's undated policy and procedure showed, Fall Prevention Program. Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Implement universal environmental interventions that decrease the risk of resident falling. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care.

Based on record review and interview, the facility failed to ensure V5/Dietary Manager possesses the Food Handler Certification or Certified Food Protection Manager certification. This failure has the potential to affect all 62 residents residing in the facility.The facility's Dietary Manager Job Description, not dated, documents: QUALIFICATIONS: Food Handler Certification or Certified Food Protection Manager certification required.The Centers for Medicare and Medicaid Services, Form 671-Long-term Care Facility Application for Medicare and Medicaid, signed 1/13/26, by V1/Administrator, document 62 residents reside in the facility.During the initial kitchen tour, on 1/13/26, at 9:00 a.m., V5 confirmed since being hired, as the Dietary Manager, in October 2025, he has yet to obtain the certification required in the facility's job description.

Based on interview and record review, the facility failed to implement antibiotic stewardship by failing to ensure infection surveillance was thoroughly conducted, met the required criteria for antibiotic use and obtain/review culture results to track and trend infections for nine of nine residents (R1, R7, R8, R29, R53, R68, R71-R73) reviewed for antibiotic stewardship in the sample of 71. Findings include:The Infection Surveillance policy dated 6/2023 documents the facility will collect data to properly identify possible communicable diseases or infections among residents by identifying the infection site, pathogen, signs and symptoms and residents' locations. Observations of staff including the identification of ineffective practices, infection trends and patterns. All resident and infections will be tracked. The facility will conduct specimen collection and testing in a manner consistent with standards of practice. Data to be used in the surveillance include laboratory reports, antibiotic use, medication regimen review reports, skills validation for hand hygiene, personal protective equipment and high-risk procedures, rounding observation data, documentation of signs and symptoms in clinical records and transfer/discharge summaries for new or readmitted residents.The Antibiotic Stewardship Program policy, not dated, documents the program includes antibiotic use protocols and a system to monitor antibiotic use. Antibiotic use protocols include that laboratory testing which shall be in accordance with current standards of practice. The facility uses the updated McGeer criteria to define infections. Antibiotic use shall be measured by monthly prevalence, antibiotic starts and/or antibiotic days of therapy. Documentation includes assessment forms and data collection forms for antibiotic use, process and outcome measures.The Legionella Surveillance policy, dated 11/26/24, documents the facility shall use the McGreer criteria when diagnosing pneumonia.The facility's McGeer Criteria for Long Term Care Surveillance Definitions for Infections Updated 2012 documents for Urinary Tract Infections (UTI) without indwelling urinary catheters surveillance definition:Must fulfill both 1 AND 2.1. At least one of the following sub criteria:Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostateFever or leukocytosis, and one or more of thefollowing:Acute costovertebral angle pain or tendernessSuprapubic painGross hematuriaNew or marked increase in incontinenceNew or marked increase in urgencyNew or marked increase in frequencyIf no fever or leukocytosis, then at least two ofthe following:Suprapubic painGross hematuriaNew or marked increase in incontinenceNew or marked increase in urgencyNew or marked increase in frequency2. At least one of the following microbiologiccriteria:At least 100,000 cfu/mL (colony forming units per milliliter) of no more than 2 species of organisms in a voided urine sample at least 10,000 cfu/mL of any organism(s) in a specimen collected by an in-and-out catheter.For Urinary Tract Infections in resident with a catheter both criteria must be present:At least 1 of the following subcriteria:1. Fever, rigors, or new-onset hypotension, with no alternate site of infectionEither acute change in mental status or acute functional decline, with no alternate site of infectionNew onset suprapubic pain or costovertebral angle pain or tendernessPurulent discharge from around the catheter or acute pain, swelling, or tenderness of the testes, epididymis, or prostateAnd2. Must have Urinary catheter specimen culture with at least 10,000 cfu/mL of any organism. The facility's October 2025-December 2025 Resident Infection Control logs document the following:1. R1's Medication Administration Record (MAR) dated December 2025 documents R1 received Levaquin (antibiotic) 12/9/25 thru 12/15/25 for Pneumonia.There is no documentation in R1's medical record that a McGreer form was completed for R1's Pneumonia treatment.The Monthly Report of Resident Infections dated December 2025 did not include R1's infection surveillance data. 2. R7's MAR dated December 2025 documents R7 was treated with an antibiotic for Sepsis (Blood Stream Infection) secondary to a Urinary Tract Infection, although did not identify the organism that contributed to R1's Sepsis diagnosis.R7's Hospitalization Record dated 12/18/25 documents R7's urine culture grew Proteus Mirabilis greater than 100,000 cfu/mL.The Monthly Report of Resident Infections dated December 2025 did not include R7's culture results from the 12/18/25 hospitalization.There is no documentation in R7's medical record that a McGreer form was completed for R7's Sepsis treatment. 3. R8's MAR dated November 2025 and December 2025 document R8 received Ciprofloxin (antibiotic) 11/29/25 thru 12/4/25 for a Urinary [NAME] Infection.R8's records include a urine culture report dated 11/26/25 which documents greater than 100,000 Escherichia Coli.There is no documentation in R8's medical record that a McGreer form was completed for R8's Urinary Tract Infection treatment.The Monthly Report of Resident Infections dated November 2025 and December 2025 did not include an entry for R8's Urinary Tract Infection. 4. R29's MAR dated October 2025 documents R29 received Doxycycline (antibiotic) 10/14/25 thru 10/24/25 for a thigh abscess.There is no documentation in R29's medical record that a McGreer form was completed for R29's Skin Infection treatment.The Monthly Report of Resident Infections dated October 2025 did not include an entry for R29's Skin Infection treatment. 5. R53's MAR dated November 2025 documents R68 received Ciprofloxin (antibiotic) on 10/29/25 thru 11/7/25 and Rocephin (antibiotic) on 11/17/25 thru 11/20/25 for a Urinary Tract Infection.The Monthly Report of Resident Infections dated November 2025 did not include R53's urine culture results.There is no documentation in R53's medical record that a McGreer form was completed for R53's Urinary Tract Infection treatment. 6. R68's MAR dated November 2025 documents R68 received Keflex (antibiotic) on 11/8/25 thru 11/13/25 for a Urinary Tract Infection.R68's records include a urine culture report dated 11/4/25 which documents greater than 100,000 cfu/mL Klebsiella Pneumonia.There is no documentation in R68's medical record that a McGreer form was completed for R68's Urinary Tract Infection treatment.The Monthly Report of Resident Infections dated November 2025 did not include R68's culture results from the 11/4/25 hospitalization. 7. R71's MAR dated November 2025 documents R71 received Ampicillin (antibiotic) for 7 days for Urinary Tract Infection from 11/6/25 to 11/13/25.There is no documentation in R71's medication that a McGreer form was completed for R71's Urinary Tract Infection.R71's Progress Note dated 11/6/25 at 1358 states, Clarification received from Urology: Start ampicillin 500 mg TID (three times a day) x (times) 7 days for positive U/A, (urinalysis) will await final urine culture results from Urology.R71's Progress Note dated 11/12/25 at 1019 states, Urology calls and states doctor has reviewed culture results current ABT (antibiotic) sensitive finish current ATB orders.The Monthly Report of Resident Infections dated November 2025 states no urine culture was completed and does not include identified organism. 8. R72's MAR dated November 2025 documents R72 received Bactrim DS (antibiotic) for 5 days for Urinary Tract Infection from 11/11/25 to 11/16/25.There was no urine culture completed for R72 prior to administration of antibiotic. There is no documentation in R72's medical record that a McGreer form was completed for R72's Urinary Tract Infection treatment. 9. R73's MAR dated September and October 2025 documents R73 received Macrobid (antibiotic) for 7 days for a Urinary Tract Infection from 9/29/25 to 10/6/25.There was no urine culture completed for resident prior to administration of antibiotic. There is no documentation in R73's medical record that a McGreer form was completed for R73's Urinary Tract Infection treatment.The Monthly Report of Resident Infections dated September 2025 and October 2025 did not include an entry for R73's Urinary Tract Infection.On 1/15/26 at 2:00 PM, V17 (Chief Nursing Officer) agreed the infection surveillance was not thoroughly conducted, did not meet the required criteria for antibiotic use and did not obtain/review culture results to track and trend infections.

