Every finding on record at Alta Rehab at Oak Brook

Based on observation, interview and record review, the facility failed to inform a resident's Healthcare Power of Attorney of the provision of atypical care requests. This applies to 1 of 3 residents (R1) reviewed for resident rights in a sample of 5.The findings include:MDS, dated [DATE], shows R1's cognition was severely impaired. Grievance dated 12/29/25 shows V4 (Healthcare Power of Attorney) expressed concern that R1's pubic hair was shaved by a facility CNA (Certified Nursing Assistant) without permission. The grievance resolution shows education to staff was provided regarding notifying resident power of attorney of special requests that do not fall within standards listed in facility policy. On 1/14/26 at 11:53 PM, V4 (Family - Healthcare Power of Attorney) stated she never gave the facility staff permission to shave R1's pubic hair. On 1/13/26 at 10:53 AM with V2 (Director of Nursing) and V17 (Restorative), R1's pubic area was examined, appeared to have been recently shaved, and showed approximately 1/4 inch outgrowth of hair. R1 was asked if she was aware her pubic area was shaved and R1 nodded yes and stated yes. R1 was then asked if she wanted to have been shaved and R1 shook her head and said no. On 1/13/26 at 9:45 AM, V2 (Director of Nursing) stated she was informed by V4 (Family - Healthcare Power of Attorney) that R1's pubic hair was shaved without V4's permission while residing in the facility. V2 stated V4 informed V2 that shaving R1's pubic area was a dignity issue and staff should not have shaved her mother without permission. V2 stated she told V4 that V7 (Family) requested that R1's pubic area was shaved in the past. V4 responded that if R1's pubic hair needed to be trimmed, V4 would trim it herself with scissors she had in R1's dresser drawer. On 1/13/26 at 10:19 AM, V5 (CNA - Certified Nursing Assistant) stated V7 (Family) was visiting R1 and told V5 she wanted her mother nice and clean and requested that V5 shave R1's pubic hair. V5 stated V7 made the request before but supplies were not available at the times of requests. V5 stated she left R1's room to look for razors, found razors, returned to the room, told V7 she found razors, and V7 replied, Oh, good! V5 stated V7 left R1's room and V5 proceeded to shave R1's pubic area, change her incontinence brief, then transferred R1 to her wheelchair and dressed R1 before V7 returned to the room. On 1/13/26 at 12:40 PM, V11 (CNA) stated she was in the room with V5 and assisted V5 in shaving R1's pubic hair. V11 stated it was clear that V7 requested R1's pubic hair be shaved. On 1/13/26 at 1:45 PM, V7 denied she ever asked staff to shave R1's pubic hair. V7 stated she was aware that all care decisions needed V4 to be asked because V4 was the decision maker and Healthcare Power of Attorney for R1's care. V7 stated she had no right to give permission to staff to shave R1's pubic hair. On 1/13/26 at 2:07 PM, V12 (LPN - Licensed Practical Nurse) stated she was not aware of V4 ever asking/approving staff to shave R1's pubic hair but V7 did ask V12 to shave R1's pubic hair in the past. On 1/14/26, V2 and V14 (Regional [NAME] President of Operations) stated staff were expected to check with residents' healthcare power of attorney prior to providing any care that families request. V2 and V14 stated any special care requests outside of typical services should be discussed with the resident's healthcare power of attorney and V2 prior to delivering the care request. Resident Rights document, reviewed/approved 1/4/19, shows, Purpose: To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems, and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability. Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement.

Based on interview and record review, the facility failed to ensure a resident's foot was supported during wheelchair transport which resulted in a fracture of the lower leg. This past noncompliance occurred from October 27, 2025, through October 29, 2025.This applies to 1 of 3 residents (R1) reviewed for accidents in the sample of 6.The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including multiple sclerosis, spastic hemiplegia affecting the right dominant side. Paraplegia, fracture of both the right and left femurs with surgical repair, diabetes mellitus, dementia, and left tibia fracture added October 27, 2025. R1's MDS (Minimum Data Set) dated November 26, 2025, showed R1 was cognitively intact and required assistance with ADLs including set up assistance with eating, partial assistance with oral hygiene, substantial assistance with upper body dressing and dependent on staff for lower body dressing, toileting, bathing, bed mobility and transfer. The facility sent a report to the department dated October 28, 2025, showed that R1 sustained a fracture to her left lower leg, while a therapy assistant was transporting R1 in a wheelchair from the therapy room to R1's room, and R1's leg was abruptly placed on the floor.On December 12, 2025, at 2:05 PM, V2 (Physical Therapy Assistant), stated on October 27, 2025, V2 was transporting R1 in the wheelchair both to and from therapy using only one footrest on the wheelchair.On December 13, 2025, at 1:35 PM, V5 (NP-Nurse Practitioner) stated on October 27, 2025, V5 was in the facility when R1 was injured, and alerted by staff that R1 was complaining of left leg pain. V5 stated she examined R1 and stated R1 was in pain and had limited ROM (Range of Motion) to the left leg and ordered X-rays of R1's entire left leg due to a history of previous fractures. V5 stated the injury was caused by R1's left leg not being supported by a footrest while being transported in a wheelchair, when R1's leg was caught under the wheelchair. V5 stated staff informed her that the staff was unable to find the second footrest for R1's wheelchair, and proceeded to transport R1 without the footrest, resulting in the fracture.R1's Xray result dated October 27, 2025, showed R1 sustained an acute nondisplaced fracture of the proximal left tibia.Prior to the survey entrance date of December 12, 2025, the facility had taken the following action to address the noncompliance.1. The Facility held an emergency QA (Quality Assurance) meeting, on October 28, 2025, that was attended by the Medical Director and the interdisciplinary team, to develop a plan to address the noncompliance. 2. The Facility found R1's wheelchair footrest and did a 1:1 training regarding supporting feet during wheelchair transport with V2. 3. The Facility in serviced the therapy department staff and nursing staff on October 28, 2025, regarding the use of footrests while transporting residents in their wheelchairs. 4. The facility did a facility wide audit of residents who use wheelchairs for transport to ensure footrests were available and their care plans were updated.5. The Facility developed a QA Audit tool to ensure compliance. The facility had completed the audit tool in accordance with their plan of 5 random residents per week for 2 months. The initial audit was completed on October 29, 2025, and the most recent audit tool was completed on December 12, 2025.

Based on the interview and record review, the facility failed to transfer a resident using a mechanical lift safely. This failure caused R1 to be dropped from mechanical lift resulting in an ankle fracture. This applies to one of three (R1) reviewed for falls in the sample of 7.This past non-compliance occurred from May 16, 2024, to June 2, 2024.Past noncompliance-no plan of correction required.The findings include:On 10/31/2025 at 11:30 AM, V10 (R1's family) said R1 was dropped from the mechanical lift on 05/16/2024 due to only one staff member attempting the transfer and without properly applying the sling. V10 stated the fall broke R1's ankle. V10 said R1 was transferred to the hospital the next day. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility with diagnoses of dementia, atrial fibrillation, congestive failure, and pain. A physician order dated 05/06/2024 showed R1 was admitted to hospice care. Minimum Data Set, dated [DATE] showed R1 was severely cognitively impaired. The care plan dated 04/18/2024 showed R1 required two assist transfers per mechanical lift. The progress notes dated 05/16/2024 by V13 (Registered Nurse-former employee) stated V14 (Agency Certified Nursing Assistant [CNA]- former employee) reported R1 had fallen from the mechanical lift while being transferred to bed and slings were not appropriately applied. The nursing notes dated 5/17/24 at 12:12 PM stated the hospice nurse visited the facility and arranged for R1 to be transported to the hospital for an evaluation.The hospital physician's progress notes dated 5/17/24 showed R1 was sent to the emergency room after a fall from a mechanical lift, and the x-ray report dated 5/17/24 showed a displaced fracture to the distal tibia and fibula (lower leg bones).The facility's incident report dated 5/16/24 showed R1 required two people's assistance and had a fall while a former Certified Nursing Assistant transferred R1 via mechanical lift, and that staff were in-serviced on mechanical lift transfers.The facility policy for manual gait belt and mechanical lifts with a revision date of 1/19/18 in part showed to protect the safety and wellbeing of the staff and residents, and to promote quality care. This facility will use mechanical lifting devices. The transferring needs of residents will be assessed on an ongoing basis and designated into one of the mechanical lift with two caregivers.On 10/31/2025 at 3:00 PM, V1 (Administrator) and V2 (Director of Nursing) stated the facility had an ownership change survey with an exit date of 05/23/2024, and the facility was cited for R1's fall and a plan of correction was submitted and accepted. V2 Director of Nursing said two staff should be present during mechanical lift transfers, and the staff should ensure the sling is attached adequately prior to lifting the resident. V2 said all staff were provided with in-services and training has been ongoing.The facility's accepted Plan of Correction (POC) showed their date of completion as June 2, 2024.-A whole-house transfer audit was conducted. -The training binder showed the facility provided in-services beginning on 5/17/24, indicating the appropriate number of staff assistants for mechanical lift transfers is two and sling pads must be securely placed before transfers.-Signs were in place as reminders to have two assists for mechanical lift transfers.-The Nursing Observation Audit Tool was used to track compliance for number of staff used for mechanical lift transfers with no concerns.

Based on interview and record review, the facility failed to ensure that a resident representative was given accurate information regarding authorization to use an electronic monitoring device in the resident room, resulting in miscommunication and lack of informed consent related to resident rights. This applies to 1 of 3 residents (R1) reviewed for electronic monitoring device in the sample of 8.The findings include: R1 was admitted to the facility on [DATE] with multiple diagnoses including muscle wasting and atrophy, COPD (chronic obstructive pulmonary disease), acute bronchitis, and positive Covid 19, based on the face sheet.R1's admission observation record dated August 29, 2025 showed that the resident was alert and oriented x two (to person and place). R1's OT (occupational therapy) evaluation dated August 30, 2025 showed that the resident was moderately impaired with decision making. R1's OT treatment encounter notes dated September 1, 2025 showed, that the resident was confused. On September 4, 2025 at 9:58 A.M, V7 (daughter) stated she is the POA (Power of Attorney) for R1. V7 stated that on August 30 2025, she talked to V11 (RN (Registered Nurse)/ Supervisor) about installing a video surveillance camera inside R1's room. V7 stated that she was informed by V11 that according to V2 (Director of Nursing), video surveillance is not allowed. V7 stated that she had sent an email to V2 on September 1, 2025 for the follow up of video surveillance and V2 had not replied to the email.The facility's grievance/complaint form dated August 31, 2025 at 1:30 PM created by V11 (RN Supervisor) showed that R1's family would like to install camera in the room, emphasizing rights.On September 6, 2025 at 3:35 PM, V2 (Director of Nursing) stated that on Sunday, August 31, 2025 she received a call from V11 informing her that V7 (daughter) was requesting to have a surveillance camera inside R1's room. According to V2 she informed V11 that she believed the facility's policy prohibits the use of the camera in the resident room. V2 stated that after talking to V11 she requested a copy of the admission contract, which she received via text message (does not remember who among the administrative staff sent the text message). According to V2, she reviewed the facility's admission contact, which showed that video camera in resident room is prohibited. V2 stated that she called back V11 after reviewing the admission contract and told V11 that camera inside a resident room is prohibited. During the same interview, V2 admitted that when she read the admission contract she focused on the statement, Video cameras are prohibited in resident rooms and she did not noticed the following statement on the same admission contract that read, unless the resident and/or resident representative has followed the steps outlined under the law. V2 stated that she did not receive any email from V7, nor did she talk personally or over the phone to V7 with regards to video camera in R1's room.On September 6, 2025 at 4:02 PM, V14 (admission Assistant) stated that on Sunday, August 31, 2025 (not sure of the time), V2 requested a copy of the facility's admission contract, specifically the part regarding video camera in the resident room and also requested to show the specific part to V11. According to V14, she sent the requested copy to V2, and she showed R1's unsigned admission contract regarding video camera in the room to V11. After showing the said part of the admission contract to V11, she (V14) proceeded to R1's room to discuss the contract and have it signed by the resident. V14 stated that on August 31, 2025 between 1:00 PM and 2:00 PM, she arrived at R1's room and at that time V7 (daughter) was present. According to V14, the contract was discussed and signed by R1 in the presence of V7 and during the discussion, V7 asked about installing a camera inside R1's room. V14 stated that she showed the part of the admission contract regarding video camera to V7 while R1 was present. V14 stated that V7 made a comment, This tells me that I have to do certain procedures, but it is allowed as long as steps are followed to which she (V14) agreed. According to V14, V7 did not ask for any further question.R1's signed admission contract dated August 31, 2025 showed under electronic device policy, Cameras: Video Cameras are prohibited in resident rooms unless the resident and/or Resident Representative has followed the steps outlined under Illinois law Authorized Electronic Monitoring in Long Term Care Facilities. (210 ILCS 32/1, et seq.). This includes notifying the Facility of an intent to place the camera and obtaining consent from the Resident and Resident's Roommate, if any. Once the Facility has been notified of the intent to place a camera, the other aspects of the applicable law will be reviewed with the Resident and/or Representative to ensure compliance and to answer any questions.On September 6, 2025 at 4:13 PM, V11 stated that on Sunday, August 31, 2025 at around 1:30 PM, V7 (daughter) asked about putting a camera inside R1's room. According to V11, she told V7 that she was not familiar with the facility's policy regarding camera in the room, but she will find out. V11 stated that she called V2 and asked if the facility allows camera in resident room. V11 stated that according to V2, camera is not allowed in the room, so she went back to V7 and informed that according to V2, camera in the room is not allowed. After providing the said information, V7 insisted that she wanted to put a camera in the resident's room and that it is the resident's right, so she called back V2 about V7's insistence. Prior to her (V11) calling back V2, V14 (admission Assistant) was at the unit and according to V14 she will go inside R1's room to discuss and have R1 sign the admission contract. V11 denied seeing the facility admission contract, specifically regarding the use of camera in the resident room. V11 stated that while V14 was inside R1's room, she called back V2 and informed that V7 was insisting that she wanted to put a camera in the room, V2 again told her that per facility policy, camera is not allowed in the room, which according to V2 had been verified with the Regional Nurse consultant. According to V11, she went back to R1's room after V14 had left the room on August 31, 2025 and she (V11) informed V7 that she again talked to V2 and was again informed that camera in the resident room is not allowed. V11 added that after the said conversation with V7, V7 stated that family will file a complaint about the facility not allowing resident to have camera in the room.On September 6, 2025 at 4:25 PM, V2 stated that she was not aware that V11 had informed the family that camera is not allowed in the room, after V14 had discussed and shown the family the facility's admission contract. V2 again stated that when she reviewed the facility's admission contract, she was focused on the statement that video camera is prohibited in resident room, not realizing that there was a following statement that read, unless the resident and/or resident representative has followed the steps. According to V2, based on R1's signed admission contract, the resident has the right to have a camera in the room as long as steps are followed including signing of the consent, since R1 at the time had no roommate.