Based on observation, interview, and record review the facility failed to provide an appropriate indication for use of an antipsychotic medication for one (R8) of six residents reviewed for unnecessary medications in a sample of 71.Findings include:The facility policy titled, Use of Psychotropic Medication(s), undated, documents not in its entirety, It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint .Psychotropic medications are to be used only when a practitioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s).[NAME]-Hill Nurse's Drug Handbook Seventh Edition documents, Quetiapine Fumarate/Seroquel (antipsychotic) indication for use as Schizophrenia with off-label uses for Bipolar Disorder, Mania, Obsessive-Compulsive Disorder, Post Traumatic Stress Disorder, and psychosis related to Parkinson's Disease and is not to be given to elderly patients with dementia-related psychosis. R8's admission Record documents R8's date of admission to the facility was 11/13/25 and her diagnoses include but not limited to Cognitive Communication Deficit, Unspecified Dementia, unspecified severity, with other Behavioral Disturbance, Insomnia, and History of falling.R8's Minimum Data Set (MDS) assessment dated [DATE], documents that R8 is cognitively intact and has had no behaviors.R8's current care plan documents R8 is on psychotropic medications for dementia with other behavioral disturbance, insomnia.R8's Physician orders dated 11/13/25 documents R8 has an order for Seroquel (antipsychotic) 25mg (milligram) 1 tablet at bedtime for Dementia with Behavioral Disturbance.On 1/15/26 at 9:00 AM, V8 (Registered Nurse/RN) stated, Her (R8) behaviors are mainly exit seeking, lack of safety awareness but not too bad lately unless she has a UTI (Urinary Tract Infection). She (R8) is usually easily redirected but does require lots of supervision especially at night. We have to keep her up here in a recliner for a while because she tries to get up on her own all the time.On 1/15/25 at 11:10 AM, V2 (Director of Nursing/DON) stated, I'd have to look at her (R8) Call House notes to see what type of behaviors she was having prior to coming here but she has been good since admitting here. Her only issue is her dementia and lack of safety awareness. I feel she's appropriate to start reducing her Seroquel (antipsychotic) to get her off of it. V2 (DON) would not specifically state that R8's indication for use of the Seroquel was not appropriate but did agree that antipsychotic medications should not be used in dementia patients.

Based on observation, interview, and record review the facility failed to provide appropriate catheter care and failed to provide privacy/dignity of one (R53) resident of five residents reviewed for urinary catheters in a sample of 71.Findings include:The facility's policy titled, Catheter Care, undated, documents not in its entirety, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.Privacy bags will be available and catheter drainage bags will be covered at all times while in use.Male: Gently grasp penis, draw foreskin back if applicable.R53's admission Record documents R53's date of admission to the facility was 4/21/22 and his diagnoses include but not limited to Hematuria, Unspecified, Chronic Kidney Disease Unspecified, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Retention of Urine, Unspecified, Presence of Urogenital Implants, Malignant Neoplasm of Prostate, and Personal History of Urinary Tract Infections.R53's current care plan documents R53 is on Enhanced Barrier Precautions due to indwelling urinary catheter and R53 has indwelling urinary catheter related to BPH (Benign Prostatic Hyperplasia), urinary retention, prostate cancer, and hematuria.R53's Physician orders dated 6/30/25 documents R53 has an order for EBP (Enhanced Barrier Precautions), and orders dated 7/16/25 for 18 F (French) Indwelling (urinary) Catheter with 5 cc (Cubic Centimeter) balloon to dependent drainage. Change catheter Q (every) 3 days and PRN (As Needed) if dislodged or plugged and unable to clear with irrigation, every night shifts every 30 days related to Retention of Urine, Unspecified.R53's Electronic Medical Record documents R53 was treated for urinary tract infections on 7/19/25 for seven days and 10/31/25 for seven days.On 01/14/2026 at 12:52 PM R53 noted to be lying on his bed, covered with a blanket up to his waist and urinary collection bag noted to be hanging on bed frame facing toward the hallway showing pink tinged urine in bag, and not covered by a dignity bag. On 01/14/2026 at 12:55 PM V7 (Certified Nursing Assistant/CNA) observed doing urinary catheter care on R53. V7 (CNA) cleansed hands, placed gloves and gown and proceeded to provide urinary catheter care. R53 was lying on the bed and noted to not be circumcised. During cleansing R53's penis V7 (CNA) did not retract the foreskin of R53's penis.On 1/14/26 at 1:10 PM V7 (Certified Nursing Assistant/CNA) stated, I should have retracted the foreskin when I was cleaning him (R53), and his catheter bag should be covered.On 1/14/26 at 1:30 AM V1 (Administrator) and V2 (Director of Nursing/DON) both stated that all residents with indwelling urinary catheters should have their urinary collection bags in a privacy bag and they both verified that during catheter care on an uncircumcised male the foreskin should be retracted for cleaning.

Based on interview, observation and record review, the facility failed to conduct hand hygiene and change gloves per standards of care and don personal protective equipment (PPE) correctly for two of three residents (R40 and R47) reviewed for infection prevention practices in a sample of 71. Findings include: The facility's policy titled, Personal Protective Equipment, undated, documents not in its entirety, This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff.Change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another, when heavily contaminated or when torn. The Center for Disease Control Sequence for Putting on Personal Protective Equipment (PPE) documents to fasten the back of the gown when putting the gown on. The facility's policy titled, Clean Dressing Change, undated, documents not in its entirety, It is the policy of this facility to provide wound care in a manner in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. Loosen the tape and remove the existing dressing. If needed to minimize skin stripping or pain, moisten with prescribed cleansing solution or adhesive remover to remove tape; remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle; wash hands and put on new gloves; cleanse wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound (i.e. clean outward from the center of the wound. Pat dry with gauze; Measure wound using disposable measuring guide. (Note: If performing photo documentation, remove gloves and wash hands. Photograph wound being careful to avoid any contamination of the camera equipment); Wash hands and put on clean gloves; Apply topical ointments or creams and dress the wound as ordered. Protect surrounding skin as indicated with skin protectant. 1. R40's admission Record documents R40's date of admission to the facility was 4/14/23 and her diagnoses include but not limited to Unspecified Dementia, unspecified severity, with Psychotic Disturbance, Pressure Ulcer of Sacral Region, unstageable, Morbid (Severe) Obesity due to Excess Calories, and Type 2 Diabetes Mellitus with Hyperglycemia. R40's Minimum Data Set (MDS) assessment dated [DATE], documents that R40 has severely impaired cognition, is at risk for developing pressure ulcers and has one unstageable pressure ulcer. R40's current care plan documents R40 is on Enhanced Barrier Precautions due to Unstageable pressure injury to sacrum. R40's Physician orders dated 1/9/26 documents R40 has an order for EBP (Enhanced Barrier Precautions) dated 4/4/24 and has a treatment to sacrum for cleanse with N.S (Normal Saline), apply Santyl (Enzymatic Debriding Agent) to wound bed and cover with (Abdominal) pad daily and PRN (as needed). On 01/14/2026 02:30 PM V8 (Registered Nurse/RN), V6 (Registered Nurse/RN), and V10 (Certified Nursing Assistant/CNA) observed doing treatment to R40's sacral pressure ulcer. V8 (RN) was dressed in gown, gloves and face mask and she entered R40's room, grabbed the end of R40's bed with her gloved hands and proceeded to move the bed so V10 (CNA) who was also dressed in a gown, gloves and mask could get to other side to help hold R40 over for treatment. V6 (RN) walked into room with gown, gloves, and face mask in place and with her gloved hands pulled privacy curtain around R40's bed. V8 (RN) and V10 (CNA) rolled R40 onto her right side and sacral wound was noted to be open to air with no dressing in place. V8 (RN) still had her initial pair of gloves on, she (V8/RN) grabbed saline wetted gauze from V6 (RN) and cleansed R40's wound. V6 (RN) was still wearing her initial pair of gloves when she (V6/RN) picked up the clean gauze and placed saline on it for V8 (RN). V6 (RN) then grabbed a clean cotton swab and placed a small amount of Santyl (enzymatic debridement agent) on the swab still wearing her (V6/RN) initial pair of gloves and handed the swab to V8 (RN) who was still wearing her initial pair of gloves. V6 (RN) picked up a clean (abdominal) dressing and handed it (dressing) to V8 (RN) who placed the dressing on R40's sacral wound. During the entire treatment to R40's sacral pressure ulcer V8 (RN) and V6 (RN) did not change gloves and wore the initial pair placed when entering R40's room to start treatment. On 1/14/26 at 2:40 PM V8 (Registered Nurse/RN) stated that she probably should have changed her gloves before taking cotton swab with medication on it from V6 (Registered Nurse/RN). On 1/14/26 at 2:43 PM, V1 (Administrator) and V2 (Director of Nursing/DON) both stated that glove changes with hand hygiene in between should be performed when going from something dirty to something clean and stated during wound care gloves should be changed after removing soiled dressing and after cleaning of the wound. 2. R47 was on Enhanced Barrier Precautions due to an indwelling urinary catheter. On 1/14/25 at 10:10 AM, V18 (Certified Nurse Aide/CNA) and V19 (CNA) were observed to perform catheter care on R47. V18's gown was not tied while cares were performed. R47 was incontinent of stool and V18 cleaned stool from the catheter with wash clothes. V18 wet new wash clothes in a pan of water with the same gloves used to clean R47's stool. V18 emptied the pan of water contaminated with stool into R47's bathroom sink, removed gloves and donned new gloves without conducting hand hygiene. V18 then cleansed R47 bottom, removed her soiled brief, then changed gloves without conducting hand hygiene. V19 emptied R47's urine from the catheter bag into a plastic container, placed the container on R47's bedside table, then emptied the container in R47's bathroom sink. V2 removed her PPE and left the room without conducting hand hygiene. V18 and V19 then transferred R47 into her wheelchair and exited the room without conducting hand hygiene, cleansing the bedside table or disinfecting R47's bathroom sink. On 1/15/25 at 1:30 PM, V17 (Chief Nursing Officer) stated hand hygiene should be conducted after each glove change, PPE gowns should be tied in the back, urine or feces contaminated water should not be discarded in a residents sink and urine should not be placed on a resident's bedside table and the bedside table should have been disinfected after use.