Based on interview and record review, the facility failed to ensure that grievances were identified, documented, and addressed in accordance with facility policy. This applies to 1 of 4 residents (R1) reviewed for grievances.The Findings Include: Review of the Electronic Medical Record (EMR) showed that R1, a [AGE] year-old male, was admitted to the facility on [DATE], from a hospital following a fall. R1's documented diagnoses included, but were not limited to: dementia, repeated falls, ataxia, muscle wasting, lack of coordination, type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), cirrhosis, protein-calorie malnutrition, and depression. The Minimum Data Set (MDS) dated [DATE], identified R1 as having moderately impaired cognition and requiring substantial to maximum assistance with activities of daily living (ADLs).An admission skin assessment dated [DATE], documented the following impairments: -Left elbow skin tear measuring 0.5 cm x 0.5 cm x 0.1 cm with 100% bright pink tissue and light serous drainage -Deep tissue injury (DTI) to sacrum measuring 3.0 cm x 2.5 cm with 100% dark maroon tissue --Bruise to left hip measuring 2 cm x 2 cm x 0 cmFurther initial assessment observations by the Wound Nurse (V3) included: -multiple bruises to upper arms, lower legs, right chest, right foot, and ankle; edema in the upper arms; scabbing to the right knee and anterior lower leg. Facility-acquired skin tears were documented as follows: -Left shoulder - Identified August 1,2025 : measured 2 cm x 0.1 cm -Right shoulder - Identified August 1,2025 : measured 1.45 cm x 1.0 cm x 0.1 cm -Right forearm - Identified August 4,2025: measured 15 cm x 13 cm x 0.1 cm with light bloody drainage. -Lesion to top of head - Identified August 1,2025: measured 0.5 cm x 0 cm with scant serosanguinous drainage and 100% slough/necrotic tissue.On August 20, 2025, at 2:30 P.M., the Wound Care Nurse (V4) stated that she performed a dressing change on the right forearm wound on August 6, 2025 at approximately 6:45 A.M. She observed significant bloody drainage and used four ABD pads and Kerlix wrap for coverage. However, she did not notify the physician or Nurse Practitioner (V6) despite the change in wound status.On August 20, 2025, at 12:22 P.M., V8 (Social Service Director) stated that V7 (R1's spouse) had voiced concerns regarding poor wound care on August 4, 2025, citing dried blood leaking through R1's shirt. V7 subsequently requested R1's transfer to another facility. V8 acknowledged that she did not report this grievance to either the Administrator (V1) or the Assistant Director of Nursing (V2).During a phone interview on August 20, 2025, at 1:00 P.M., V7 stated: They butchered my husband. what they called a ‘skin tear' was a huge wound, bleeding, and extending from the wrist almost to the elbow. No one told me how bad it was until I saw it at the other facility. He was immediately sent to the hospital and is now in hospice.Review of the facility's grievance documentation showed no record that V7's concerns were reported, investigated, or resolved.On August 20, 2025, at 4:40 P.M., both the Administrator (V1) and the Assistant Director of Nursing (V2) confirmed that they had not received any report of a grievance related to R1's wound care from V8 or other facility staff.Review of the facility's Grievance Policy (dated November 20, 2012) stated: The purpose of this policy is to ensure prompt resolution of all grievances related to care and treatment provided or not provided, staff and resident behavior, and other concerns during the resident's stay.

Based on interview and record review, the facility failed to provide treatment for a skin tear as ordered by the physician. The facility also failed to reassess a worsening skin impairment, did not notify the physician of its changes to ensure timely and appropriate interventions, and lacked a care plan outlining specific interventions to manage multiple skin impairments.This applies to 1 of 4 residents (R1) reviewed for skin impairments. The Findings Include:The Electronic Medical record (EMR) showed that R1, a [AGE] year-old male admitted to the facility on [DATE], from a hospital following a fall. R1's diagnoses included, but were not limited to, dementia, repeated falls, ataxia, muscle wasting, lack of coordination, type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), cirrhosis, protein-calorie malnutrition, and depression.The Minimum Data Set (MDS) dated [DATE], identified R1 as having moderately impaired cognition and requiring substantial to maximum assistance with activities of daily living (ADLs).The admission skin assessment dated [DATE] documented the following skin impairments: 1) Left elbow skin tear measuring 0.5 cm x 0.5 cm x 0.1 cm with 100% bright pink tissue and light serous drainage. Treatment Order: Cleanse with normal saline, pat dry, apply Adaptic and dry dressing three times per week (M/W/F). 2) Deep tissue injury (DTI) to sacrum measuring 3.0 cm x 2.5 cm with 100% dark maroon tissue. Treatment Order: Cleanse with saline, pat dry, apply Venelex and dry dressing daily. 3) Bruise to left hip measuring 2 cm x 2 cm x 0 cm.Review further of the initial assessment showed that additional observations by the Wound Nurse (V3) on admission included multiple bruises to the upper arms, lower legs, right chest, right foot and ankle, edema in the upper arms, and scabbing to the right knee and anterior lower leg.Subsequent wound records showed R1's facility-acquired skin tears as follows: 1) Left shoulder (identified August 1,2025): 2 cm x 0.1 cm. 2) Right shoulder (identified August 1,2025): 1.45 cm x 1.0 cm x 0.1 cm. 3) Right forearm (identified August 4,2025): 15 cm x 13 cm x 0.1 cm with light bloody drainage. Treatment Order: Adaptic dressing, ABD pads, Kerlix wrap, 3x/week (M/W/F) 4) Lesion to top of head (identified August 1, 2025): 0.5 cm x 0 cm, with scant serosanguinous drainage and 100% slough/necrotic tissue. The manufacturer specification for the ABD showed that this kind of dressing (Army Battle Dressing) is a type of wound dressing used to absorb fluids from large or heavily draining wounds. During a group interview on August 20, 2025, at 2:30 P.M., with the Assistant Director of Nursing (V2), Wound Care Coordinator (V5), and Wound Nurses (V3 and V4), the following information was obtained: -V3 said that while she observed the wounds on admission, she did not notify the physician or obtain specific orders. Instead, she implemented standard treatment protocols. -V4 stated she performed a dressing change on the right forearm wound on August 6, 2025, at approximately 6:45 A.M. She noted significant bloody drainage and used four ABD pads and Kerlix wrap for coverage. Despite observing increased drainage, V4 did not notify the physician or Nurse Practitioner (V6). -V2, V3, and V5 confirmed there was no documentation of treatment on August 4, 2025, when the right forearm skin tear was first identified. The also validated that their facility protocol was to document provided treatment into the ETAR (Electronic Treatment Administration Record). Review of the ETAR for the month of August 4,2025, wound notes, and progress notes for showed no documentation of treatment being administered to R1's right forearm skin tear on August 4, 2025.The care plan dated July 21, 2025, lacked specific interventions to address R1's fragile skin or prevent further deterioration of skin integrity, despite multiple skin injuries and diagnoses increasing risk for skin breakdown.On August 20,2025 at 12:22 P.M., V8 said that V7 (R1's spouse) reported concerns to regarding poor wound care and draining wounds on August 4,2025. V8 said that V7 noted a dried blood that leaked through R1's shirt. As a result, V7 requested a transfer to another facility.In a phone interview on August 20, 2025, at 1:00 P.M., V7 stated: They butchered my husband. what they called a ‘skin tear' was a huge wound, bleeding, and extending from the wrist almost to the elbow. No one told me how bad it was until I saw it at the other facility. He was immediately sent to the hospital and is now in hospice.On August 20,2025 at 1:05 P.M., V9 and V10 (Admissions and Executive Director at the receiving facility), R1 arrived on August 6, 2025, around noontime, was assessed by nurse (V11), and transferred to the hospital via 911 due to deep wounds and significant pain.On August 21,2025 at 6:30 P.M., V11 said that when she immediately assessed R1 upon arrival to their facility. V11 said that V7 was present during the assessment. V11 described that R1 was a poor historian, now aware of what happened to his impaired skin integrity. V11 said she noted that R1's large bandage wrapped around R1's forearm that had extended from the wrist to the elbow. V11 said that the outer bandage was a mixed of saturated dried and fresh red blood drainage. V11 said she used approximately 200 cc of normal saline to ensure that when primary dressing be removed, there would be easy to remove without compromising what was under the dressing. V11 said that she noted multiple ABD pads, and a mesh like dressing that was embedded to the skin tissue to a deep wound on the right forearm. V11 describe the wound an approximated size from wrist to the elbow. V11 added that aside from the multiple dressing to shoulders, R1's extremities were with scattered bruises and note especially the left middle finger that extend to the elbow. V11 said that R1 was retracting his arm when the dressing was removed, whimpering of pain. V11 said she was not able to open other dressing and R1 was send via 911 for further evaluation of the large weeping wounds and pain.The documentation dated August 8,2025 entered by V11 validated V11's statement. The Hospital ED (Emergency Department) report dated August 6,2025 showed that R1 was noted with diffuse bruising and swelling in upper and lower extremities; multiple skin tears to right forearm and with significant bruising ; upper and lower patchy bruising diffused around trunk. On August 20,2025, V6 (Facility's Nurses Practitioner) stated that she was not notified that it was a large wound and not a skin tear. V6 added that a skin tear was non-significant since it was superficial, but a weeping, draining large wound need further evaluation and treatment. V11 added that should she been notified, R1 would have been sent out for further evaluation and treatment of wounds to prevent complication such as infection.

Based on observation, interview and record review the facility failed to ensure supplements were given to residents with a history of significant weight loss as ordered by their physician. This failure resulted in R63 not receiving her nutritional supplements as ordered for her severe weight loss. This applies to 3 of 3 residents (R63, R12 & R73) reviewed for weight loss in the sample of 62. The findings include: 1.R63's face sheet shows, she was admitted on [DATE] with diagnoses to include: muscle wasting and atrophy, protein-calorie malnutrition, dementia, anoxic brain damage, liver disease, underweight and altered mental status. R63's weights and vitals summary printed on 8/5/25 shows, her weight on admission was 100.2 pounds (lbs). The same summary shows, her weight on 8/1/25 (approximately 1 month later) was 93 lbs. A 7% weight loss in one month (severe). R63's progress notes dated 8/2/25 shows, Spoke with daughter, she said patient is a very picky eater even from before. She is fat adversed. Will refuse fried foods and if its dairy will need to say that its nonfat or else she wont eat it. She prefers eating cheese pizza, cottage cheese, chocolate milk, cheerios and bacon. Per daughter, she will have snacks delivered here for her that she prefers and family friend can bring some too. NP (nurse practitioner) with order to give Ensure (nutrition supplement) BID (twice daily). R63's nutrition progress note dated 8/1/25 shows, 1. Nutrition Progress note: Sig (significant) wt (weight) loss of 7.2% x 1 mo (month). BMI (body mass index) 15.5 underweight. On general diet, IDT (interdisciplinary team) reports intake varies greatly. IDT spoke with family and obtained food preference, res (resident) noted to be very selective eater. NP added order for Ensure BID R63's order summary report printed on 8/5/25 shows, Ensure two times a day, give 1 can twice a day. Start date: 8/1/25. On 8/3/25 from 9:35 AM to 12:04 PM, R63 was up in the dining room in her wheelchair. She could self propel around the room by herself. She was also observed at the noon meal. She was never provided with an Ensure (nutrition supplement). On 8/4/25 during observations in the AM and at the noon meal, R63 was never provided an Ensure. On 8/4/25 at 1:11 PM, V17 Registered Nurse stated, she has 3 residents she gives Ensures too. She stated the 3 residents. R63 was not one of the 3 residents she named. When asked if R63 received one, she went to the computer and looked at R63's MAR (medication administration record). It showed she was scheduled to receive an Ensure at 1400 (2:00 PM). She stated, the order was new and she hadn't gotten used to it yet. R63's August MAR shows, an order for Ensure scheduled at 10:00 AM and 2:00 PM. V17 RN had already signed out the 10:00 AM order but never actually gave it to her. 2. R12's face sheet shows list her diagnoses to include: Alzheimer's disease and dementia. R12's weights and vitals summary printed 8/5/25 shows, her current weight is 98.3 lbs. R12's order summary report printed 8/5/25 shows, House nutrition supplement, two times a day with lunch and dinner. Order start date: 1/26/24. On 8/4/25 and 8/5/25 at the noon meal, R12 was eating lunch. She did not have a house supplement. R12's meal ticket dated 8/5/25 shows, Notes: PCC (point click care): finger foods, cueing with meals. The ticket does not show, she is supposed to have a house supplement. 3. R73's face sheet lists her diagnoses to include: Alzheimer's disease, dementia, bipolar disorder, paranoid schizophrenia, and major depressive disorder. R73's weights and vitals summary printed 8/5/25 shows, her current weight is 163.4 lbs. R73's order summary report printed 8/5/25 shows, general diet, regular texture, thin consistency, double entree of egg and toast for breakfast juice all meals, ice cream or pudding for lunch/dinner, cueing with meals. Order start date: 1/27/24. House nutrition supplement, three times a day one serving. Order start date: 3/7/24. On 8/4/25 and 8/5/25 at noon meal, R73 was not served ice cream/pudding or a house nutrition supplement. On 8/5/25 at 1:11 PM, V16 Certified Nursing Assistant (CNA) stated, the nurses give out the nutrition supplements. On 8/5/25 at 1:11 PM, V17 RN stated, she only gave ensures to 3 residents and R63, R12 & R73 were not one of the residents she gives nutrition supplements too. She also stated, she only gives out Ensures. If it is ordered as something other than an Ensure she does not give it to the residents. On 8/5/25 at 1:23 PM, V27 dietary manager stated, the nurses give out the nutrition supplements. On 8/4/25 at 1:11 PM, V4 Dietitian stated, Ensure and nutrition supplements are the same thing. Nutrition supplement is just a generic way of saying Ensure. The facility should be giving any supplements that are recommended/ordered by the physician. They are on them because they had some kind of weight loss and its to supplement the loss. The facility's fortified foods, supplements, and snacks policy (no date) shows, Guideline: Residents who cannot consume adequate amounts of regular foods at meals to meet their nutritional needs may be considered for fortified foods, snacks, or supplements in order to increase nutritional intake. Commercially prepared supplements and nutritional interventions may be ordered by the food service manager, dietitian, or nursing staff. Fortified foods, house supplements, or snacks will be provided within the specifications of the diet order and may be substituted with nutritionally equivalent interventions if a specific brand or type of supplement is unavailable. Example of house nutrition supplement: pudding, ice cream, health shakes, chocolate milk, med pass, super donut, cookies-including fortified cookies, magic cup/nutrition treat 6. All house supplements and snacks that are given between meals will be prepared by the dining services department and delivered to nursing for distribution. 7. Commercially prepared supplements are discouraged at mealtime. It is preferred to use items from the menu that may be fortified to allow maximum mealtime intake of foods. These are generally called fortified or enhanced foods. There may be indications to serve these items at mealtime, however, and the rationale may be included in nutritional documentation

Based on observation, interview, and record review the facility failed to ensure residents'' rooms were located at or above ground level which applies to 24 of 62 residents (R6, R12, R14, R15, R26, R29, R34, R41, R51, R53, R55, R63, R66, R70, R73, R78, R79, R81, R83, R85, R90. R113, R114, R115) reviewed for facility enviorment in a sample of 62.The findings include: On 8/5/25 at 10:00 AM 24 residents (R6, R12, R14, R15, R26, R29, R34, R41, R51, R53, R55, R63, R66, R70, R73, R78, R79, R81, R83, R85, R90. R113, R114, R115) were observed on the lower-level floor in rooms located below ground level.The facility's memory care roster (100 unit) showed a census of 24 residents.On 8/4/25 at 11:00 AM, V1 Administrator stated the memory care unit (100 unit) rooms are below the level of the ground. The facility has not obtained a waiver for the rooms and is aware of the issue.