Based on observation, interview, and record review, the facility failed to assess a resident with new onset pain, failed to document the new onset pain, and the facility failed to ensure the resident's provider received notification of new onset pain. This applies to 1 of 3 residents (R1) reviewed for injuries of unknown origin in the sample of 4. The findings include: R1's admission Record (Face Sheet) showed an original admission date of 10/9/24 with diagnoses including, but not limited to, generalized osteoarthritis, overweight, dementia, and a fracture of the lower end femur (thigh bone, onset date 6/24/25). R1's 4/10/25 Quarterly Minimum Data Set (MDS) showed severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 3 out of 15. R1's MDS showed she was dependent upon staff for toilet hygiene, bathing, lower body dressing, and all types of transfers. R1's MDS showed she received scheduled pain medication; however, she denied pain for the previous six days and she did not receive as-needed pain medication during the review period. R1's June 2025 Medication Administration Record (MAR)/Treatment Administration Record (TAR) showed twice-daily pain assessments. The pain assessments showed no documented pain until the PM documentation on June 22, 2025, (Sunday) at a rating of 3 out of 10. The MAR showed an order for Acetaminophen (an over-the-counter pain medication), two 650-milligram tablets to be given every 8 hours as-needed for pain. The MAR showed this medication was not given for the month of June 2025 until June 21, 2025, (Saturday) at 11:38 PM. The acetaminophen was documented as being given by V12 Nurse for a pain rating of 9 out of 10. R1's Progress Notes showed no entry for 6/21/25. R1's 6/22/25 Health Status Note (Nurse's Note) from 12:56 PM showed, CNAs (Certified Nursing Assistant) alerted this nurse that resident seemed to be having some right leg pain and is not tolerating bearing on that side. This nurse assessed resident, resident not tolerating range of motion well, winces and says 'no' .CNAs used [mechanical lift, crane type] for transferring resident from bed to chair. No fall or event noted that would indicate cause of increased pain. Message left for provider, DON (Director of Nursing, V2) notified, POA (Power of Attorney) notified of increased pain in right leg. (Authored by V5 Registered Nurse) The next chronological note from 6/23/25 (Monday) at 9:09 AM showed the nurse practitioner assessed R1 and ordered an X-ray of R1's right knee. R1's 6/24/25 progress note from 12:06 PM, showed the nurse practitioner was notified of the X-Ray results and R1 was sent out via 911. R1's 6/26/25 Health Status Note from 11:37 AM showed R1 returned from the hospital with a right lower femur fracture. The note showed family declined surgical intervention and placed R1 in hospice care. On 7/9/25 at 2:20 PM, V12 Nurse stated she was notified by a CNA that R1 was having pain the evening of 6/21/25. V12 stated R1 does not typically have pain. V12 stated she prepared two acetaminophen tablets and then entered R1's room. V12 stated R1 was crying, which was not unusual behavior for R1. V12 stated she asked R1 if she was having pain and R1 nodded her head yes. V12 stated she asked R1 where she was having pain, and due to R1's dementia, she was unable to state where her pain was. V12 stated she did not assess R1 for this new onset pain. V12 stated after she gave R1 the acetaminophen, R1 fell asleep and showed no signs or symptoms during the remainder of her shift, which ended on 6/22/25 at 7:00 AM. On 7/9/25 at 9:50 AM, V5 Registered Nurse stated she was notified by a CNA that R1 was having pain the morning of 6/22/25. V5 stated she assessed R1 and was able to identify her pain to her right leg with movement, which was not normal for R1. V5 stated there was no bruising or cuts to the leg. V5 stated R1 had not fallen and there was no indication regarding the cause of R1's pain. V5 stated R1 was normally a stand-and-pivot transfer or a mechanically assisted sit-to-stand lift. V5 stated due to R1's pain, she was changed to a crane-type mechanical lift transfer. V5 stated she notified R1's provider, however, the provider did not respond. V5 stated R1 was seen by the provider the following day (6/23/25). On 7/9/25 at 2:35 PM, V2 Director of Nursing (DON) stated V12 should have assessed and documented the assessment regarding R1's pain the evening of 6/21/25. V12 stated if a resident, like R1, is unable to verbalize their pain location due to cognitive deficits, there are alternative methods such as range of motion, skin assessments, or palpation (pressing and feeling the patient's body.) V2 said the purpose of the nursing assessment is to determine the cause of the resident's change in condition and gather information. V2 stated she was aware R1's provider had not returned V5's notification on 6/22/25; however, V2 stated she was aware R1's provider would be at the facility on 6/23/25. V2 stated she was not aware R1 had stated pain the evening of 6/21/25. V2 said, given that R1 had new onset pain with range of motion and R1's method of transfer needed to be altered to accommodate the new pain; V5 should have ensured R1's provider received the notification prior to the end of her shift. The facility's Notification of Change policy (August 2024) showed, Circumstances requiring notification include .Significant change in the resident's physical, mental, or psychosocial conditions .Circumstances that require a need to alter treatment . On 7/9/25 at 10:34 AM, V4 R1's Physician stated there was no indication R1 suffered a fall, and it is possible she received the fracture during a normal, safe transfer and that staff may not have been aware of the fracture when it occurred. V4 stated R1 has weakening of the bones (osteopenia), she has arthritis, she has had a right knee replacement, she is female, she is overweight, and she is elderly. V4 stated these are all risk factors contributing to R1's fracture. V4 stated a delay in R1 being sent to the hospital would not have altered her outcome.

Based on observation, interview, and record review, the facility failed to ensure opened food items were dated upon opening and ensure areas in the kitchen were clean. This failure has the potential to affect all 63 residents currently residing in the facility. Findings include: The facility's Labeling and Dating policy (undated) documents the following: Leftovers and opened foods shall be clearly labeled with date food item is to be discarded. Food items to be labeled and dated include items prepared in house and food items that are opened and stored for later use. On 02/24/25 at 09:50 AM, multiple scattered areas of dust and debris were adhered to the fan covers and surrounding areas of wall and ceiling in the walk-in cooler. V7 (Dietary Manager) confirmed the presence of dust and debris on the fan covers and the surrounding areas of wall and ceiling. On 02/24/25 at 09:55 AM, the reach-in cooler contained a large bag of shredded mild cheddar cheese that was open and did not contain the date it was opened. The reach-in cooler also contained a large, opened salad bag with scattered pieces of browning lettuce noted throughout the bag. The bag of salad did not contain the date it was opened. V7 verified both bags of shredded cheese and salad mix were opened and undated. V7 stated both opened items should be labeled with the date in which they were opened, and then proceeded to place both items back into the reach-in cooler. The facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS Form 671) dated 02/24/25 and signed by V1 (Administrator), documents 63 residents currently reside in the facility.