Based on observation, interview and record review the facility failed to protect the resident's right to be free from verbal/mental abuse by staff. This applies to 1 of 62 residents (R14) reviewed for abuse in the sample of 62. The findings include: R14's face sheet shows, he was admitted on [DATE] for therapy. His diagnoses include: dementia. He was residing in the memory care unit. On 8/4/25 at 1:30 PM, R14 was sitting up in his wheelchair visiting with his wife in the dining room. V24 (R14's wife) stated, everything was fine at the facility except the episode last night (8/3/25). She stated, she came to visit her husband (R14) around 6:30/7:00 PM and bring him some dinner. She knows he doesn't eat well at the facility so she brings him food sometimes. When she arrived at the facility, R14 was in bed. She saw V18 Certified Nursing Assistant (CNA) coming out of the room across the hall from her husband. She asked V18 CNA if she could please get her husband up in his wheelchair so he could eat the food she brought. V18 CNA told her, no he was resting. If she got him up then she would have to put him back to bed and she didn't want to do that. The situation escalated from there. She was arguing and blabbing to everyone. V24 told her she needed to stop, she was being rude. The PM supervisor finally came and told her, she heard what happened and she would get R14 up out of bed. R14 got out of bed and they went to the dining room. She was sitting with her husband at a table while he was eating the food she brought. V18 CNA was also sitting at some chairs in the dining room, talking on the phone. She gets up and goes through the staircase doors and comes back with a lady she had never seen. It was V18's mother. V18's mother was being very aggressive with her and yelling at her not to disrespect her daughter like that. V18 and her mother left and that was the end of the episode. On 8/6/25 at 11:23 AM, V18 CNA stated, R14 refused to eat dinner and the nurse told her to lay R14 down. A while later she was coming out of R41's room (across the hall from R14) when V24 asked if she could get R14 out of bed so she could give him some food she brought. V18 told her just a minute and wanted to talk with V17 Registered Nurse (RN) first. V24 started calling her a b**ch and saying she works for her so she should do what she says. She stated, V17 RN was of no help so she started calling V2 Director of Nursing (DON) and she didn't answer. She felt like no one cared or was helping her. She called her mom and her mom came to the facility. Her mom was talking with V24 and then they left. On 8/6/25 at 1135 AM, V20 CNA stated she was orienting on 8/3/25 and was there for the incident with R14, V24 and V18 CNA. She was sitting in the dining room watching the residents when V24 came in and went straight down to R14's room. She heard V18 CNA come down to talk with V17 RN. V24 was behind her saying, I asked you something and V18 CNA said, I said just a minute and they started arguing. V24 was calling V18 a b**ch and stupid. V18 said, don't call me a b**ch, your a b**ch. V17 RN was just letting them argue and not saying anything, so she got up and went over telling them to stop arguing and yelling at each other. V24 said, she just wanted her husband up and V18 CNA said then someone else can get him up, she wasn't. She told V18 CNA, that she would help get the husband up. They walked down to R14's room to get him up. R14 started calling V18 CNA a b**ch saying he didn't want her to get him up. She told V18 CNA to just leave and give him some space. So they left the room. The supervisor ended up getting him up out of bed. After that, V18 CNA called her mom and her mom did come to the facility. R14 and V24 were in the dining room when V18's mom came. The mom started yelling and arguing with V24 telling her not to disrespect her daughter like that. R14 keep saying, don't talk to my wife like that, stop talking to my wife like that. V18 CNA and V24 were both cursing at each other, in the hallway by residents' rooms. All of the residents room doors were open. She stated, if she could hear it then so could the other residents plus there were other residents up in the dining room. On 8/6/25 at 12:03 PM, V17 RN stated, V18 CNA had reported to her that R14 refused to eat dinner and she was laying him down. V24 had come around 6:45 PM and had asked if V18 CNA would get him up. V18 CNA came up to her saying V24 wanted her to get R14 up again and she didn't want too. She told her to just get R14 up. She didn't know what happened between V18 and V24. She felt is was simple, V24 wanted him up so she said to get him up. By the time V18 called her mom, she was already gone and never saw the mom come. On 8/6/25 at 9:47 AM, V1 Administrator stated, they were aware of the situation with V18 and V24. Basically, V18 CNA refused to get R14 up for V24. They were arguing when V18 CNA let an unauthorized visitor in the facility to argue with V24. He identified this as a customer service issue and V18 CNA has since been terminated. The facility's abuse prevention and reporting-Illinois dated 11/28/16 shows, Guidelines: The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents Definitions: Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidations, or punishment with resulting physical harm, pain, or mental anguish to a resident. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish Mental and Verbal abuse: Mental abuse is the use verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples of mental or verbal abuse include, but are not limited to: harassing a resident; mocking, insulting, ridiculing; Yelling or hovering over a resident, with the intent to intimidate; Threatening residents, including but limited to, depriving a resident of care or withholding a resident for contact with family and friends; and Isolating a resident from social interaction or activities.

Based on observation interview and record review the facility failed to ensure transportation was arranged for a resident to a Urology appointment and failed to ensure a daily weight was performed. This failure applies to 2 of 2 residents (R30, R8) reviewed for care and services in the sample of 62.The findings include:1. R30's facility assessment dated [DATE] show R30 has a BIMS of 15-no cognitive impairment. On 8/04/2025 at 10 am during the initial tour, R30 said he was supposed to see his Urologist today, but his appointment had to be cancelled due to no one arranged his transportation. R30 said he is worried; he'd been going to the bathroom often to urinate like every 2 hours now he needs to see his urologist. R30's Physician Order Sheet with an order date of 5/25 show 3 month follow up for Urology. R30's Urology notes dated 5/19/25 show, R30 history of BPH, complaining of voiding every 2 hours unable to sleep, does not drink much water due to urinary frequency, years ago had guided prostate artery embolization. Will start with new medications for (overactive bladder) and to be seen for follow up for 3 months. On 1:39 PM, (V7) Sub Acute Manager said R30 saw the Urologist last 5/19/25 to check R30's prostate level. R30 was to follow up in 3 months scheduled yesterday 8/4/25. R30 missed his appointment because the nurses did not make sure transportation was arranged. V7 said it has been rescheduled for 8/11/25. V7 said follow up appointments are important for continuity of care and manage conditions as needed. 2. 08/04/2025 10:26 AM, R8 was sitting up in her wheelchair in the dining room participating in activities. R8's Medication Administration Record (MAR) for July 2025 shows and order dated 4/24/25 Daily weight (order in the MAR) Notify MD/NP if resident has a weight gain of 3lbs in a day or 5lbs in a week. every day shift for CHF Program. This same MAR has weights only listed for July 5, 10-12, 17, 21, 24, 30-31 (9 days out of 31 days in the month of July). R8's Weights and Vitals Summary for July shows additional weights charted for July 2, 6, and 7th that were not included in the MAR for a total of 12 out of 31 weights taken for the month of July 2025. R8's Nutrition Progress Note dated 7/30/25 shows Significant weight gain of 5.3% x 2 weeks. At risk for weight shift due to diuretic use. Noted several weight shifts this month. On 08/05/2025 at 10:53 AM, V3 Registered Nurse said daily weights are done to monitor for weight gain that could be fluid related. On 08/06/2025 at 9:22 AM, V2 Director of Nursing said daily weights are to be done as ordered.

Based on observation, interview and record review the facility failed to ensure residents were transferred in a safe manner to 2 of 62 residents (R9, R42) reviewed for safety in the sample of 62. The findings include:1.R9's face sheet printed on 8/4/25 show R9 has diagnoses that include hemiplegia affecting right dominant side, multiple sclerosis, renal failure and bladder mass.R9's facility assessment show R9 has no cognitive impairment.R9's progress notes dated 7/18/2025 timed at 4:20 PM, documents, resident (R9) was transferring from wheelchair to bed with two staff assist using stand lift machine when her legs started to give out, resident said she has right leg pain and cannot stand longer in the machine, so resident was lowered to the floor by staff. Resident eased to lie down on the floor with pillow underneath her head, resident wanted to go back to bed so staff transferred resident to bed using (Mechanical lift machine). NP was notified with orders to administer PRN pain medication and if pain persists order an X-ray follow up assessment, resident said she's fine, no new complaints of pain were reported.On 8/5/2025 at 11 AM, R9 was in bed alert and pleasant. R9 said when she was being transferred from her chair to go to bed, her knees gave out. R9 said she had pain after it happened, then the pain was on and off. On 8/6/25 at 3:30 PM, V22 (R9's daughter) said R9's knees buckled, she was not able to hold unto the lift machine.On 8/4/25 at 12:38 PM, V24 (Certified Nursing Assistant-CNA) said he was R9's CNA. It was around 4PM last 7/18/25, R9 was being transferred from her wheelchair to bed via the mechanical stand lift machine. After the safety straps were applied, it was noted that R9's right side was not working well, her right hand was weak she had a stroke, she was only able to hold unto the handle using her left hand. As R9 was being raised to standing position, she leaned towards her right side, she was not able to stand. V24 said he pulled R9 from the chair to a standing position. R9 made a loud sound like she was in pain while her knees buckled with her legs spread out. V24 said he asked the other CNA to get help. The Nurse was passing meds just outside R9's room, the nurse came and R9 was lowered to the floor.On 8/5/25 at 10:10 AM, V11 (CNA) said it was her second day on the job. This was her first job as a CNA. On 7/18/25, she was working with CNA (V24) who was showing her around and observing how things were being done. R9 was being transferred to bed using the stand lift machine. V11 said she assisted V24 to place R9's foot in the sit to stand. V11 said she then stayed behind the wheelchair to observe how R9 was being transferred in the stand lift machine. V24 transferred R9 by himself As R9 was being lifted with the stand lift, she noticed R9 was no longer in the machine and all of a sudden all of R9's weight came down, R9 was so closed to the ground, V11 said she went to get help, as V24 was holding unto R9. The Nurse (V10) was just outside the room, V10 came in and assisted to lower R9 to the floor. On 8/4/25 at 1PM, V10 (License Practical Nurse-LPN) said she was passing evening meds, she was called to R9's room, R9 was hanging on the sit to stand, her legs buckled. V10 said R9's left hand was able to hold unto the stand lift but R9's right hand was weak, her right arm cannot hold on, that made her buckled. R9 was lowered down to the floor. V10 said she put pillows on the floor to cushion R9's head. R9 was complaining of pain to right leg. Unable to assess full range of motion because it was limited due to foot drop and MS. (R9's baseline) V10 said she notified the NP. (V12)On 8/5/25 at 11:05 AM, V12 (Nurse Practitioner) said she was notified that while R9 was being transferred to bed via stand lift, her legs buckled outwards, she was lowered to the ground she did not fall. V12 said she was surprised when she was told R9 was being transferred via seat to stand instead of a mechanical lift. R9 has MS, foot drop right sided weakness. Mechanical lift would have been safer for R9.On 8/5/25 at 9:25 AM, V13 (Physical Therapist) said she assessed R9 for a stand lift transfer. Due to R9's right sided weakness, two staff need to assist R9. One staff should be in the R9's right-sided weakness assisting in the hand placement of the right hand (weak side) and the other staff to maneuver the machine, this ensures R9's safety during the transfer.On 8/6/25 at 1PM, V2 (Director of Nursing) said R9 was now on mechanical lift on all transfers.2. R42's Physician Order Sheet POS dated 7/25 show R42 has diagnoses that include hemiplegia and hemiparesis due to cerebral infarction (stroke) affecting her left dominant side. On 8/4/2025 at 2:05 pm, V14 and V15 both Certified Nursing Assistants- (CNAs) transferred R42 from wheelchair via mechanical stand lift machine to be toileted. After the safety sling was applied, R42 was instructed to hold unto the stand lift handle. R42 was able to hold unto the right handle with a tight grip using her right hand. R42 was not able to lift her left hand to hold unto the left handle. R42's left hand was hanging in her left side R42 was not able to lift her left hand. R42 complained of discomfort to left armpits as it rubbed in the sling. V15 applied a washcloth as a cushion under both armpits. R2 was then transferred to the bathroom with V14 maneuvering the sit to stand machine. V15 was behind R42 holding unto R42's pants. R42 was leaning to her left side with her left hand hanging to her side. When R42 was done using the bathroom, R42 was again placed in the stand lift machine to her wheelchair with R42 in the stand lift with right hand holding in the handle and left hand hanging in her side. On 8/5/25 at 9:25 AM, V13 (Physical Therapist) said when using stand lift machine to a resident with weakness due to stroke, there should be 2 staff assisting the resident. One staff assisting the resident assisting the weak side and other staff guiding the machine for resident's safety.

Based on observation, interview, and record review the facility failed to ensure a resident received their prescribed tube feeding for 1 of 2 residents (R105) reviewed for tube feeding in the sample of 62. The findings include: On 08/04/2025 at 10:29 AM, R105 was in bed. R105 was connected to a tube feeding that was infusing. The tube feeding being infused was jevity 1.5 calories. R105's Order Summary Report printed on 8/4/25 showed an order for jevity 1.2 calories. The order had a start date of 7/20/25. On 08/04/25 at 1:10 PM, V3 (Registered Nurse) confirmed R105 had jevity 1.5 calories infusing. V3 said the facility did carry jevity 1.2 calories. On 08/05/2025 at 10:53 AM, V3 said yesterday (8/4/25) R105 had the wrong tube feeding infusing. On 08/05/2025 at 1:36 PM, V4 (Registered Dietitian) said the expectation was for the resident to receive the ordered tube feeding. R105's Care plan (undated) showed R105 had a nutritional problem or potential related to the need for a tube feeding. Listed under interventions was provide tube feeding as ordered. The facility's Enteral Nutrition (EN) - Tube Feeding policy dated 2020 showed monitoring of the individual with tube feeding is an interdisciplinary team effort an includes ensuring the tube feeding is being delivered as ordered by the physician.

Based on observation, interview and record review the facility failed to have behavioral interventions in place for a resident with a diagnosis of dementia. This applies to 1 of 2 residents (R41) reviewed for dementia in the sample of 62. The findings include:R41's face sheet shows she was admitted on 716/25 for physical therapy after a fall sustaining a fractured femur. Her diagnoses include: severe dementia, degenerative disease of the nervous system and anxiety disorder. Her face sheet does not list her primary language, however R41 primarily spoke in Spanish. On 8/4/25 at 9:35 AM, R41 was sitting up in her wheelchair in the dining room. She would intermittently yell stupid and her own name in Spanish. She would also, clap and act frustrated for a few seconds. She also constantly fidgets by rubbing her hands through her hair and pulling the sleeves up on her long sleeve shirt. On 8/4/25 at 10:32 AM, V19 R79's daughter was in the dining room talking with R63. She stated, R41 yells all the time. She never stops. The staff just let her yell. There is nothing they can do. R63 stated, R41 was her room mate and she hasn't slept in 2 days because R41 just yells all night long. On 8/5/25 at 9:16 AM, R41 was in her room yelling the same things (stupid and her own name) as she was doing the day before (8/4/25). Occupational therapy got R41 out of bed and put her in the dining room. She was still yelling and fidgeting with her hair and arms. At 11:50 AM, R41 was eating lunch. No one was helping her eat. She was feeding herself (using her hands) so fast that her cheeks were puffed out. Her lunch tray consisted of country fried steak, mashed potatoes with gravy and coleslaw. She had mashed potatoes and coleslaw all over her hands. She would randomly rub her hands through her hair and fidget with her arms. Every time R41 was observed on the locked memory care unit she was yelling and fidgeting with her hair and arms. The only thing the staff did to help her was give her a baby doll. Otherwise the staff continued with their work. Residents were observed being upset by R41 yelling all the time. R41's care plan on 8/4/25 & 8/5/25 did not show that R41 had a diagnosis of dementia or any behaviors of yelling/fidgeting. On 8/6/25 the facility presented a care plan for R41 dated 8/5/25 showing, Resident exhibits episodes of agitation characterized by screaming and yelling, which may be triggered by unmet needs, confusion, or environmental stressors. I have a behavior problem. When confused or agitated, I may shout out random words and clap my hands. Interventions listed include: Play her favorite Mexican music and videos on I-pad, provide comfort toys to include baby doll and stress therapy strawberry plush. Take her on a walk and talk about pleasant things that she enjoys doing. On 8/5/25 at 11:29 AM, V17 Registered Nurse (RN) stated, she has had these behaviors since admission. She doesn't have any medications to give her because she already has medications scheduled. They just bring her out to the dining room. On 8/6/25 at 9:47 AM at V5 VP of Operations confirmed the facility didn't have any interventions in place for R41 until the concerns were brought up during the survey process.

Based on observation, interview, and record review the facility failed to ensure mechanical soft foods were served to a resident on a mechanical soft diet for 1 of 1 resident (R17) reviewed for mechanical soft diets in the sample of 62. The findings include:On 8/4/25 at 12:02 PM, R17 was sitting at the dining room table for lunch. V25 (R17's Daughter) was sitting with R17 and assisting R17 to eat. R17 was feeding herself with some assist to put food on fork and move food items within reach. R17 had a cup of fresh fruit including watermelon and cantaloupe with her meal. V25 said R17 is supposed to have a mechanical soft diet, she is not supposed to have this cantaloupe. R17 attempted to chew the cantaloupe and unable to, then spit the melon out. V25 said R17 was supposed to get sliced bananas and pointed to R17's meal ticket. R17's Lunch-Day 23, 8/4/25 meal ticket shows texture mechanical soft with sliced banana listed for dessert. On 8/4/25 at 2:09 PM, V26 Director of Therapy/Speech said hard/unripe cantaloupe would not be considered mechanical soft fruit. The facility's Diet Spreadsheet for Week 4 for Day 23 the Mechanical Soft Ground Meats Diet Lunch meal dessert is sliced banana.

Based on observation, interview, and record review the facility failed to implement enhanced barrier precautions (EBP) for residents with urinary catheters and pressure injuries for 3 of 62 residents (R2, R3, and R56) reviewed for infection control in the sample of 62.The findings include: On 08/05/2025 at 9:14 AM, R2 was in bed reading. R2 had a urinary collection bag hanging from the bed frame. R2 said she has a urinary catheter, a nephrostomy catheter and an ileostomy. On 8/04/2025 at 9:53 AM, R3 was sleeping in bed on an air mattress and had heel protection boots on. On 08/05/2025 at 10:48 AM, R56 was sitting up in her wheelchair in her room. R56 said she has a sore on her right heel that has been there for a while and she used to have one on her bottom but that is now healed. R56 said they do dressing changes for her heel sore and she was on antibiotics for it at one time.R2, R3 and R56 did not have isolation signs on their doors.The facility's Wound Report dated 8/3/25 shows R3 has a right heel pressure wound and R56 has left and right heel pressure wounds.R2's Physician Orders for July 2025 shows left percutaneous nephrostomy tube. Monitor output every shift and change urostomy bag every 4 days as needed.On 08/06/2025 at 9:33 AM, V15 Infection Control Nurse said R2 should be on EBP. V15 said R2 and R4's wounds are chronic pressure wounds that are open, have daily dressing changes, and are not colonized with any MDRO. The facility's Enhanced Barrier Precaution (EBP) Policy dated 5/7/24 shows EBP are indicated for residents with any of the following: Chronic wounds and/or indwelling medical devices.

Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care for residents who required staff assistance for toileting, repositioning, and bathing. This applies to 16 of 16 residents (R1-R16) reviwed for ADL (Activities of Daily Living) care in a sample of 16. The findings include: 1. Face sheet, dated 3/18/25, shows R3's diagnoses include senile degeneration of brain, Alzheimer's disease, bipolar disorder, history of seizures, depression, psychosis, and anxiety. MDS (Minimum Data Set), dated 1/7/25, shows R3 was severely impaired and required substantial assistance from staff for toileting. The MDS showed R3 was always incontinent of bowel and bladder. Bowel and bladder incontinence care plan, initiated 2/17/25, shows R3 was unable to make her needs known and needed assistance with toileting. The care plan shows R3's approaches include checking R3 every two hours and assisting with toileting her as needed. Advanced Practice Registered Nurse progress note, dated 2/18/25, shows R3 was recently treated for a urinary tract infection. On 3/18/25 at 10:11 AM, V5 (Restorative Aide) stated R3 required two staff for transfers and R3 would have her incontinence brief checked and changed after lunch. On 3/18/25 during continuous observation in the multipurpose room between 10:00 AM and 1:05 PM , R3 sat in the dementia unit multipurpose room in her wheelchair without her incontinence brief being checked/changed and without being repositioned. At 1:05 PM R3 was taken to her room by V7 (CNA-Certified Nursing Assistant) to have her incontinence brief changed and be placed in bed. V7 stated R3's incontinence brief was not wet but had a smear of bowel movement in the brief. On 3/18/25 at 1:10 PM, V5 stated the last time R3 had her incontinence brief checked/changed was when she got her up and out of bed at approximately 9:45-10:00 AM. On 3/18/25 at 1:05 AM, V7 (CNA-Certified Nursing Assistant) stated she had not checked/changed R3's incontinence brief during her shift that day. On 3/18/25 at 2:00 PM, V5 (Restorative Aide) stated all incontinent residents were to be checked and changed every two hours. V5 stated if residents can not communicate if they wanted to go to the bathroom and were incontinent, the staff were to take them to their room and have their briefs checked/changed. V5 stated staff were expected to reposition residents every two hours or more often. On 3/18/25, V2 (Director of Nursing) stated incontinent residents were to have their incontinence briefs checked and changed every two hours. V2 stated residents were also to be repositioned every two hours. Facility Incontinence Care Policy, revised 1/16/18, shows the purpose of the policy was to prevent excoriation and skin breakdown, discomfort, and maintain dignity. The policy guidelines show incontinent residents will be checked periodically in accordance with the assessed incontinent episodes or every two hours and provided perineal and genital care after each episode. 2. Face sheet, dated 3/18/25, shows R4's diagnoses included dementia and anxiety. MDS, dated [DATE], shows R4's cognition was severely impaired, R4 was dependent on staff for toileting, and R4 was frequently incontinent of bowel and bladder. R4's care plans show R4 required a mechanical lift and two staff for transfers and two staff for assistance with incontinence brief checks/changes. The care plan shows R4 was to be kept clean and dry and was to be repositioned every two hours. On 3/18/25 during continuous observation in the multipurpose room between 10:00 AM and 12:23 PM, R4 sat in her wheelchair in the multipurpose room with no repositioning and no staff checked/changed her incontinence brief. On 3/18/25 at 12:23 PM, V7 (CNA) stated she was assigned to R4 as her CNA and last toileted R4 when she got her up when she got R4 up for breakfast some time prior to 9:00 AM. V7 checked/changed R4's incontinence brief and stated the brief was not wet with urine but R4 had had a bowel movement. 3. Face sheet, dated 3/18/25, shows R2's diagnoses included fractured left femur, dementia, protein-calorie malnutrition, depression, and lack of coordination. MDS, dated [DATE], shows R2 was severely cognitively impaired, was dependent on staff for toileting, and R2 was occasionally incontinent of urine and frequently incontinent of bowel. R2's care plan, dated 3/11/25, shows R2 was dependent on two staff for transfers and incontinence brief checks and changes. R2's care plan, dated 3/10/25, shows R2 had a pressure injury to her right him related to immobility. On 3/18/25 during continuous observation in the multipurpose room, R2 sat in her wheelchair from 10:00 AM to 10:31 AM when she was taken to therapy. At 11:02 AM, R2 was returned to the multipurpose room from therapy and V11 (Occupational Therapist) stated R2 was not toileted while in therapy. Between 11:08 AM and 11:14 AM R2 was removed briefly from the multipurpose room and returned without toileting. R2 continued to sit in her wheelchair in the multipurpose room from 11:14 AM to 12:42 PM when she was taken to her room by V7 for incontinence brief check/change and to be placed in bed. V7 stated R2's brief was dry when it was changed. On 3/18/25 at 12:42 PM, V7 stated R2 was assigned to V7 and V7 had not checked/changed R2's incontinence brief since before 9:00 AM. 4. Face sheet, dated 3/18/25, shows R1's diagnoses included dementia, morbid obesity, depression, and anxiety. MDS, dated [DATE], shows R1's cognition was moderately impaired, R1 required substantial/maximum assistance with toileting, and was always incontinent of bowel and bladder. Care plan, revised on 4/4/24, shows R1 required one staff to assist resident with incontinence brief check and changes. On 3/17/25 at 1:14 PM, V10 (Family) stated when she arrived to visit R1, R1 was in a soiled incontinence brief. V10 stated after visiting for 2.5 hours, no staff came to check/change R1's incontinence brief. V10 stated she checked R1's incontinence brief and it was soiled so she put the call light on for staff to come change the brief. V10 stated the prior week she arrived to visit R1 and R1's incontinence brief was so soiled it soaked through her clothes and through her bed linens. Review of R1's weekly skin observations and skin condition assessments, dated 2/25/25 to 3/11/25, show R1's sacrum was reported to have blanchable redness with skin intact as well as a fungal rash on her bilateral inner buttocks. On 3/18/25 at 1:39 PM, V9 (Wound Nurse) stated R1 has on and off fungal rashes on her buttocks. V9 stated R1 has chronic loose bowel movements that irritate her skin. V9 state R1's skin never opens and R1 is treated with antifungal powder and zinc ointment. 5. Grievance, dated 12/17/25, shows a concern was expressed that staff were very slow and not responding to R6's request for assistance. The grievance shows R6 waited 45 to 60 minutes for staff to respond to her request for assistance. Grievance, dated 1/20/25, shows R7 was found by family to be soaked through his incontinence brief and did not get any assistance feeding him lunch. The family reported that the resident did not get assistance with feeding at lunch a day they visited a week prior. The family expressed ongoing concerns regarding lack of assistance which was the reason the family visited often. The resolution showed a staff was assigned to provide feeding assistance and education was provided to the CNA about rounding and checking on residents with cognitive impairment. Grievance, dated 1/20/25, shows on 1/18/25 the family of R8 was requesting her incontinence brief to be changed and reported overhearing a CNA state that the resident had an upcoming shower on the 3/11 shift and would have her incontinence brief changed at that time. Grievance, dated 1/21/25, shows the family of R9 expressed concern that no CNA came in overnight to check and change the resident's incontinence brief. Grievance, dated 1/22/25, shows the family of R10 reported the resident was in need of an incontinence brief change. Grievance, dated 2/2/25, shows the family of R11 placed R11's call light on to use the bathroom and the daughter came out of the room twice to see if assistance was coming. The grievance shows the daughter spoke to staff who asked if she needed something and the family reported the resident needed to use the bathroom. The grievance shows the family was told the resident could walk to the toilet. Grievance resolution shows the resident requires one staff to transfer her while toileting and education was provided to staff. Grievance, dated 2/3/25, shows R12 expressed concern that he was experiencing long wait times at night for assistance toileting and that staff were not rounding overnight. The grievance resolution shows the resident required assistance with transfers and toileting. Grievance, dated 2/15/25, shows the family of R13 arrived to visit the resident on 2/14/25 at approximately noon and the resident was still in bed with her gown on and not up, dressed and out of bed. The grievance shows when the family asked for assistance to get the resident dressed and out of bed, staff responded they would not be able to assist until after lunch trays were finished. The grievance resolution shows the staff had a slow start due to staffing delays. Grievance, dated 3/6/25, shows the family of R14 visited the resident and found her with her incontinence brief overflowing with feces and R14 was attempting to clean herself with wipes and tissues she had available at the bedside. The family also expressed concerns that the resident was still in the same clothes as the day prior at 1:30 PM the following day. Grievance, dated 3/7/25, shows family expressed concerns that R15 did not receive a shower on his scheduled shower days. Grievance, dated 3/11/25, shows R16 expressed concern that she pressed her call light for assistance from staff to use the restroom for over 25 minutes while she heard staff talking outside the room near the nursing station. The grievance shows staff finally arrived, put R16's walker near her while sitting in a lift recliner, and told her she was in a lift recliner and could go to the bathroom herself without staff assistance. The resolution shows R16 would no longer be assigned that CNA. Resident council meeting minutes, dated 12/19/24, show a resident expressed concerns he was not getting him up early enough on the weekends. Resident council meeting minutes, dated 1/23/25, show that families of residents stated the CNAs have to wait to use the facility mechanical lift because it is in use and there are delays in resident care. Resident council meeting minutes, dated 2/20/25, show a request for the facility to purchase an additional mechanical lift, a resident reported that her roommate was left on the toilet for over 30 minutes, and multiple residents stated the CNA response time to call lights could improve.