Based on Observation, Interview and Record Review, the facility failed to ensure residents were provided range of motion exercises and contracture alleviation devices to prevent further decline in range of motion and care plan and assess a resident's contracture for three of three residents (R6, R7, R27) reviewed for limitations in range of motion in the sample of 33. Findings include: The facility's Prevention of Decline in Range of Motion policy, dated 8/2024, documents Range of Motion means the full movement potential of a joint. Residents who exhibit limitations in range of motion, initially and thereafter, will be referred to the therapy department for a focused assessment of range of motion. Nursing assistants will report any significant changes in range of motion, as noted during daily care activities, to the resident's nurse when any changes are noted. The assessment should include identified risks which could impact resident's range of motion including, but not limited to; Immobilization, Neurological conditions causing functional limitations, any condition where movement may result in pain, spasms or loss of movement, Clinical conditions such as immobilized limbs or digits because of injury, fractures or surgical procedures including amputations. Based on comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion. Care plan interventions will be developed and delivered through the facility's restorative program, or through specialized rehabilitative services as ordered by the attending practitioner. This same policy documents Staff will be educated on the risk factors for a decline in range of motion. These include but are not limited to: Limbs or digits immobilized because of injury or surgical procedures, immobilization, deformities arising out of neurological deficits (such as strokes, multiple sclerosis, cerebral palsy, and polio), pain spasms, and immobility associated with arthritis, late state Alzheimer's disease or other conditions. Residents will receive services from restorative aides or therapists as needed. The facility's Restorative Nursing Programs policy, dated 10/2024, document It is the policy of this facility to provide maintenance and restorative services designated to maintain or improve a resident's abilities to the highest practicable level. Residents, as identified during the comprehensive assessment process, will receive services from restorative aides when they are assessed to have a need for restorative nursing services. These services may include Passive or Active range of motion, Splint or brace assistance, Bed mobility training and skill practice. This same policy documents Potential candidates for restorative nursing services may be identified through one or more of the following processes: physical assessments, MDS (Minimum Data Set assessments), Specialized Rehabilitation assessments, In-house referrals due to unusual occurrence/event. 1. On 2/24/25 at 1:50 PM, R6 was in her room lying in bed. R6's left hand was balled into a contracted fist. R6 stated she cannot move her left arm and her hand stays in that position unless she uses her right hand to force the fingers open. R6 stated she does not receive any range of motion exercises or therapy and she has not had a cone, or any devices placed into her left hand since living in the facility (8/5/24). R6's Minimum Data Set assessment, dated 2/7/25 documents R6 has no impairments to her upper or lower extremities. R6's Current Care Plan, dated 8/5/24, documents (R6) has an ADL (Activities of Daily Living) self-care performance deficit related to dementia, dizziness, epilepsy, muscle wasting and atrophy, history of CVA (Cerebrovascular Accident) with decreased use of left arm, generalized weakness, need for assistance with personal care, muscle weakness. This plan has an intervention of AROM (Active Range of Motion) program three to six days a week for bilateral upper extremities with two pound weight, one set of 20 repetitions. This Care Plan does not address R6's contracted left hand or document any interventions to relieve the contracture tightness, prevent skin breakdown under the tightened hand or provide Passive Range of Motion to the left hand. R6's Active Range of Motion Point of Care documentation dated 2/8/25- 2/26/25, documents R6 was not provided with any minutes of AROM and documents Not applicable on six occasions within that time frame. On 2/26/25 9:00 AM V5 (Chief Nursing Operations director) stated When (R6) was admitted to the facility, she never had a formal written therapy evaluation and was only put on the restorative plan (AROM). On 2/26/25 at 9:40 AM V5 stated I went down and assessed (R6). We are going to add her to OT (Occupational Therapy) for 12 sessions and they are going to be placing a rolled cloth in her left hand now. I don't have any therapy evaluations, care plan for her specific contracture or documentation of any further restorative exercises or assessments. At this time, V5 confirmed the Minimum Data Set assessment and the Care Plan for R6 do not include her contracted left hand impairment and stated they both should address that impairment. 49187 2. R27's Admission Record, dated 2/26/25, documents R27 was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Essential Hypertension, Need for Assistance with Personal Care, Type Two Diabetes Mellitus with Hyperglycemia, and Muscle Weakness. R27's MDS (Minimum Data Set) Assessment, dated 9/5/2020, documents R27 is cognitively intact and has an impairment to his left upper and lower extremity. This same MDS Assessment documents R27 does not receive any splint assistance. R27's current Care Plan documents R27 has an ADL (Activity of Daily Living) self-care performance deficit related to history of stroke with left side hemiplegia, lack of coordination, muscle weakness, and need for assistance with personal care. R27's Occupational Therapy Plan of Care, dated 12/24/21, documents General Long Term Goal: Therapist will facilitate (R27) with maintaining and/or increasing LUE (Left Upper Extremity) (shoulder/forearm/wrist/all five digits of hand) joint ROM (range of motion), splinting/brace wear, and optimal positioning in order to prevent worsening of existing contracture, prevention potential subluxation of shoulder, promote increased blood flow, prevent edema, optimize joint excursion, purposeful activities, and to assess LUE (extra space) for pressure sores or red areas. On 02/24/25 at 11:14 AM R27 was sitting in a recliner in his room. R27's left hand was in a closed fist with fingers facing his palm. R27 stated, I am supposed to wear a splint to my left hand every day. Only one staff member (V9/Restorative Nursing Assistant) puts it on me when they work, no one else puts it on me. I want to wear it, so my fingers don't get worse. On 2/25/25 at 11:25 AM R27 was sitting in his recliner in his room. R27's left hand was in a closed fist with fingers facing his palm. R27 did not have on his left-hand splint. R27 stated, See no one has put my left-hand splint on today. I wish they would. On 2/25/25 at 11:32 AM V2/Director of Nursing stated according to R27's care plan in December 2024, R27 should wear his splint one time a week then gradual increase to tolerate. V2 stated, I don't see where anyone increased (R27) to wear his splint more often. (R27) should be wearing it more than one time a week. (R27) used to wear his left-hand splint during the day and off at night. I am not sure why it even got changed. On 2/25/25 at 12:42 PM V9/Restorative Nursing Assistant stated, I have not been putting (R27's) splint on him that often. Sometimes if I remember I will put it on (R27) for two hours and then take it off him. There is no consistency on when to put (R27's) left-hand splint on him. I did not put it on (R27) yesterday or today. On 2/26/25 at 9:30 AM V5/Chief Nursing Officer stated We (the facility) clearly have a deficiency in the restorative programming. (R27) should have orders in the treatment record on when to apply his left-hand splint and when to remove the splint. Clearly we need to fix things. On 2/26/25 at 11:10 AM V10/Registered Nurse/Care Plan Coordinator stated, (R27) was supposed to be wearing his splint two hours a day every day. It was something that slipped through the cracks. I just updated (R27's) care plan yesterday so restorative is aware (R27) should be wearing it daily for two hours. We (the facility) want (R27) to wear his splint to prevent contractures to his left hand, since (R27) is unable to move his left hand/fingers. 31283 3. R7's current medical record documents R7's diagnoses to include: History of falling, Need for Assistance with Personal Care, Weakness, Fatigue, Vertigo, Osteoarthritis, Unsteadiness on Feet, Difficulty in Walking, Displaced Oblique Fracture of Shaft of Fibula, Subsequent Encounter for Closed Fracture with Routine Healing, Abnormalities of Gait and Mobility. R7's Minimum Data Set Assessment (dated 12/12/24) documents (in section GG), R7 has impairment on one side of her lower extremities. This section also documents R7 utilizes a wheelchair. R7's current Physician's Orders document an order in place to discontinue skilled physical therapy on 01/27/25. On 02/26/25 at 11:15 AM, R7 was sitting in her wheelchair at a table in the dining room drinking a cup of coffee. R7 stated she is currently not receiving any type of range of motion/restorative exercises. R7 stated, I haven't done anything since they told me I was finished with therapy about a month ago. I wish they would do something. That is the only way that I will be able to walk again, and I want to be able to walk. R7's Activities of Daily Living self-care performance deficit documents the following: Nursing Rehab/Restorative: Active Range of Motion program 3-6 days a week. Hand bike Resistance Level 6 up to 15 minutes; Bilateral Lower Extremity exercises with 2 pound weights 1 set 10 reps; Fine motor-concentration game; Bilateral upper extremities with two pound wand or dumbbells all planes-curls, push outs, etc. 1 set of 10 reps. On 02/26/25 at 10:35 AM, V5 (Chief Nursing Officer) stated she could not provide documentation to confirm R7 has received range of motion/restorative exercises as indicated after she was discharged from physical therapy on 01/27/25.

Based on observation, interview and record review, the facility failed to apply physician-ordered compression stockings for one of one resident (R31), with a known history of acute/chronic heart failure, reviewed for edema, in a sample of 33. FINDINGS INCLUDE: R31's facility Admission Record documents that R31 was admitted to the facility on [DATE] with the following diagnoses: Chronic Diastolic (Congestive) Heart Failure; Atrial Fibrillation; Chronic Kidney Disease, Stage 3; Edema. R31's current Physician Order Sheet, dated February 2025 includes the following orders: (Compression stockings) to bilateral lower extremity, on in AM (morning), off at HS (bedtime) for bilateral lower extremity edema on 9/7/2024. R31's current Care Plan, dated 9/7/24 includes the following Focus Area: (R31) has an activity of daily living self-care performance deficit related to impaired mobility, osteoarthritis, muscle weakness, visual and hearing deficits. Also included are the following Interventions/Tasks: (R31) requires substantial assist of one for upper/lower body dressing and putting on/taking off footwear. (R31) dependent on staff for (compression stockings) to be worn on bilateral lower extremity due/to edema, on in morning and off at bedtime. This same form includes the following Focus Areas: (R1) has altered cardiovascular status related to Congestive Heart Failure, Hypertension, Bilateral Lower Extremity Edema, Anemia. Also included are the following Focus Areas: (R31) to wear (compression stockings on bilateral lower extremities, on in the morning, off at bedtime. R31's Cardiology Progress Notes, dated 01/31/2025 documents, Follow up for cardiac med reconcile, titrating cardiac meds, lab follow up, following volume status, adjusting diuretics as needed, monitoring hemodynamics/symptoms during and post physical therapy, and increased risk for cardiac re-admission. Chief Complaint / Nature of Presenting Problem: Diastolic CHF (Congestive Heart Failure), A fib (Atrial Fibrillation), HTN (Hypertension). Review Of Systems General: Ext (Extremities) 4+ edema (swelling caused by buildup of fluid in body tissues) BLE (bilateral lower extremity). PLAN: --continue antihypertensive meds --avoid hypotension (low blood pressure) --avoid hypertension--heart healthy low sodium diet--cont (continue) to monitor. Echocardiogram to be ordered in the near future to determine baseline cardiac function. Will monitor to assess for CHF and possible myocarditis (inflammation of heart tissue). Limit sodium intake to augment blood pressure control and avoid worsening renal function. Maintain a healthy weight and increase activity as tolerated. On 2/24/25 at 10:01 A.M., R31 was lying in bed, sleeping. 3-4+ bilateral pitting edema was noted to (R31's) feet and ankles. (R31's) feet and legs were not elevated but resting on the mattress. No compression stockings were in place. On 2/24/25 at 2:55 P.M., (R31) was up in a wheelchair, in her room. R31's feet were resting on unelevated foot rests. Edema was present to R31's bilateral feet, the edema was over the top of R31's slippers. R31 did not have (compression stockings) on. At that time, R31 stated she does not wear compression stockings, as staff do not put them on her. On 2/25/25 at 9:56 A.M., (R31) was lying in bed, sleeping. 4+ bilateral edema was present to (R31's) lower legs, ankles, and feet. (R31's) legs and feet were resting on the mattress, not elevated, no (compression) stockings were present to (R31's) bilateral lower extremities. On 2/25/25 at 4:30 P.M., V1/Registered Nurse/Administrator verified R31 had a current physician's orders for the application of compression stockings daily.

Based on interview, observation and record review, the facility failed to maintain a resident's dignity by ensuring clothing attire was clean and free of debris for one resident (R47) reviewed for dignity in the sample of 33. Findings include: R47's Minimum Data Set Assessment (dated 02/20/25) documents (in Section C), a Brief Interview for Mental Status score of 3, indicating R47 is severely cognitively impaired. On 02/26/25 at 11:20 AM, R47 was sitting in a high back wheelchair with V8 (R47's husband) sitting next to her. R47 had a full mechanical lift sling in place underneath of her. V8 pointed to several scattered areas of dried, crusted debris on the lap of R47's pants and stated, I am not sure if they are just not using the (clothing protectors) at breakfast. I keep finding her wearing dirty pants from food spilled on her. The pants she was wearing on Monday (02/24/25) were like this as well. They had areas of dried food that had been spilled all over them. I wish they would change her clothes when they look like this. She would have never kept a dirty pair of pants on if food had been spilled on them, V8 then began scraping the dried, crusted areas of debris off of R47's pants with his fingernail. On 02/6/25 at 11:40 AM, V1 (Administrator) stated facility staff should be changing a resident's clothing if it becomes soiled after a meal.

Based on observation, interview and record review, the facility failed to ensure a nebulizer mask and nebulizer tubing was changed every 72 hours and stored in a bag between uses and ensure oxygen tubing was changed every seven days for one of one resident (R57) reviewed for respiratory care in a sample of 33. Findings include: The facility's Nebulizer Therapy Policy, dated 2024, documents Policy: it is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. If the nebulizer will supply oxygen to the patient, refer to policy Oxygen Concentrator. Care of the Equipment: 7. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag. 8. Change nebulizer tubing every seventy-two hours or per facility policy. The facility's Oxygen Administration Policy, dated 2024, documents Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy Explanation and Compliance Guidelines: 5. Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include: If applicable, change nebulizer tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. On 02/24/25 at 11:20 AM R57's nebulizer mask was lying on R57's dresser undated and unbagged. On 2/24/25 at 11:25 AM R57 was in the dining room with oxygen flowing via nasal cannula. R57's nasal cannula oxygen tubing was un-dated. On 2/24/25 at 11:40 AM V4/Registered Nurse verified R57's nebulizer mask and nebulizer medication cup was undated and un-bagged. V4 also verified R57's nasal cannula oxygen tubing was undated. V4 stated, Nebulizer masks and nebulizer medications cups should be changed at least every 72 hours, dated, and placed in a bag after each use. Oxygen tubing should be changed at least once weekly and dated as well.

Based on observation, interview and record review facility staff failed to disinfect a shared glucometer between resident use for three of three residents (R6, R11 and R25) reviewed for infection control, in a sample of 33. The (undated) facility policy, Glucometer Disinfection directs staff, The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne diseases to residents and employees. The facility will ensure blood glucometer's will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. The glucometer's will be disinfected with a wipe pre-saturated with an EPA (Environmental Protection Agency) registered healthcare disinfectant that is effective against HIV (Human Immunodeficiency Virus), Hepatitis C and Hepatitis B virus. R6's current Physician Order Sheet, dated February 2025 includes the following diagnosis: Diabetes Mellitus with Hyperglycemia. Also included are the following physician orders: Finger stick blood glucose monitoring three times daily. R11's current Physician Order Sheet, dated February 2025 includes the following diagnosis: Diabetes Mellitus with Diabetic Polyneuropathy. Also included are the following physician orders: Finger stick blood glucose monitoring before each meal and at bedtime. R25' current Physician Order Sheet, dated February 2025 includes the following diagnosis: Diabetes Mellitus with Diabetic Retinopathy. Also included are the following physician orders: Finger stick blood glucose monitoring before each meal daily. On 2/24/25 at 11:01 A.M., V6/Licensed Practical Nurse (LPN) prepared to perform a blood glucose finger stick for R6. V6/LPN removed a glucometer from the top of her medication cart, placed it in her pocket and went to R6's room, performed a finger stick blood glucose test with the glucometer, returned to the medication cart and without cleansing the machine, prepared to administer medications and perform a finger stick blood glucose test for R11. On 2/24/25 at 11:12 A.M., V6/Licensed Practical Nurse (LPN) prepared to perform a blood glucose finger stick for R11. V6/LPN picked up the nondisinfected glucometer machine from the top of her medication cart, performed a finger stick blood glucose test with the glucometer on R11, returned to the medication cart and without cleansing the machine, prepared to administer medications and perform a finger stick blood glucose test for R25. On 2/24/25 at 11:21 A.M., V6/Licensed Practical Nurse (LPN) prepared to perform a blood glucose finger stick for R25. V6/LPN removed a nondisinfected glucometer from the top of her medication cart, placed it in her pocket and went to R25's room, performed a finger stick blood glucose test with the glucometer, returned to the medication cart and without cleansing the machine, prepared to administer medications for the next resident. At that time, V6/LPN confirmed she had not disinfected the shared glucometer between R6, R11 and R25.

Based on interview and record review the facility failed to provide the resident/resident representatives with a written notice of transfer. This has the potential to affect all 63 resident's residing in the facility. Findings include: 1. R12's medical record documents that R12 was transferred to a local hospital on 11/5/24. No evidence of a facility notification to R12 or R12's representative of a transfer/discharge was present in R12's chart 38396 2. R219's Nursing Progress Notes, dated 2/16/2025 at 6:06 PM documents R219 was sent to the local emergency room due to a recent change in condition. R219's electronic medical record does not document that R219 or R219's representative was provided with a written notice of transfer when R219 was sent to the hospital. The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 2/24/24 and signed by V1/Administrator documents 63 residents currently reside within the facility. On 2/26/25 at 10:20 AM V1 (Administrator) verified the facility did not provide (R12 and R219) or their representatives with a written notice of transfer. V1 stated, I know the resident's have not been receiving a written notice of transfer when they are discharged to the hospital because we do not have a good process in place. I doubt anyone has received them.

Based on interview and record review the facility failed to provide a copy of the bed hold policy for facility residents discharging to the hospital. This failure has the potential to affect all 63 residents currently residing in the facility. Findings include: The facility's Bed Hold Notice, dated 2025, documents It is the policy of this facility to provide written information of the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave. Policy Explanation and Compliance Guidelines: 2. In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed hold policies to the resident and/or the resident representative with 24 hours. The facility will document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. The facility will keep a signed and dated copy of the bed-hold notice information give to the resident and/or resident representative in the resident's file and/or medical record. 1. R12's medical record documents that R12 was hospitalized on [DATE]. R12's medical record does not contain documentation of the facility bed hold policy given to R12 or R12's representative. 38396 2. R219's Nursing Progress Notes, dated 2/16/2025 at 6:06 PM documents R219 was sent to the local emergency room due to a recent change in condition. R219's electronic medical record does not document that R219 was provided with a bed hold notice when R219 was sent to the hospital. The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 2/24/24 and signed by V1/Administrator documents 63 residents currently reside within the facility. On 2/26/25 at 10:20 AM V1 (Administrator) verified the facility did not provide (R12 and R219) or their representatives with a bed hold. V1 stated, I know the residents' have not been receiving a bed hold when they are discharged to the hospital because we do not have a good process in place. I doubt anyone has received them.