Based on interview and record review, the facility failed to ensure a resident was promptly assessed for injury following an incident during transfer with the mechanical lift machine. This applies to 1 of 3 residents (R1) reviewed for assessment, in the sample of 7. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] and was discharged to the local hospital on September 6, 2024. R1 did not return to the facility. R1 had multiple diagnoses including drug-induced polyneuropathy, sepsis, left food drop, metabolic acidosis, hemorrhage, UTI (Urinary Tract Infection), acute kidney failure, colon cancer, abnormal posture, history of falling, cardiac arrhythmia, anemia, and atrial fibrillation. R1's MDS (Minimum Data Set) dated June 25, 2024 shows R1 was cognitively intact, required supervision with eating, oral and personal hygiene, substantial/maximal assistance with bed mobility, and was dependent on facility staff for all other ADLs (Activities of Daily Living), including transfers between surfaces. R1 was always incontinent of bowel and bladder. The facility's incident report dated September 5, 2024 shows R1 Suffered abrasion and redness in his left arm. V7 (CNA-Certified Nursing Assistant) documented R1's statement: Per resident he was being transferred using stand lift from wheelchair to bed. When he could not feel the bed behind him and thought he would fall, that is why he just let go of the machine. The facility's incident report does not have documentation to show R1 was assessed for pain, range of motion, vital signs, or injury following the incident involving the sit-to-stand mechanical lift device. On September 5, 2024 at 6:46 PM, V4 (LPN-Licensed Practical Nurse) documented, Resident suffered abrasion and redness in his left arm. Seen by treatment nurse and nurse on duty. Applied A&D to affected areas. V4 did not document an assessment of R1, including vital signs, the range of motion of R1's right and left arms, or R1's pain level. V4 did not document notifying R1's physician or family member. On September 5, 2024 at 4:45 PM, V3 (WCN-Wound Care Nurse) documented, Seen resident with bruises and redness on the left arm and A&D ointment applied. NOD (Nurse on Duty) and ADON (Assistant Director of Nursing) aware. V3 did not document the appearance of R1's left arm, including area of redness or bruising, or the size of the bruises. V3 did not document R1's pain level. On February 18, 2025 at 1:53 PM, V7 (CNA) said, I wrote a report and gave it to my supervisor. I was training another CNA (V6). [R1] wanted a shower. He did not want a bed bath. We transferred him to the shower chair next to his bed. We used the sit-to-stand lift. When we finished, we went back to the room, and I told him to hold onto the lift. I told the other CNA where to hook the sling for the sit-to-stand, and when he was standing, she was able to guide him to the bedside, and he was screaming he wanted us to go faster. He let go of the handles, and the sling from the lift was hitting his arm by his intravenous line on his arm. He got really angry, and he said his arm hurt. He was saying his arm hurt a lot. He was literally about six inches above the mattress when [R1] let go of the sit-to-stand handles and his butt just lowered the six inches to the mattress. He never fell . I notified the nurse. On February 18, 2025 at 1:40 PM, V4 (LPN) said, [R1] let go of the sit-to-stand during transfer. He did not fall. I did not assess his pain or skin. I asked the wound care nurse to do that. On February 19, 2025 at 10:23 AM, V3 (WCN) said, I remember the resident. His skin was intact. I put A&D ointment on it for protection. I don't remember much about it. I was only there to look at his skin. I did not assess his pain or range of motion. On February 19, 2025 at 8:52 AM, V2 (DON-Director of Nursing) said the facility does not have documentation to show R1 was assessed following the incident on September 5, 2024 involving the sit-to-stand mechanical lift. V2 continued to say if the resident was complaining of extreme pain, the resident should have been assessed, including vital signs, range of motion, and level of pain. On September 6, 2024 at 6:09 PM, V26 (NP-Nurse Practitioner) documented, [R1] seen and examined. Patient seen lying in bed with left arm swelling, erythema, and warmth to touch. Patient with limited ROM (Range of Motion) and inability to straighten elbow and is in severe pain during physical assessment. Doppler and X-ray orders sent to NOD. [V8] (Spouse of R1) came to my office later in the day asking about ultrasound and room status. Directed to social services or admission for room concerns, NOD check on STAT orders for doppler ultrasound and X-ray. Later in the day, DON contacted me reporting testing was not yet completed and patient's wife requesting to send patient out for quicker evaluation and results. Agreed to sent patient out to ED. V23's (RN) SBAR (Situation, Background, Appearance, Review and Notify) Communication Form dated September 6, 2024: Upon greeting patient in AM, noticed that left forearm is bruised and swollen and area directly under PICC (Peripherally Inserted Central Catheter) line is reddened. Forearm is warm to touch and patient having difficulty moving arm. The form continues to show V8 (Spouse of R1) was notified on September 6, 2024 at 11:00 AM. On February 19, 2025 at 11:19 AM, V23 (RN) said, I was not in the facility on the day of the incident (September 5, 2024). When I went in to see him on September 6, I noticed his left arm was swollen. It was swollen from the elbow down. The dressing on his midline catheter was intact. [R1] said he had a fall, and he was telling me it was hurting and sore, and when I touched the arm, his arm felt boggy, and I told him I would have the nurse practitioner look at it. I put in STAT orders from the nurse practitioner for a left arm X-ray and venous doppler. When [V8] (Spouse of R1) came in, I updated her and told her about the orders and told her the nurse practitioner saw [R1]. When the resident told me he was in pain, I offered morphine, and he declined. He left the facility around dinnertime. I never saw any open skin on his arm. Hospital records show R1 had an ultrasound venous doppler of his left arm on September 6, 2024. The results showed: Conclusion: 1. Left upper extremity DVT (Deep Vein Thrombosis) with occlusive axillary vein thrombus possibly extending into junction with one of the brachial veins in the proximal arm. Left forearm X-rays completed at the hospital on September 6, 2024 were negative for acute fracture or subluxation. On February 20, 2025 at 10:43 AM, V19 (Physician) said facility staff should assess a resident following an incident where the resident complains of extreme pain. The facility's policy entitled Accidents and Incidents - Investigating and Reporting revised September 2021 shows: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation: 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); .g. The time the injured person's attending physician was notified, as well as the time the physician responded and his or her instructions; h. the date/time the injured person's family was notified and by whom; i. the condition of the injured person, including his vital signs .

Based on interview and record review, the facility failed to ensure a resident's leaking indwelling urinary catheter was changed in a timely manner, and a resident's indwelling urinary catheter was changed monthly as documented by the physician. This applies to 2 of 3 residents (R2, R4) reviewed for indwelling urinary catheters in the sample of 7. The findings include: 1. The EMR (Electronic Medical Record) shows R2 was admitted to the facility on [DATE]. The EMR continues to show R2 was sent to the local hospital on December 24, 2024 and returned to the facility on [DATE]. R2 has multiple diagnoses including, cellulitis of the left and right lower limbs, heart failure, chronic kidney disease, acute kidney failure, COPD (Chronic Obstructive Pulmonary Disease), lack of coordination, unstageable pressure ulcer of the sacral region, nicotine dependence, unsteadiness on feet, morbid obesity, and PVD (Peripheral Vascular Disease). R2's MDS (Minimum Data Set) dated January 9, 2025 shows R2 is cognitively intact, requires supervision with eating, partial/moderate assistance with oral hygiene, and is dependent on facility staff for all other ADLs (Activities of Daily Living). R2's MDS continues to show R2 has an indwelling urinary catheter and is always incontinent of stool. The MDS continues to show R2 had one unstageable pressure ulcer present on admission to the facility. Facility documentation dated February 19, 2025 shows R2 has an unstageable pressure ulcer of the sacrum that was present on admission to the facility. R2's pressure ulcer measurements on February 19, 2025 were 9.0 cm. (centimeters) long by 8.0 cm. wide, by 2.5 cm. deep. On February 18, 2025 at 10:18 AM, R2 was lying in bed, on a low air loss mattress. The mattress was fully inflated. R2 had an indwelling urinary catheter with clear, yellow urine draining into the collection bag. R2 said several weeks ago, she experienced an entire day where her indwelling urinary catheter was leaking, and she felt she was soaking wet while lying in bed. R2 said she asked multiple staff members to check and change the catheter, but no staff addressed her concerns. On January 31, 2025 at 7:32 AM, V22 (RN-Registered Nurse) documented, At the end of shift, CNA (Certified Nursing Assistant) reported resident's [indwelling urinary catheter] was leaking, during report to oncoming nurse, writer informed nurse regarding [indwelling urinary catheter], and oncoming nurse acknowledged to follow up. On January 31, 2025 at 7:00 PM, V11 (LPN-Licensed Practical Nurse) documented, Around 7:30 AM, received report from night shift nurse, patient [indwelling urinary catheter] was leaking last night, it was reported by the staff CNA. Around 8:00 AM, nurse did rounds, noticed patient was a sleep. Around 8:30 AM, informed to the morning staff CNA to let me know if the patient is wet, the CNA stated She is passing morning breakfast, after she is done, she will check on the patient. 9:30 AM the CNA went to resident room to change the patient, noticed patient was on the phone talking to family. Around 9:40 AM, the CNA insisted to change patient briefs, patient refused. 10:40 AM, patient family POA (Power of Attorney) came, she was yelling to the staff nurse. The nurse tried to explain to the POA, the POA was over talking, Stating give me a [profanity] time, she was threatening saying I am going to call the police, she is going call the lawyer. On February 18, 2025 at 1:07 PM, V11 (LPN) said, I remember the catheter situation with [R2]. I received report in the morning around 7:15 AM from the night shift that the resident's indwelling urinary catheter needed to be observed by the nurse because the CNA said it was leaking. What the nurse told me was I needed to go and check on her. I finished report and then did the narcotic count. I went to check on her and she was asleep. I came out and I told my CNA to let me know if the catheter was leaking or not. The CNA was passing breakfast. She told me as soon as she was done passing breakfast she would go and check on her. Then the DON (Director of Nursing) sent me a message around 11:00 AM and said the catheter needed to be changed. I do not know if she was sitting in wetness from the day before. I was not aware of that. V11 said she did not change R2's indwelling urinary catheter as requested by the DON. On February 18, 2025 at 3:23 PM, V2 (DON) said on February 1, 2025 she was told R2 was having problems with her indwelling urinary catheter and gave directions to staff to change out the catheter. V2 said, I said, please change it out. I got an okay from [V11] (LPN), and then she told me she did not change it out. Then I was notified by [V13] (Daughter/POA of R2) that it still had not been changed out. I had to send someone else to change it. It was a considerable amount of time before it was changed. I expect the staff to follow my direction the first time. It sounds like [R2] had a lot of sediment in the tubing, and the night nurse flushed it, and she thought it was working. On February 19, 2025 at 9:19 AM, V13 (Daughter/POA of R2) said, The incident with the leaking catheter happened on January 31, 2025. I had to literally talk to [V2] (DON) before we could get something done about it. It took until the next day to get the catheter situation taken care of. In the meantime, she sat in a soaking wet bed with her huge pressure ulcer sitting in all that urine. Facility documentation shows R2's indwelling urinary catheter was noted leaking in the early morning hours of January 31, 2025. Facility documentation shows R2's indwelling urinary catheter was changed on February 2, 2025 at 12:48 PM. On February 2, 2025 at 12:48 PM, V16 (LPN) documented, [V13] (Daughter/POA of R2) .Resident [indwelling urinary catheter] leaking, catheter balloon deflated. Removed 30 cc (cubic centimeters) of sterile water. [Indwelling urinary catheter] replaced by Supervisor using sterile technique, 16 French catheter inserted with urine return noted. POA made aware. 2. The EMR shows R4 was admitted to the facility on [DATE]. R4 has multiple diagnoses including, metabolic encephalopathy, acute kidney failure, urinary tract infection, heart failure, low potassium, multiple sclerosis, hemiplegia, diabetes, anxiety disorder, lack of coordination, dementia, major depressive disorder, heart failure, and hypertension. R4's MDS dated [DATE] shows R4 is cognitively intact, requires supervision with eating and oral hygiene, partial/moderate assistance with personal hygiene, substantial/maximal assistance with toilet hygiene, and is dependent on facility staff for all other ADLs (Activities of Daily Living). R4 has an indwelling urinary catheter and is always incontinent of stool. On February 19, 2025 at 10:27 AM, R4 was lying in bed in her room. R4 had an indwelling urinary catheter in place draining clear, yellow urine into a collection bag. R4 said she has had multiple UTIs (Urinary Tract Infections). The EMR shows the following order dated October 27, 2024: Insert [indwelling urinary catheter]. Facility documentation shows R4 had multiple urine cultures with results indicating urinary tract infections with multiple organisms, including urine cultures dated November 4, 2024, December 19, 2024, and January 7, 2025. Facility documentation shows R4 was hospitalized from November 22, 2024 to November 29, 2024 due to UTI and altered mental status. On November 18, 2024 V19 (Physician) documented, Patient seen and examined for recurrent UTI, ESBL (Extended Spectrum Beta-Lactamases) UTI, mental status changes, diabetes mellitus type 2, history of CHF (Congestive Heart Failure), restless leg syndrome. Patient seen examined seems stable, seems to be doing well, no current complaints, tolerating medications, has completed the nitrofurantoin (antibiotic), and prophylactic antibiotics have been resumed. She continues with [indwelling urinary catheter] and we did discuss exchanging the catheter on a monthly basis. She seems to be tolerating this well . On December 12, 2024, V19 (Physician) documented, Bladder: Continue with [indwelling urinary catheter] and, exchanges monthly. On December 24, 2024, V19 (Physician) documented, Bladder: Continue with [indwelling urinary catheter] and, exchanges monthly. On December 26, 2024, V19 (Physician) documented, History of multiple sclerosis with neurogenic bladder: Continue with [indwelling urinary catheter] and, exchanges monthly, due this week. On December 30, 2024, V19 (Physician) documented, Patient seems stable, doing well. [Indwelling urinary catheter] has not been exchanged, we did discuss this with the nursing staff, they verbalized understanding. History of multiple sclerosis with neurogenic bladder: Continue with [indwelling urinary catheter] and, exchanges monthly, due this week. On January 6, 2025, V19 (Physician) documented, History of multiple sclerosis with neurogenic bladder: Continue with [indwelling urinary catheter] and, exchanges monthly, due this week. On January 9, 2025, V19 (Physician) documented, History of multiple sclerosis with neurogenic bladder: Continue with [indwelling urinary catheter] and, exchanges monthly, due this week. On January 23, 2025, V19 (Physician) documented, History of multiple sclerosis with neurogenic bladder: Continue with [indwelling urinary catheter] and, exchanges monthly, due at the end of the month, round the 25th. On January 27, 2025, V19 (Physician) documented, History of multiple sclerosis with neurogenic bladder: Continue with [indwelling urinary catheter] and, exchanges monthly, due at the end of the month, round the 25th. On February 3, 2025, V19 (Physician) documented, History of multiple sclerosis with neurogenic bladder: Continue with [indwelling urinary catheter] and, exchanges monthly, due at the end of the month, round the 25th. On February 10, 2025, V19 (Physician) documented, History of multiple sclerosis with neurogenic bladder: Continue with [indwelling urinary catheter] and, exchanges monthly, due at the end of the month, round the 25th. On February 13 2025, V19 (Physician) documented, History of multiple sclerosis with neurogenic bladder: Continue with [indwelling urinary catheter] and, exchanges monthly, due at the end of the month, round the 25th. On February 17, 2025, V19 (Physician) documented, History of multiple sclerosis with neurogenic bladder: Continue with [indwelling urinary catheter] and, exchanges monthly, due at the end of the month, round the 25th. The facility does not have documentation to show R4's indwelling urinary catheter was changed monthly as documented in V19's (Physician) progress notes. On February 20, 2025 at 10:43 Am, V19 (Physician) said R4 has had multiple UTIs, and it was his expectation that R4's indwelling urinary catheter be changed monthly. V19 continued to say he discussed changing the indwelling urinary catheter monthly with the nursing staff. The facility's policy entitled Equipment Replacement - Disposable - Nursing revised on 1-16-18 shows: Purpose: Equipment will be changed following established schedules to prevent contamination. a. [Indwelling urinary catheter] bags are changed only if they become cloudy, leak, or have an odor. b. [Indwelling urinary catheters] are changed only for system breakdown and prn (as needed) unless physician's order specifies otherwise . The facility's policy entitled Urinary Catheter Care revised on 2-14-19 shows: 10. Urinary catheter and tubing may be removed and reinserted when any of the following are observed: a. Inability to observe urine contents in the urinary drainage bag or tubing. b. Observation of gross contamination. c. Obstruction of the catheter or tubing. d. Upon physician's orders.17. The date of the catheter insertion shall be documented in the nurse's notes and Treatment Record.

Based on observation, interview, and record review, the facility failed to ensure a resident was transferred with two people while using a mechanical lift as shown in the facility's policy. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 5. The findings include: On November 25, 2024 at 9:01 AM, R1 was sitting in the dining room in a high back wheelchair. R1 was unable to answer questions due to her cognitive status. On November 25, 2024 at 10:28 AM, R1 was transferred to her bed from the high back wheelchair using a mechanical lift. V8 (CNA-Certified Nursing Assistant) provided incontinence care to R1. As V8 removed R1's pants, a four-by-four-inch dressing was visible on R1's left shin. The date 11/24 was written on the dressing. The dressing was dry and intact. No bruising was noted. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 has multiple diagnoses including, senile brain degeneration, dementia with agitation, depressive episodes, dysphagia, hypertension, and restlessness and agitation. R1's MDS (Minimum Data Set) dated October 16, 2024 shows R1 has severe cognitive impairment, requires substantial/maximal assistance with eating, personal hygiene, and bed mobility, and is dependent on facility staff for transfers between surfaces, lower body dressing, showering, toilet hygiene, and oral hygiene. R1 is always incontinent of bowel and bladder. R1's mechanical lift care plan, initiated on March 16, 2024, and revised on May 17, 2024 shows multiple interventions. The goal of the mechanical lift transfer care plan, also initiated on March 16, 2024 shows: I will be able to transfer with the use of the [total body mechanical lift] safely from bed to chair and vice versa with 2-person assist. The following intervention was initiated on March 16, 2024: There will always be 2 staff to assist resident. One staff will control the lift as the other will guide resident and support back and neck to transfer surface. The following intervention was initiated on May 17, 2024: Updated room signage related to [total body mechanical lift] transfers x 2 assist. On November 3, 2024 at 2:59 AM, V7 (RN-Registered Nurse) documented R1 was being transferred using a total body mechanical lift by the CNA on November 2, 2024 at 9:00 PM. R1 slid out of the mechanical lift to the floor between the bed and the mechanical lift. V7 noticed a skin tear on R1's left lower extremity. R1 denied discomfort or pain, the skin tear was cleaned with normal saline, and a dressing was applied. R1 was assessed by facility staff and hospice nursing staff, and no further injuries were identified. On November 25, 2024 at 11:17 AM, V2 (DON-Director of Nursing) said, On November 2, 2024, [R1] was transferred from the chair to the bed using a [total body mechanical lift]. [V3] (Agency CNA) failed to ask another staff member to assist her. There are supposed to be two CNAs present when using a mechanical lift, but [V3] was alone. All agency staff are educated on our transfer protocols. She was trying to get [R1] back into bed as quickly as possible. There was an issue where the sling came unhooked on one side and [R1] fell from the sling onto the floor and sustained a skin tear to her shin. V2 continued to say R1 did not sustain any other injury following the fall from the mechanical lift. The facility's policy entitled, Transfers - Manual Gait Belt and Mechanical Lifts revised 1-19-18 shows: Purpose: In order to protect the safety and well-being of the staff and residents, and to promote quality care, this facility will use mechanical lift devices for the lifting and movement of residents. Guidelines: 1. Mechanical lifting devices shall be used for any resident needing a two person assist, or who cannot be transferred comfortably and/or safely by normal transfer technique. Except during emergency situations or unavoidable circumstances, manual lifting is not permitted.5. The transferring needs of residents will be assessed on an ongoing basis and designated into one of the following categories: 0 = Independent. 1 = 1 person transfer. 2 = 2 person transfer with gait belt (only when use of mechanical lift is not possible). SS = sit-to-stand lift with 2 caregivers. H = Mechanical lift [total body mechanical lift] with 2 caregivers.8. Failure to comply with the lifting guidelines may result in disciplinary action as deemed appropriate.

Based on interview and record review, the facility failed to follow physician orders to administer antihypertensive and pain medications to a resident (R1) with diagnoses of hypertension, recent back surgery, and chronic back pain. This applies to 1 of 4 residents (R1) reviewed for significant medications in the sample of 4. The findings include: The EMR (Electronic Medical Record) showed that R1, a [AGE] year-old with diagnoses that includes spondylosis with radiculopathy, lumbar region, encounter for orthopedic after care, hypertension, hyperlipidemia, GERD (gastro-esophageal regurgitation disease), hypothyroidism, anemia, protein calorie malnutrition, lactose intolerance, s/p (status post) L5/S1 (lumbar and sacral) laminectomy on October 8,2024, and chronic back pain. R1 was admitted to the facility on [DATE] at 1:36 P.M., and was discharged home against medical advice on October 11,2024. R1 left the facility at 9:45 A.M. The POS (Physician Order Sheet) for the month of October 2024 showed physician orders dated October 10,2024 for the following antihypertensive and pain medications that included but not limited to: -Gabapentin 100 mg. 1 capsule by mouth every evening for pain scheduled to be given 6:00 P.M. daily -Losartan Potassium -HCTZ (hydrochlorothiazide) 100-12.5 mg., 1 tablet a day for hypertension scheduled to be given 8:00 A.M. The pharmacy delivery manifesto showed that R1's medications were delivered to the facility on [DATE] at 3:42 A.M. The medications that were delivered included Losartan Potassium- HCTZ 100-12.5 mg. with total of 14 tablets; and Gabapentin 100 mg with total of 14 tablets. The nurses notes dated October 11,2024 at 7:58 A.M., which was documented by V7 (LPN/Licensed Practical Nurse) showed that R1 was upset and wanted her medications, before she eats breakfast, immediately. V7 noted then that R1's blood pressure was 184/95 at 8:08AM. V7 documented that V10 (physician) was notified and ordered to give R1 her morning medications and added a new medication and directed V7 to check the blood pressure again. V7's notes document that R1 called her son and he picked her up at 9:25AM and R1 left the facility. On November 8,2024 at 1:20 P.M., V7 stated that R1 was upset on October 11,2024 around 8:00 A.M. V7 said that R1 was asking for the blood pressure medications. V7 said that upon checking R1's vital signs, R1 blood pressure was high. V7 said the BP was 184/95. V7 said that R1's antihypertensive medications were not available, so she called V10 for an alternate medication. V7 said that at 8:10 A.M., she was able to get an order from V10 for an alternate medication for hypertension and was to be given one time, and immediately and to resume the original order for antihypertensive medications when it arrives from pharmacy. V10 said that the alternate medications were Amlodipine 5 mg. 1 tablet and Losartan Potassium 50 mg. 1 tablet. V7 said that EMAR is to be always utilized to show that medications were administered. V7 had no explanation why R1's EMAR was not signed that she gave the alternate medications Amlodipine and Losartan Potassium 50 mg.) The EMAR (Electronic Medication Administrator Record) for the month of October 2024 showed Gabapentin was not given to R1 as ordered on October 10,2024 at 6:00 P.M. The EMAR also showed that Losartan Potassium HCTZ 100-12.5 mg. and or the alternate Amlodipine 5 mg and Losartan Potassium 50 mg. as ordered by the physician were not given to R1. On November 8,2024 at 1:30 P.M. the EMAR for October 2024, nurse's notes dated October 11,2024 pharmacy manifesto dated October 11,2024, list of medications available in the convenience box at the facility were reviewed with V2 (Director of Nursing). V2 said that R1's medications including the antihypertensive (Losartan-Potassium 100 mg-12.5 mg.) and pain medication (Gabapentin 100 mg) were delivered to the facility on [DATE] at 3:35 A.M. V2 added that R1's original order for antihypertensive medication which was the Losartan Potassium combined with HCTZ was delivered but was not administered to R1. V2 also said that the Gabapentin for pain was also not given as ordered. V2 also said that V7 must have not able to find R1's delivered medications but can take the alternate medications from the facility's convenience box. On November 8,2024 at 1:45 P.M., V10 (R1's Attending Physician) said that she saw R1 the day of admission which was October 10,2024 in the afternoon. V10 said that R1 expressed going home because her specific brand of antihypertensive medication was not available in the facility. V10 said that the morning of October 11,2024 around 8:00 A.M., the nurse in the facility had updated her because R1's blood pressure was high so V10 had given an alternate medication to be given while waiting for the right medications. V10 added that she had expected that these alternate medications for hypertension was administered so R1's blood pressure will go down. V10 also added that the antihypertensive medication (Amlodipine, Losartan) and pain medication (Gabapentin) were significant medications since it can cause a significant result if medications were omitted. The facility's policy for medication administration dated September 2019 shows: Policy: Medications administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so . Procedure: 7. The medication administration record (MAR) is always employed during medication administration. Documentation including electronic: 1. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications.