Based on observation, interview and record review the facility failed to serve drinks at palatable temperatures. This failure has the potential to affect all 59 resident who currently reside in the facility. Findings Include: The Facility's Record of Food Temperatures Policy dated 01/01/2024 documents Hot foods will be held at 135 degrees Fahrenheit or greater. Potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit. Place cold menu items such as ham salad or egg salad over an ice bath in a pan (preferably on a separate cart) and not beside a heated steam table. Resident Council Meeting Minutes dated December 2023 documents The food is sometimes cooled off by the time it gets to the rooms. On 01/17/24 at 11:30 AM V4 (Dietary Manager) sat all lemonades, prune juices, waters and milks pre poured on the counter outside of the serving window in the kitchen. None of these fluids were sitting in an ice bath. On 01/17/24 at 12:10 PM V4 (Dietary Manager) began serving the trays and did not stop serving the non iced fluids until 1:15 PM. On 01/18/24 at 11:30 AM V4 (Dietary Manager) sat all lemonades, prune juices, waters and milks pre poured on the counter outside of the serving window in the kitchen. None of these fluids were sitting in an ice bath. On 01/18/24 at 12:05 PM V4 (Dietary Manager) began serving the trays and continued to serve fluids off the counter until 1:30 PM. On 01/17/2024 at 8:05 AM R5 was served her breakfast tray. R5's milk temperature was 57.2 degrees Fahrenheit. When R5 took a sip of her milk she stated I've had colder. On 01/16/24 02:05 PM R 28 Reported milk is warm and hot foods are served cold 75% of the time. On 01/18/24 at 12:05 PM R28's milk temperature was 49.6 degrees Fahrenheit and his prune juice temperature was 59.2 degrees Fahrenheit. R28 made a thumbs down motion when asked if his fluids were cold enough for his liking. On 01/17/2024 at 12:25 PM R26's milk temperature was 56.2 degrees Fahrenheit and her supplemental shake temperature was 61.1 Fahrenheit. On 01/17/2024 at 12:30 PM R24's milk temperature was 54.2 degrees. On 01/17/2024 at 12:34 PM, R45's milk temperature was 59.8 degrees. On 01/17/2024 at 12:36 PM R11's milk temperature was 55.6 degrees. On 01/18/2024 at 1:45 PM V4 (Dietary Manager) confirmed that all residents who drink any fluids out of the dining room during meals would be served from the fluids that were sitting on the counter not in ice. V4 stated I bet if I put the drinks on some ice they would stay colder longer. I will start to do that. The Facility's Daily Census dated 01/15/2024 documents 59 residents are currently residing in the facility.

Based on observation, record review and interview the facility failed to provide safe mechanical lift transfer for one resident (R26) of 15 residents reviewed for falls and failed to supervise for three residents (R22, R25, R26) requiring supervision during meals of nine residents in the sample of 27. Findings include: 30899 1. Facility Policy/Safe Resident Handling/Transfers dated 2023 documents: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees who assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. Mechanical lifting equipment or other approved transferring aids will be used based on the resident's needs to prevent manual lifting except in medical emergencies. Staff will perform mechanical lifts/transfers according to the manufacturer's instructions for use of the device. Sit -to-Stand Lift Operators Instructions dated 12/21/10 documents: Transferring the patient: Position harness (sling) around the upper body of the patient so the sides of the harness are between the patient's torso and arm, resting 2-3 inches below the underarm. For the safety of the patient, securely fasten the safety strap around patient's torso. Secure the buckle and pull the strap to tighten. As the patient is being raised, simultaneously tighten the safety strap buckled around their torso. Stop lifting when the patient is in a standing position. Current Physician Order Report Summary indicates R26 has diagnoses that include Neurocognitive Disorder with [NAME] Bodies, Dementia with Psychotic Disturbance, Parkinson's Disease with Dyskinesia. Progress Notes dated 12/19/23 at 1:12pm indicates R26 is moderately cognitively impaired. R26's Current Care Plan indicates R26 was positive for Influenza A on 1/15/24. Care Plan also indicates R26 is weight bearing as tolerated and requires extensive assist of two staff using a sit-to-stand lift for transfers. On 1/16/24 at 11:37am V11, CNA (Certified Nurse Assistant) attempted to stand R26 up from a wheelchair, with a gait belt to transfer R26 to the toilet. V11 was unable to transfer R26, as R26 could not fully stand up. V11 then left the room and returned with a sit-to-stand style lift. V11 placed the sling around R26's upper back, secured the sling loops to the lift arms, placed R26's hands onto the lift handles, was joined by another staff member and proceeded to lift R26 up to a semi-standing position. R26 appeared weak and struggling to comprehend and follow instruction. As V11 pushed the lift from the middle of the room into the bathroom, R26 was suspended from the lift sling with the sling riding up R26's upper back under her arms until R26 appeared to be hanging from the sling. V11 did not secure the safety strap around R26's torso at any time during transfer. During transfer onto the toilet R26 appeared to be struggling to keep hold of the handle grips and required repeated instruction from V11 to hold on. The same procedure was used to lift and transfer R26 back into the wheelchair from the toilet, however R26 required several attempts by V11 to replace R26's hands onto the handles. At no time during transfer onto or off the toilet was R26 able to fully stand and was transferred while being suspended from the sling under R26's arms. On 1/16/24 at 11:55am V11 acknowledged R26 seemed weaker recently due to having the flu, had more difficulty holding onto the handle grips and was not as secure in the lift. On 1/18/24 at 2:30pm V2, DON (Director of Nursing) stated residents should not hang in the sling when being transported in a lift and acknowledged R26's risk of falling through the sling if she were to let go of the handles. 2. Facility Policy/Meals Supervision and Assistance dated 2023 documents: --The resident will be prepared for a well-balanced meal in a calm environment, location of his/her preference and with adequate supervision and assistance to prevent accidents, provide adequate nutrition, and assure an enjoyable event. This include: Identifying hazards and risks; Evaluating and analyzing hazards and risks; Implementing interventions to reduce hazards and risks; Monitoring for effectiveness and modifying interventions as necessary. --Supervision/Adequate Supervision refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed. This determination is based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. --The facility will develop an individualized care plan based on the Resident Assessment Instrument to address the resident's needs and goals, to monitor the results of the planned interventions such as adequate supervision during meal time. --Assemble equipment and supplies needed. Do not serve the meal until the attendant is ready to assist the resident. Alternate food and liquids, as desired and needed in order to cleanse mouth of food. Current Care Plan indicates R22 has a potential nutritional problem related to Dysphagia, history of CVA (Cerebrovascular Accident) and Malnutrition. Care Plan interventions include: Monitor/document report as needed any signs/symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat; Provide/serve diet as ordered; Pudding thick liquids; Supervision for all intake and resident to sit upright in chair; R22 requires supervision during meals due to dysphagia; eats meals in Rehab DR (dining room). On 1/16/24 at 12:15pm R22's lunch tray was brought into her room and placed on a bedside table in front of R22. No staff were seen returning to R22's room until 1pm when staff entered R22's room and removed R22's meal tray. On 1/17/24 and 1/18/24 R22 was seen in her room with a breakfast tray which included oatmeal and several thickened liquids. No staff were present at that time. R22 verified that prior to getting the flu she ate all her meals in the dining room, but staff had not been present during meals since she had to stay in her room due to the flu. 3. Current Care Plan indicates R25 has an ADL (Activities of Daily Living) self-care performance deficit related to Dementia and psychomotor deficit. Care Plan interventions dated 8/8/23 include: Dining Program 7 days/week; R25 to eat all meals in Rehab DR; Set up tray, hand R25 utensils; Provide encouragement as needed; R25 can feed herself after set-up help with supervision, but requires partial/moderate assist times one. Monitor/document report as needed any signs/symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat; On 1/16/24 at 12:20pm R25 was in bed with eyes closed. A meal tray was on a bedside table next to R25's bed. At no time between 12:20pm and 1pm did staff enter R25's room until R25's lunch tray was removed at 1:05pm. On 1/17/24 at 8:23am R25 was sitting up in a chair at bedside, drinking from a cup with a handle and several food items still on a plate. No staff were present in the room. 4. Current Care Plan indicates R26 has a nutritional problem related to diagnoses of Dysphagia, Parkinson's Disease and Dementia. Care Plan interventions (date revised 12/18/23) include: R26 requires supervision and/or assistance at meals. R26 to use a scoop plate; offer small bites and sips; R26 to sit upright at 90 degree angle during meals and eat all meals in the Rehab DR (dining room). On 1/16/24 at 11:40am R26 was in her room, with the door closed, sitting in a wheelchair with breakfast tray in front on a bedside table in front of R26. R26 was sitting with her head down and eyes closed and did not initially respond to name called. None of the breakfast items on R26's plate appeared to have been eaten. Milk or some white liquid was spilled under R26's table and wheelchair. At that time, R22 - R26's roommate - stated She doesn't eat. R26 was asked if staff had assisted her with her meal R22 replied No. They just put the food there. On 1/16/24 at 12:15pm R26's lunch tray was brought into her room and placed on a bedside table in front of R26. Lids were not removed from the cups of liquids and utensils were not given to R26. Continuous observations from 12:15 to 1pm found no staff were seen returning to R26's room until 1pm when staff entered R26's room and removed R26's meal tray. 1/17/24 at 8:20am R26 was sitting in her wheelchair with breakfast meal on bedside table in front of R26. R26 was holding a milk carton and attempting to drink from the carton. No staff were present in the room while R26 was eating/drinking. On 1/17/24 at 9:45am R26 had cups and cartons of liquids on the bedside table and was attempting to chew on the plastic lid from one of the cups. On 1/17/24 at 12:15pm V9, CNA was assisting R16 with the lunch meal. V9 stated that she took R16's tray early from the kitchen because two other residents, R25 and R26, would also require assistance with eating when their trays arrived. V9 stated that R25 and R26's trays had not yet been delivered to their rooms so she would assist them when she was done with R16. On 1/18/24 at 2:40pm V2, DON (Director of Nursing) stated that R22, R25 and R26 all ate in the Rehab Dining room until they became positive for the flu. V2 acknowledged R22, R25 and R26 should have supervision while eating/drinking.