Based on observation, interview, and record review, the facility failed to report, assess, and obtain treatment orders for a resident identified with a new wound before it became unstageable. This failure resulted in R61 receiving delayed wound care and deterioration of the wound. This applies to 1 of 3 residents (R61) reviewed for pressure ulcers in a sample of 23. The findings include: The EMR (Electronic Medical Record) showed R61 admitted to the facility on [DATE]. R61's EMR showed multiple diagnoses including encephalopathy, malnutrition, intervertebral disc degeneration of the lumbar region, history of malignant neoplasm of the prostate, dementia, anxiety, pain, ataxia, and left foot drop. R61's MDS (Minimum Data Set) dated 3/15/2024 showed R61 required substantial to maximal staff assistance with personal hygiene and bed mobility. The MDS continued to show R61 was at risk for developing pressure ulcers because R61 had acquired an unstageable ulcer at the facility. On 7/16/2024 at 11:23 AM, V16 (Wound Care Nurse/WCN) said she was going to change R61's sacral wound dressing. V16 removed R61's sacral packing dressing and said R61's wound had muscle and bone exposed and there was undermining between 9-2 o'clock. V16 continued to say R61's sacral wound had 30% slough tissue (non-viable tissue). V16 said R61's stage 4 pressure ulcer to his sacrum was facility-acquired. On 7/18/2024 at 12:47 PM, V23 (Certified Nurse Assistant/CNA) said she reports any skin alteration right away to the nurse on duty. V23 said in February 2024, she noticed R61 had a small open area to his sacrum that was covered with a dressing. V23 said she reported the new skin alteration to the nurse on duty. On 7/18/2024 at 10:56 AM, V15 (Wound Care Coordinator/WCC) said she was notified of R61's sacral wound on 2/27/2024. V15 said she assessed the wound, and it measured 4 cm x 5 cm x 0.1 cm (centimeters) and had 90% slough tissue and 10% granulation tissue on 2/27/2024. V15 said R61's sacral wound was determined to be an unstageable pressure ulcer. V15 said she then obtained treatment orders. V15 said the facility has wound care nurses on duty 7 days a week and R61 was being managed for other wounds at that time. V15 said she was concerned and interviewed the staff involved with R61's care. V15 said she interviewed V23 (CNA) and V23 said that she had notified the nurse on duty a week prior to 2/27/2024 of R61's identified skin alteration to his sacrum. V15 (WCC) said she reviewed R61's EMR and was unable to find documentation of when R61's wound was identified, nor if wound care was initiated prior to 2/27/2024. V15 said nursing staff is expected to report any new skin alteration immediately to ensure wounds are assessed and treatments initiated. V15 said R61's sacral wound deterioration could have been prevented if reported appropriately. V15 continued to say R61's sacral wound should have not been identified at an unstageable stage and could have been prevented if reported promptly to the wound care team when it was originally identified. On 7/18/2024 at 1:54 PM, V24 (Wound Physician) said she was managing R61's wounds. V24 said R61's sacral wound was identified as an unstageable pressure ulcer. V24 said R61 was at risk for pressure ulcers because he had a history of skin alteration on his prior admission, was non-mobile, incontinent of bowel and bladder, had poor nutrition, and was dependent on staff to reposition him. V24 said she expects facility staff to be checking for skin alteration during routine care and reporting new changes. V24 continued to say if the wound care staff is not notified of new skin alterations and/or treatments are not started promptly, the wounds can worsen. R61's Skin Risk Assessment Tool dated 1/02/2024 showed R61 was at a high risk for pressure ulcers. R61's Care Plan reviewed on 7/18/2023 showed R61 was at risk for impaired skin integrity. The care plan showed multiple interventions including Assess/record changes in skin status and follow facility policies/protocols for the prevention/treatment of skin breakdown. R61's Weekly Skin Observation assessment dated [DATE] showed R61 had a new skin problem observed to his sacral area. The assessment said the new pressure injury to his sacrum was unstageable mesuring 4.0 cm x 5.0 cm x 0.1 cm with 90% slough and 10% granulation. R61's Physician Order dated 2/27/2024 showed Apply to sacrum topically one time a day for pressure injury cleanse wound with NSS. Pat dry. Apply santyl and alginate. Cover with dry dressing daily. R61's Wound Visit Report dated 2/28/2024 said R61 acquired an unstageable pressure ulcer to his sacral area on 2/27/2024. The report said the wound measured 3.5 cm x 3.3 cm x 0.3 cm and had a medium amount of serous drainage noted. The report continued to show the wound was noted to have a foul odor after cleansing and had 67-100% (large amount) of necrotic tissue within the wound bed including slough tissue. The report showed daily treatment orders to R61's sacrum, to apply moist gauze with Dakin's solution to the wound bed and cover it with gauze; and an order to start on antibiotic Augmentin 875 mg BID x 14 days for sacral wound infection. R61's Wound Assessment Details Report dated 7/17/2024 said R61's sacral wound measured 6.5 cm x 4.0 cm x 2.5 cm with an undermining of 5.0 cm between 9-6 o'clock. The report continued to say R61's wound had 10% deep maroon tissue, 80% bright pink or red tissue, and 10% slough loosely adherent tissue with moderate serosanguineous drainage. The facility's policy titled Pressure Injury and Skin Condition Assessment with a revision date of 1/17/2018 showed Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented .1. A skin condition assessment and pressure ulcer risk assessment (Braden) will be completed at the time of admission .2. Residents identified will have a weekly skin assessment by a licensed nurse. 3. A wound assessment will be initiated and documented in the resident chart when pressure and/or other ulcers are identified by licensed nurse. 4. Each resident will be observed for skin breakdown daily during care and on the assigned bath days by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment .6. Care givers are responsible for promptly notifying the charge nurse of skin breakdown. 7. At the earliest sign a pressure injury or other skin problem, the resident, legal representative, and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes . The facility's policy titled Pressure Ulcer Prevention with a revision date of 1/15/2018, showed Purpose: To prevent and treat pressure sores/pressure injury. Guidelines: . 2. Inspect the skin several times daily during bathing, hygiene, and repositioning measures .5. Turn dependent residents approximately every two hours or as needed and position residents with pillow or pads protecting bony prominences as indicated .8. If redness does not disappear within 30 minutes the turning schedule may be shortened to 1 hour .

Based on interview and record review the facility failed to ensure residents received adequate nutrition, thorough assessment and assistance with eating to prevent significant weight loss. This failure resulted in R1 experiencing a weight loss of 20.7 % in three months. This applies to 1 of 3 residents (R1) reviewed for weight loss in the sample of 4. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including dementia, presence of left artificial hip, malignant neoplasm of the prostrate, and pressure ulcer of the sacrum. R1's MDS (Minimum Data Set) dated March 15, 2024, showed R1 was severely cognitively impaired and required assistance with ADLs including partial assistance with eating and dependent on staff for bed mobility, dressing, bathing, toileting and transfer. R1's care plan for ADLs revised on March 27, 2024. showed per report, resident noted able to lift utensils and appear to place food in his mouth during meals but spills them to his clothes. Resident may benefit with staff feeding assistance with meals. R1's weight record documentation showed: January 3, 2024- 163.0 lbs. (Pounds) January 16, 2024- 152.2 lbs. February 6, 2024-152.6 lbs. March 5, 2024-142.2 lbs. March 14, 2024-134.0 lbs. March 16, 2024-129.3 lbs. March 31, 2024-128.2 lbs. April 4, 2024-126.5 lbs. April 10, 2024-127.1 lbs. On April 9, 2024, at 2:30 PM, V3 (CNA) stated R1 used to go to the dining room and feed himself at meals but had a hard time holding the utensils and would spill the food a lot. V3 also stated now that the staff feed him on a 1:1 basis he eats 100%. of his meals. V3 was unsure how long R1 was receiving 1:1 feeding assistance but stated maybe a week. On April 10, 2024, at 11:15 AM, V7 (CNA) stated she has been R1's caretaker since his admission to the facility. V7 stated prior to R1 being in contact isolation, R1 would eat his meals in the dining room and after the staff set up his meal tray R1 would feed himself. V7 stated when R1 fed himself, there would be a lot of food spillage and it seemed R1 would only see half of his plate of food. V7 described R1 would also lean to the side while sitting in his wheelchair and wasn't sure if that caused R1 to reach only for half of his plate of food or not. R1's physician orders showed R1's diet order revised on March 27, 2024, General diet, regular texture, thin consistency, feeding assist. An order for contact precautions for MRSA (Methicillin Resistant Staphylococcus Aureus) of the sacral wound was initiated on April 8, 2024. R1's Documentation Survey Report for the task of Eating, the ability to use suitable utensils to bring food and or liquid to the mouth and swallow food, for February 2024, showed documentation on 22/29 days coded as follows: Code 6-Independent, - 7 days, Code 5-set up assistance provided -9 days. Code 4- Supervision, verbal cues provided - 4 days. Code 3- partial assistance provided-2 days. R1's OT (Occupational Therapy) discharge note for dates of service March 10, 2024, through April 8, 2024, showed R1 required partial/moderate assistance with the task of eating, which did not change from baseline level of function. The OT discharge recommendation dated April 8, 2024, showed R1 required MAX A (Maximum Assistance) globally with ADL's. The OT discharge summary was amended on April 10, 2024, to include continue with restorative 1:1 feeding program. R1's EMR showed R1 had continued weight loss of 15.7 lbs. while receiving OT services. R1's weight was documented as 142.2 lbs. on March 5, 2024, and 126.5 lbs. on April 4, 2024. On April 10. 2024, at 11:38 AM, V8 (Restorative Nurse) and V9 (Restorative Aide) both stated that R1 was never on a restorative 1:1 feeding program. On April 10, 2024, at 2:45 PM, V5 (RD, Registered Dietician) stated she has been the facility's RD since February 1, 2024, and was made aware of R1's weight loss in early February, however V5's initial assessment was completed on March 7, 2024. V5's progress note identified significant weight loss of 6.8% in one month and 12.8% weight loss in 2 months and made no recommendation. V5 stated she has access to the EMR and can look at intake records remotely but was unaware of R1's spillage of food during self-feeding. V5 stated the food spillage would affect R1's food intake and could contribute to weight loss. On April 10, 2024, at 3:20 PM, V4 (Physician) stated when the dietician becomes aware of weight loss, he would expect a nutritional assessment be completed. V4 stated in the event of significant weight loss he would expect the facility staff to monitor the resident's meal intake and that food spillage during a meal would affect the resident's meal intake, which would contribute to weight loss. V4 stated for residents with significant weight loss, he would expect that a weight be taken every 1 or 2 weeks, nutritional supplements be given, and assessments completed to determine the reason for the weight loss as well as put interventions in place to prevent further weight loss. The Facility's policy titled Unintentional Weight Loss, dated 2022, showed Causes /Risk Factors of Unintentional Weight Loss .frequent causes of unintentional weight loss include inadequate oral food and beverage intake . and Screening to Identify Individuals with Unintentional Weight Loss .Observation of individuals at mealtimes is often the best way to identify people that have a change in normal eating patterns, or are eating poorly and at risk for weight loss.

Based on observation, interview, and record review, the facility failed to ensure a resident was transferred by two facility staff members as shown on the resident's ADL (Activity of Daily Living) care plan. This failure resulted in R2 sustaining a head laceration following a fall due to an improper transfer. This applies to 1 of 3 residents (R2) reviewed for falls in the sample of 4. The findings include: On March 30, 2023, at 3:45 PM, R2 was sitting in her wheelchair in her room. R2 had two staples on the back of her head. R2 said, A few days ago, I fell backwards in the shower and hit my head. There was only one CNA (Certified Nursing Assistant) with me when the shower was over. I was grabbing onto the bar, and I couldn't hold myself up anymore. The CNA was with me for most of the shower, but she had me stand up holding onto the bar in the shower while she got my wheelchair. I couldn't hold onto the bar anymore and I fell backwards. R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, Alzheimer's disease, heart failure, osteoporosis, and anxiety. R2's MDS (Minimum Data Set) dated January 27, 2023, showed R2 was cognitively intact and required extensive assistance of two facility staff for transfers. The MDS continued to show R2 required two facility staff physical assistance with bathing. R2's ADL (Activity of Daily Living) care plan dated April 7, 2022, showed Resident requires assistance with bed mobility, transfers, locomotion in unit, locomotion off unit, ambulation, dressing, personal hygiene, eating, and bathing. The care plan continued to show multiple interventions dated April 7, 2022, including, Provide two person assist with transfer. On April 3, 2023, at 10:31 AM, V6 (CNA) said, I gave [R2] a shower on March 28, 2023. I put all of clothes on and helped her stand up using the shower bar. I went a couple steps away to get her wheelchair, but she let go of the shower bar and fell . She fell on to her butt and then hit her head on the wall. I transferred [R2] by myself. [R2] is supposed to be a two person assist for transfers. On March 30, 2023, at 3:25 PM, V8 (Nurse Practitioner) said, [R2] fell in the shower and suffered a head laceration and a forearm skin tear. [R2] is on blood thinners so I wanted her to get a head CT (Computerized Tomography). She went to the hospital and got two staples for the head laceration. My expectation is staff follow a resident's transfer status. The improper transfer of [R2] is what could have led to her falling. On March 30, 2023, at 12:43 PM, V2 (Director of Nursing/DON) said V6 (CNA) performed an improper transfer of R2. V2 continued to say R2 required the assistance of two facility staff members to transfer. V2 said on the day of R2's fall, V6 transferred R2 by herself and did not have anybody else with her during the transfer. A progress note dated March 28, 2023, at 11:57 AM, by V13 (Registered Nurse/RN) showed, Assessment Findings: back of the head, occipital site bleeding, right forearm skin tears. Describe Incident in Detail: CNA stated that she was trying to transfer the patient after shower to the wheelchair, and patient lost balance and slid down to the floor. Send patient out to the emergency room .