Based on interview, and record review the facility failed to obtain a PASARR (Preadmission Screening and Resident Review) Level I prior to admission to the facility and failed to request or obtain a PASARR Level II Screening for two (R10 and R22) of five residents reviewed for PASARR Screenings in the sample of 27. Findings include: The facility's Resident Assessment - Coordination with PASARR Program, dated 1/1/24, documents: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I - initial pre-screening that is completed prior to admission. i. Negative Level I Screen - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level I Screen - necessitates a PASARR Level II evaluation prior to admission. b. PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD (mental disorder), ID (intellectual disability), or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. 3. A record of the pre-screening shall be maintained in the resident's medical record. On 01/18/24 at 9:00 am V1 Administrator confirmed a PASARR Level I and II have not be completed for R10 and R22 and she has already started the process and stated It should have been done prior to admission and was not. 1. The EHR (electronic health record) for R10 documents R10 admitted to the facility on [DATE] with the following diagnoses: Bipolar, GAD (General Anxiety Disorder), Dementia, Brief Psychotic Disorder, and MDD (Major Depressive Disorder). This same EHR does not include documentation of the PASARR Level I or II having been completed prior to R10 admitting to the facility. The current Care Plan for R10, documents a Focus area as: R10 currently prescribed anti-psychotic medication related to Bipolar Disorder with Generalized Anxiety Disorder and Brief Psychotic Disorder. On 1/18/24 V1 Administrator confirmed there was no prior PASSR Level I or Level II screen found or presented for R10 prior to 10/18/23. V1 provided a PASARR Level I screen request for R10, dated 1/17/23, and a referral, dated 1/18/23 to local company for a PASARR Level II to be completed. This referral documents Reason For Screening: This nursing facility resident has never had a PASRR Level II evaluation and shows signs or symptoms that indicate she/he may have a PASARR condition. 30899 2) Physician Order Report Summary indicates R22 was admitted to the facility on [DATE] with diagnosis of Generalized Anxiety Disorder. Resident Medical Diagnosis List indicates R22 has diagnoses that include: Moderate, Recurrent Major Depressive Disorder (6/27/23) Adjustment Disorder (7/15/21) Delusional Disorder (12/27/21) Initial Pre-Admission OBRA (Omnibus Budget Reconciliation Act) Screen dated 6/8/20 indicates at that time there was no reasonable basis for suspecting DD (Developmental Disability) or MI (Mental Illness). State Screening Verification Form dated 6/8/20 indicates This form is used for prospective residents who are being admitted from another nursing facility where a copy of the original screening assessment completed for admission to the transferring nursing facility cannot be found. Admitting facilities must make every effort to obtain a copy of the screening assessment from the discharging facility prior to completing this form. State Notice of PASRR (Preadmission Screening and Resident Review) Level l Screen Outcome dated 1/18/24 indicates the screening completed for R22 on 1/18/24 shows that R22 needs a face-to-face Level ll evaluation. Notice indicates (R22) may have a serious mental illness or an intellectual/developmental disability. Level l Screen dated 1/18/24 indicates (R22) has never had a PASSR Level ll evaluation and shows signs or symptoms that indicate (R22) may have a PASARR condition. No prior PASSR Level l or Level ll screen was found or presented for R22 prior to 1/18/23.

Based on interview and record review the facility failed to refer one resident (R20) for a Preadmission Screening and Resident Review (PASARR) after onset of new possible serious mental illness of five reviewed for PASARR in a total sample of 27. Findings Include: The Facility's Resident Assessment-Coordination with PASARR Program policy dated 01/01/2024 documents This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include: a.) A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis) b.) A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. R20's current Physician Order Sheet dated January 2024 documents 09/30/2020 as R20's original admitted . R20's Admitting History and Physical done by V5 (Attending Physician) dated 05/18/2020 documents Psychiatric/Behavioral: Negative for behavioral problems. R20's Office Visit done by V8 (Attending Physician) dated 07/14/2020 documents Psychiatric/Behavioral: Negative for agitation and confusion. R20's Nurse's Notes dated 10/09/2022 documents resident was verbally foul and swinging at staff. R20's Nurse's Notes dated 10/27/2022 documents inappropriate comments and sexual demands of nurse. R20's Nurse's Notes dated 11/05/2022 documents making sexual comments to CNAs (Certified Nurse Aides). R20's Nurse's Notes dated 11/24/2022 documents confused and delusional. R20's Current Physician Order Sheet dated January 2024 documents Bipolar Disorder as a diagnosis as of 12/06/2022. On 01/18/24 at 10:30 AM V1 (Administrator) stated that the Bipolar Disorder Diagnosis was initiated by V7 (Psychiatric Doctor) on 11/14/2022. R20's Nurse's Notes dated 12/06/2022 documents Wife notified of new diagnosis of Bipolar Disorder and wife stated (R20)'s family had a strong history of bipolar disorder. R20's PASARR dated 9/25/2022 documents Based upon all information and data available to me for this person there is a reasonable basis for suspecting DD (Developmental Disability) or MI (Mental Illness): No. On 01/18/24 at 9:00 AM V1 (Administrator) confirmed that no new PASARR was initiated or completed after new onset of behaviors and/or new diagnosis of Bipolar Disorder. It should have been done and was not.

Based on observation, interview and record review the facility failed to ensure privacy during incontinent care for one resident (R26) of 15 residents reviewed for privacy in the sample of 27. Findings include: Facility Policy/Promoting/Maintaining Resident Dignity dated 2023 documents: Maintain resident privacy. Current Physician Order Report Summary indicates R26 has diagnoses that include Neurocognitive Disorder with [NAME] Bodies, Dementia with Psychotic Disturbance, Parkinson's Disease with Dyskinesia. Progress Notes dated 12/19/23 at 1:12pm indicates R26 is moderately cognitively impaired. On 1/16/24 at 11:37am R26 and R22 roommates, both sitting in wheelchairs in the room. R26 was closest to the window which covered 75% of the wall nearest R22's bed. The shade was completely retracted to the top of the window. The window view was directly to a parking lot on the ground floor with a car parked approximately 2 car widths from R26's window. At that time, R26's shirt was completely unbuttoned, exposing most of R26's breasts and abdomen. R26 was only wearing an incontinent brief, no pants. R26 had no linen or blanket covering her bare legs. R26 had pulled the brief loose from the side tabs and was constantly tugging at the front part of the brief. V11, CNA (Certified Nurse Assistant) responded to request for assistance with R26. V11 stated he did not know who got R26 dressed in the morning but thinks it was a nurse. V11 attempted to stand R26 up with a gait belt to transfer R26 to the toilet with the bathroom door open in full view of R22. V11 was unable to transfer R26 and brought R26 back out into the room where R26 sat nearby R22 until V11 returned a few minutes later. R26 was left sitting with the brief open and exposing R26's front groin area. V11 returned, backed R26 into the middle of the room, lifted R26 up with a sit-to-stand style lift, exposing R26's entire bare body from mid-back to feet except for the incontinent brief that was saturated on the back side with urine and feces. R26's body was exposed to the entire window area and to R22 while being suspended from the sit-to-stand lift and transported into the bathroom. The bathroom door was left open in view of R22 while R26 received incontinent care. At that time R22 stated the staff Never pull the window blind down. On 1/18/23 at 9:35am R22 confirmed she was a nurse in the Army for [AGE] years and stated staff should provide privacy for her and R26 when they are giving them care, stating It's not right. We should have privacy. On 1/18/24 at 2:15pm V2, DON (Director of Nursing) acknowledged the proximity of the parking lot to R26's room, the very large window next to R26's bed and V2 confirmed the shade should be pulled while providing care as well as the privacy curtain between resident beds.

Based on observation, interview, and record review, the facility failed to identify, notify a Physician, and obtain a Physician ordered treatment for [REDACTED]. This failure resulted in a Stage one pressure ulcer worsening to a Stage three when a Physician ordered treatment was obtained. Findings include: The National Pressure Injury Advisory Panel Pressure Injury Stages, dated 2016, documents, A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. The Panel also documents, Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. The facility's Wound Dressing policy, dated 6/2013, documents, Objective: to provide an appropriate type of protective wound covering that facilitates the healing process. The policy also documents, Change the dressing using clean technique according to physician's orders [REDACTED]. The facility's Pressure Ulcer Treatment and Management policy, no date available, documents, Resident with pressure ulcers will have a physician's orders [REDACTED]. On 10/01/20 at 11:08 AM, R2 had an open area located on the bony prominence of R2's coccyx area. The wound had dark pink wound bed edges with yellow tissue present. R2's Braden Risk assessment, dated 6/15/20, documents a score of 7 putting R2 at a very high risk for skin breakdown. R2's Electronic physician's orders [REDACTED]. R2's physician's orders [REDACTED]. R2's Nurse's notes completed by V5 (Licensed Practical Nurse), dated 8/22/2020 at 8:52 p.m., document, R2 has a reddened unblanchable area above her coccyx. R2's current medical record has no documentation of R2's Physician being notified of the new area that V5 identified on 8/22/2020. R2's Wound Nurse Practitioner notes, dated 8/25/20, document that R2 has a Stage three pressure ulcer on a bony prominence that measures 2.4 cm (centimeters) x 2.2 cm x 0.1 cm that has moderate amounts of serous (clear) drainage. The notes also document that the wound bed is 70% yellow colored tissue and 30% of pink colored tissue. On 09/30/20 at 01:56 PM, V4 (Wound Nurse Practitioner) stated, R2 is a very tiny debilitated lady with curvy spine and bony prominence. When we first saw R2 she had an open area directly on her coccyx bony prominence that was open. The wound bed was primarily covered with slough hence the Stage three staging. If the nurse discovered the wound on 8/22/20 a treatment should have been put into place. That wound could have worsened in just a few short hours with nothing put into place. V4 confirmed that failing to obtain a physician ordered treatment would contribute to the wound worsening. R2's Weekly Wound Observation Tool, dated 8/26/20, documents that R2 has a facility acquired Stage 3 pressure ulcer that was acquired on 8/25/20. The tool also documents that this is the first observation of the wound, and the wound measures 2.4 cm (centimeters) x 2.2 cm x 0.1 cm. On 09/30/20 at 12:00 PM, V3 (Assistant Director or Nursing), stated, No wound assessment was completed on 8/22/20. On 8/24/20, I went down with the floor nurse and assessed R2's wound. V4 saw R2 the following day. If a wound is unblanchable its a Stage 1 pressure area. If the nurse identified the area as unblanchable area, the nurse should have contacted the doctor for a treatment, left a note for V4, and contacted the director of nursing. R2's documentation has nothing to show that the doctor was notified, and no new order was put into place for the new area until 8/25/20. By the time I saw it, on 8/25/20, the wound had worsened. On 10/01/20 at 12:11 PM, V5 stated, A CNA (Certified Nursing Assistant) notified me that R2's bottom was reddened. I don't see where I called the doctor or obtained an order for [REDACTED]. V5 confirmed that an unblanchable reddened area with skin intact over a bony prominence would be a Stage 1 Pressure ulcer.

Based on observation, interview and record review, the facility failed to implement dietary recommendations and failed to develop a care plan for the management of multiple pressure sores for one of two residents (R1), reviewed for pressure ulcers in a sample of three. These failures resulted in R1 developing multiple, Stage 2 and Stage 3 pressure sores. FINDINGS INCLUDE: The facility policy, Pressure Injury Risk Assessment, dated (revised) (MONTH) 2013 documents, The purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk for the developing pressure ulcers. Review the resident's care plan to assess for any special needs of the resident. Pressure injuries are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin, decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition. R1's current Braden Scale for Predicting Pressure Sore Risk, dated 8/7/19 documents R1 as At Risk for developing pressure sores. R1's Communication Form and Progress Note, dated 9/29/19 documents under Section [NAME] Skin Assessment, Right outer ankle pressure sore and Right lower leg pressure sore. No other pressure wounds are noted on the document. R1's Health Status Note, dated 10/4/19 at 1:43 P.M. documents,(R1) will be returning to this facility via ambulance today. Wound on right heel. R1's Nutritional Status Note, dated 10/22/19 documents, (R1) has a Stage (2) PU (pressure ulcer) on right achilles (2 CM X 1.5 CM) and a SDTI (suspected deep tissue injury) on right heel (5.5 CM X 5.0 CM). Recommend added protein supplement 30 ML (milliliters) for wound healing until wound is healed. R1's Wound-Weekly Observation Tool, dated 11/11/19 documents, Pressure wound to left gluteal fold, acquired on 11/11/19, Stage 3. Wound measures 4 CM (centimeters) X 1.8 CM X 0.2 CM. R1's Wound-Weekly Observation Tool, dated 11/11/19 documents, Pressure wound to right gluteal fold, acquired on 11/11/19, Stage 3. Wound measures 1 CM X 3 CM X 0.1 CM. R1's Wound-Weekly Observation Tool, dated 11/11/19 documents, Pressure wound to coccyx, acquired on 11/11/19, Stage 2. Wound measures 1.7 CM X 0.5 CM. R1's Nutritional Status Note, dated 11/12/19 documents, (R1) currently has multiple wounds. Previous recommendation for a protein supplement 30 ML BID (twice daily) was not ordered. R1's Wound-Weekly Observation Tool, dated 11/18/19 documents, Pressure wound to left gluteal fold, acquired on 11/11/19, (currently) Stage 3. Wound measures 2 CM X 1.2 CM X 0.1 CM. R1's Wound-Weekly Observation Tool, dated 11/18/19 documents, Pressure wound to right gluteal fold, acquired on 11/11/19, (currently) Stage 3. Wound measures 2 CM X 3 CM X 0.1 CM. R1's Wound-Weekly Observation Tool, dated 11/11/19 documents, Pressure wound to coccyx, acquired on 11/11/19, (currently) Stage 2. Wound measures 4 CM X 2 CM. R1's Care Plan for a Stage 2 pressure ulcer coccyx is dated 11/20/19. 0n 11/21/19 at 9:24 [NAME]M., V2/Director of Nurses stated, We did not get a physician's orders [REDACTED]. I didn't know anything about the order until then. At that same time, V2/DON verified that R1's care plan had not been updated to include interventions for R1's multiple pressure wounds. On 11/21/19 at 9:58 [NAME]M., V8/Physician stated, I wasn't aware of the dietary recommendation to add a protein supplement to (R1)'s diet until 11/13/19. While I won't say the added protein would have prevented further wounds, it definitely would have helped in the healing of those wounds.

Licensure Findings Based on interview and record review, the facility failed to implement new interventions after falls and failed to follow current fall interventions in place for two of nine residents (R4 and R14) reviewed for falls in the sample of fifteen. This failure resulted in R4 falling twice, the first time sustaining a fracture of the left femoral neck and the second fall sustaining a right intertrochanteric fracture. Findings include: 1. Facility's Incident Record Log documents R4 has fallen 13 at the times at facility on the following dates: 05/17/13, 06/25/13, 08/05/13, 08/11/13, 09/10/13, 09/23/13, 10/21/13, 10/29/13, 12/30/13, 01/02/14, 01/10/14, 01/19/14, and 02/04/14. R4's Incident Detail Form, dated 05/17/13 does not have new fall interventions documented, and R4's current care plan dated 02/11/13 does not document an intervention for this fall. On 02/24/14 at 11:38 a.m., E1, Administrator, verified that no new fall intervention was implemented nor was R4's care plan updated after R4's fall on 05/17/13. R4's Incident Detail Form dated 06/25/13 documents R4 fell and required transport to a local hospital for evaluation and treatment. Local Hospital's Radiology Report for R4, dated 06/25/13, documents, "There is a hairline fracture of the left femoral neck..." Local Hospital's Operative Report for R4, dated 06/26/13, documents R4 required a left hip pinning for a left femoral neck fracture. R4's Incident Detail Form, dated 01/10/14, documents the intervention, "Check Urinanalysis." Review of R4's current medical record does not have a urinanalysis result documented following R4's fall on 01/10/14. On 02/26/14 at 9:40 a.m., E1, Administrator, verified no physician order was obtained for a urinanalysis and a urine specimen was not collected from R4 following R4's fall on 01/10/14. E1 stated, "We (facility staff) dropped the ball on that. It was never done." R4's Incident Detail Form, dated 01/19/14, documents R4 fell at the facility, reported right hip pain and required transport to a local hospital for evaluation and treatment. Local Hospital's Radiology Report for R4 dated 01/20/14 documents, "Intertrochanteric fracture on the right..." Local Hospital's Operative Report for R4, dated 01/21/13, documents R4 underwent the surgical procedure, "Open reduction internal fixation of the right hip intertrochanteric fracture." On 02/25/13 at 3:15 p.m., E1, Administrator, verified no new fall interventions were implemented for R4 prior to R4 falling and sustaining fractures on 06/25/13 and 01/20/14. 2. R14's Incident Details Report, dated 02/03/14, documents, "Resident was put in room in wheelchair with no call light, no chair alarm, and door shut..." R14's current care plan dated 12/03/13 documents the interventions, "Anticipate resident's needs, Encourage use of call light, RN alarm to alert staff." On 02/26/14 at 12:38 p.m., E1, Administrator, verified that R14's current fall interventions were not followed on 02/03/14, resulting in R14 sustaining a fall. E1 then stated, "(R14) should have never been in (R14's) room alone."