Based on interview and record review, the facility failed to safely transfer a resident, staff utilized a stand pivot transfer instead of using a mechanical lift as care planned. This failure resulted in R1 sustaining a right femur fracture, and a laceration requiring skin staple closure following an improper transfer. This applies to 1 of 3 residents (R1) reviewed for resident injury in the sample of 3. The findings include: On November 2, 2022, at 10:15 AM, R1 way lying in her bed. R1 was not able to be interviewed due to her cognitive status. A sign posted in R1's room showed R1 required a mechanical lift for all transfers between surfaces. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE], with multiple diagnoses including [CONDITION(S)] ([CONDITION(S)]), acute respiratory failure with [CONDITION(S)], [CONDITION(S)], heart failure, dementia without behaviors, psychotic disturbance, mood disturbance and anxiety, [CONDITION(S)], [CONDITION(S)], and scoliosis. R1's MDS (Minimum Data Set) dated September 26, 2022, shows R1 has moderate cognitive impairment, requires supervision with eating, is totally dependent on two facility staff members for transfers between surfaces, and requires extensive assistance with all other ADLs (Activities of Daily Living). R1 is always incontinent of bowel and bladder. R1's Restorative Functional Assessment, created November 15, 2021, shows R1 requires a mechanical lift for transfers between surfaces. R1's Mechanical Lift care plan, effective January 27, 2021, shows Resident requires the use of [total body mechanical lift] for transfers related to weakness. The facility's Resident Medical Alerts report for R1 dated January 27, 2021 at 3:55 PM shows Transfer Support - Mechanical Lift. The facility's incident report for R1, dated October 28, 2022 shows, on October 20, 2022, R1 sustained an injury following a transfer by two facility staff requiring medical treatment at the local hospital. The incident report shows: Description of the occurrence: During bedtime care, CNA (Certified Nursing Assistant) notified nurse of open area to right lower leg. Nurse assessed area, treatment applied, and MD and family were notified. MD ordered for resident to be sent to ER (emergency room ) for evaluation. Staff involved with the incident were interviewed. It was determined that staff grazed right lower leg against the footrest area of the wheelchair during two-person transfer. Area was noted later in the shift when CNA changed resident into a nighttime gown. MD notified and ordered to send to [local hospital] for evaluation. Resident received 3 staples to area and has returned to the facility. Wheelchair inspected by building manager and all parts in working order. CNA staff were reeducated on transfer techniques and to inspect skin after transfers. Wound care will be following area to promote proper healing. Interdisciplinary plan of care reviewed and updated as indicated. The facility's incident report does not show R1 sustained a fracture. Hospital documentation dated October 20, 2022, shows R1 was admitted to the local hospital with a distal right impacted femur fracture and a laceration to her right lower leg. R1 returned to the facility on [DATE], with a right knee immobilizer in place and staples to her right leg laceration. R1's skin assessment dated [DATE], shows R1's leg laceration was 3 centimeters long and closed with 7 staples and 3 steri-strips and R1 had an immobilizer on her right lower extremity. On October 23, 2022, at 11:59 AM, V8 (Orthopedic Physician) documented, Right anterior leg laceration, right distal femur osteoporotic fracture, non-displaced, but angulated . D/C (Discharge) planning: To subacute rehab when medically stable. I discussed the potential benefits of surgical stabilization of right femur fracture. These would include improved pain management, ease of transfer, potentially less stress to cardiovascular system. She is not currently interested in surgery due to surgical risks. On November 2, 2022, at 12:07 PM, V3 (CNA) said, On October 20, I started my shift at 3:00 PM. I was surprised to see [R1] sitting up in a chair in her room since she is never out of bed. She told me she did not feel good and asked to be put back to bed. She complained of feeling nauseous. I asked [V4] (CNA) to come help me. I had never transferred her before that day. The two of us got on each side of her, picked her up, did a stand and pivot transfer, and put her on the bed. Her feet touched the ground before we turned her and put her in the bed. We put her on the bed and [V4] grabbed her top half, and I grabbed her feet and we positioned her in the bed. She kept saying her right leg hurt. She did not eat her dinner. When I went in later that evening to get her ready for bed, I removed her pants and I saw a wound on her leg. I brought the nurse back in and showed her the leg wound. The nurse went to wrap the wound up and [R1] was hollering in pain. On November 2, 2022, at 2:42 PM, V4 (CNA) said, The CNA asked me to help her transfer [R1] back to bed. There was a sign on the wall that showed we should use the [mechanical lift] but we thought it would be easier to just lift her by her armpits and put her in the bed. We did not use the [mechanical lift]. The fabric sling for the [mechanical lift] was under the resident when she was sitting in the wheelchair, but we did not use it. We did not know she got injured during the transfer. On November 2, 2022, at 12:19 PM, V2 (DON-Director of Nursing) said, Every resident room has a sign over the resident to indicate what type of transfer is needed for the resident. At the time of [R1's] injury, the sign was posted in the room. She was supposed to be transferred using a [mechanical lift]. The staff said they did not use the [mechanical lift] because they wanted to make it a quick transfer. The staff should have used a [mechanical lift] to transfer [R1]. On November 2, 2022, at 11:30 AM, V5 (NP-Nurse Practitioner) said, I am in the building Monday through Friday. I am aware [R1] has a fracture and has a knee immobilizer in place. If a resident has [CONDITION(S)], a turn or a twist can cause a fracture. You do not have to have a fall to cause a fracture. [R1] is usually bedbound. I never see her up in the chair. We can say the laceration was caused by the transfer. I would expect the facility staff to follow the recommendation by therapy to use a mechanical lift to transfer a resident, especially if the resident is not able to stand or bear weight. On November 2, 2022, at 3:09 PM, V11 (Physician) said, I do not know how [R1] is supposed to be transferred day in and day out. This is the first I am hearing of her not being transferred correctly. I would expect the staff to follow the transfer recommendations determined by the therapy or the restorative department. If she should have been transferred with a mechanical lift, then that is what they should have used to prevent her from becoming injured due to an improper transfer. The facility's Resident Transfer Policy revised 9/2015 shows: Policy: In order to provide a safe environment all residents/patients will be assessed for their ability to transfer from bed to chair and back again by either nursing or physical therapy dependent upon their condition. Procedure: 1. Residents/patients will be assessed by nursing or physical therapy upon admission and at least quarterly and annually or if there is a change in condition. 2. Transfer status will be communicated via the care plan . 3. Residents/Patients will be assigned either: a. one person transfer, b. two person transfer, c. Mechanical transfer [total body mechanical lift] required to complete transfer (2 people required), d. Sit to Stand lift required to complete transfer. 4. Safety belt usage is required for all transfers.

Based on observation, interview, and record review the facility failed to follow recommended techniques for turning residents in bed. This failure resulted in R2 sustaining a fracture during repositioning. The facility also failed to supervise a resident that requires extensive assistance for an extended period during use of the toilet. These failures affected 3 of 5 residents (R1, R2, R3) reviewed for safety and supervision during activities of daily living care in the sample of 6. Findings include: 1. R2's Face Sheet showed R2 is [AGE] years old with multiple medical diagnoses which include [CONDITION(S)], Bilateral Knee [CONDITION(S)], [CONDITION(S)] Joint Disease (DJD), Left Proximal Humerus Fracture status-post (s/p) Internal Fixation, history of Non-Displaced Acute Fracture of the Right Distal Fibular Shaft and Posterior Malleolus (6/11/20), fall at home with Right Femur Fracture s/p ORIF (Open Reduction Internal Fixation). Incident report showed: On 11/26/21 at 6:00 AM, V8 (Certified Nursing Assistant/CNA) was cleaning R2, changing incontinence brief in bed when R2 reported to V8 that she heard a pop sound as V8 was turning her. At 6:20 AM, R2 complained of left knee pain and was given a pain reliever. V4 (Physician) was notified with order to do a STAT x-ray to left femur and tibia/fibula. X-ray was done. Left femur result showed acute sub-capital femoral neck fracture. The tibia/fibula x-ray showed generalized Osteopenia. R2 is alert and oriented, with episodes of forgetfulness, however, she can express her needs and discomfort. R2 requires assistance with activities of daily living (ADL) and mechanical lift with 2-staff assistance for transfer due to weakness. On 12/1/21 at 11:00 AM, R2 was resting in bed with a pained expression on her face. R2 appeared stiff while lying in bed and stated that she was in pain with a scale of 10 out of 10. R2 stated that on the day of the incident (11/26/21), V8 (CNA) was assisting her (R2) to position on her right side. V8 rolled R2 away from him during repositioning. V8 assisted to position R2 on her right side by pushing her on her left thigh. V8 did not touch her on any other part of her body during positioning except for her left thigh. As V8 was rolling her with his hand on her left thigh they heard a loud pop coming from her thigh. R2 told V8 that she hoped she didn't break a bone. R2 also said that she didn't feel pain initially, the pain started to creep a few minutes later in her left thigh going up to the groin until it became intense. R2 added that V8 was alone when he (V8) repositioned her. On 12/1/21 at 3:55 PM, R2 was asked the same question with regards to the incident that happened to her, R2 re-told the same story that she had said that morning. On 12/1/21 at 4:19 PM, V8 (CNA) stated that on 11/26/21, R2 needed incontinence care. V8 turned R2 on her side, towards him by supporting her on her right shoulder and right hip. When V8 was asked which side of the bed he was standing, V8 said he was on the left side of R2's bed. V8 also said that he heard R2 said Ow while V8 was rolling her. V8 asked R2 was R2 was okay, and R2 said yes. V8 then went to the other side (right side) of the bed to pull the soiled pad and incontinence brief from R2 while R2 was lying on her right side. V8 was alone when he repositioned R2. During interview on December 21, 2021 at 11:25AM, V6 (Physical Therapy Assistant/ PTA) stated that residents with [CONDITION(S)] or brittle bones and requiring two-person assistance must be turned by supporting the resident through their major joints. These major joints would include the shoulder and hip. V6 continued to add that if only one person is assisting, then the resident should be rolled towards the staff to provide more control. V6 also stated that staff should not push residents in the thigh due to the possibility of injury. On 12/1/21 at 1:20 PM, V3 (Rehab Director) gave the following statement: R2 requires 2 staff assistance for repositioning. One staff on each side of the bed - one pulling the resident towards them and one away from them as support. When you roll the resident on their side you support them in the major bone such as the shoulder and hip, another safe way is the use of draw sheet; the staff have wider range for the resident especially in the mid-body for safety alignment of body mechanics for both the resident and the staff. Given R2's history, R2 is more susceptible to fracture. It's possible that the improper positioning is the cause of fracture. On 12/1/21 at 11:38 AM, V5 (Nurse Practitioner/NP) stated that [CONDITION(S)], osteopenia, and [CONDITION(S)] are all weakening of the bones. V5 is not familiar on how staffs provide care for R2. However, the staff must follow whatever is recommended for R2 with regards to procedure on ADL (activities of daily living) care to prevent injury. On 12/1/21 at 12:47 PM, V4 (Physician) stated that R2 is [AGE] years-old and it's natural that she has weakened bones. V4 was aware of the incident that happened to R1, V4 did not see the whole event but if indeed, V6 positioned R1 the way R1 described it, then yes, it could have possibly caused it. However, V4 concurred on what V6 said regarding safe positioning and whatever is recommended for R1 with regards to safety in ADL. On 12/1/21 at around 4:50 PM, V2 (Director of Nursing/DON) stated staff should have followed the recommended assistance for R2 according to the care plan for safety. On 12/2/21 at 12:50 PM, V15 (CNA) and V16 (CNA) both stated that they are familiar with R2 and her condition and they need to provide 2 staff assistance for R2's ADL care. One staff on each side of R2's bed since R2 has fragile bones and history of multiple fractures. R2's MDS (Minimum Data Set) dated 9/27/21 showed that R1 is alert and oriented and requires two staff assistance for bed mobility. R2's updated care plan (with target goal date of 1/24/22) showed that R2 has impaired bed mobility as evidenced by difficulty in repositioning self in bed. The goal for R2 is that she will be able to reposition self in bed with extensive assistance of two persons by next review. 2. R3 is [AGE] years old with multiple medical diagnoses which include age related [CONDITION(S)] without pathological fracture, presence of bilateral artificial knee joints and presence of right artificial hip joint. MDS dated [DATE] showed that R3 requires extensive assistance by 2 staff for bed mobility and toileting. On 12/2/21 at 2:20 PM, V16 (CNA) and V20 (CNA) rendered incontinence care to R3. R3 appeared stiff in the lower extremities and was unable to move by herself. V20 turned R3 on her (R3's) left side towards V20 by pulling R3 in the right shoulder and right lower thigh, just behind the upper right knee. R3 was unable to sustain being on her right side and had poor trunk control. V20 kept R3 positioned on R3's left side by holding R3 on her right side (between the rib cage and the right hip) and upper thigh. R3's upper back was leaning backward while the lower back was positioned forward making her torso not properly aligned while positioned on her left side. Facility's Competency Test: Repositioning Resident in Bed documents: Practice proper body alignment with resident. Align resident safely in the center of the bed, away from the edge. 3. R1 is [AGE] years-old with multiple medical diagnoses which include abnormalities with gait and mobility, weakness, and bilateral [CONDITION(S)] of the knees. R1's MDS dated [DATE] showed that R1 is alert and oriented and requires extensive assistance by 2 staff for toileting and transfer. R1's most recent fall risk assessment dated [DATE] showed that she is identified as a high risk for fall. During an interview of 11-30-2021 at 11:50AM, V12 (R1's family) stated that on 11/19/21 (Friday) at around 6:30 PM, V12 called R1 multiple times, and she (R1) was not responding to V12's calls. V12 stated that R1 still was not answering call after 7:00PM, so V12 became worried and called and asked staff to check on R1. The staff (V12 was not able to identify who it was) found R1 sitting on the toilet. When the staff gave the phone to R1, R1 stated that she had been sitting on the toilet for about 45 minutes. V12 then requested to talked to the nursing supervisor (V9) about this concern and about R1 turning on the call light with no response. V12 was upset that no one checked on R1 until she called the facility. On 11/30/21 at 3:03 PM, V9 (Nursing Supervisor) stated that V7 (Licensed Practical Nurse/LPN) called V9 around 8:30 PM and reported that R1 was left on the toilet for about 45 minutes. V9 investigated the incident. V9 talked to R1 and R1 informed her (V9) that V10 (CNA) put her on the toilet and left her there alone for a long period of time about 30-40 minutes. V9 talked to V10 (CNA) and was informed that she assisted R1 to the toilet and left her there to assist another resident with a shower. V10 did not endorsed to other staff members that R1 was left in the bathroom. V9 counselled V10 that she was not supposed to leave any resident unattended on the toilet. V10 informed V9 that she was aware of it, but she lost track of the time. V10 was an agency CNA; she (V10) was not familiar with the residents in the 200 unit, so it took her a while to finish assisting the other resident with showering before she could go back to R1. On 12/1/21 at 11:25 AM, V6 (PTA) stated that he is familiar with R1's condition. R1 requires extensive assistance by two staffs. R1 should not be left alone sitting on the toilet. Staff should not leave any resident alone for a long period of time in the bathroom. Thirty minutes is a long period of time. This can possibly cause discomfort to resident and if the resident who requires extensive assistance tries to get up on their own, it can cause a potential fall incident.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance while resident was consuming coffee. This applies to 1 of 3 residents (R1) reviewed for supervision and assistance during meals in a sample of 11. This failure resulted in R1 sustaining a 2nd degree burn to her right hip. Findings include: R1's admitting progress note dated 7/24/21 documents R1 being admitted with diagnoses to include Agitation and Dementia with behavioral disturbances. This note documents V14 (R1's Daughter) reported R1 requires 1:1 assistance with meals due to loss of upper extremity movement. R1's Physician Order Sheet dated 7/26/21 documents mechanical soft diet with nectar thick liquids. R1's Occupational Therapy Plan of Care Assessment completed by V10 (Occupational Therapist) dated 7/24/21, documents R1 with medical history including Dementia and Motor Vehicle Accident (2020) with a Cervical Fracture. This assessment documents R1's prior status before admission as R1 was able to feed herself occasionally with left upper extremity due to a non-functioning right upper extremity; receiving occupational therapy at home to work on R1's right hand. The assessment section documents R1's current level of self feeding ability as maximum assistance (76 - 99%). The functional deficits section document R1's current level for eating as requiring substantial/maximal assistance - helper does more than half of the effort, helper lifts or holds trunk or limbs and provides more than half the effort. Precautions initiated include 1:1 feeding. A facility Final Incident Report dated 8/5/21 documents on 8/2/21 R1 was served coffee during lunch per her request and staff were checking on R1 from time to time. Staff then noticed R1's clothes were wet with coffee. At approximately 12:30PM R1 was noted with redness and fluid filled blisters to her right hip. R1 was complaining of pain to this area and was provided pain medications. The physician was contacted for orders which included [MEDICATION(S)] (topical antibiotic, which is used to treat or prevent serious infection on areas of skin with second or third degree [CONDITION(S)]) and to cover with a dressing. R1's Progress Note dated 8/2/21 documents R1 with a new burn to her right hip with an intact fluid filled blister measuring 28 X 5 centimeters. R1's Physician Progress Note dated 8/4/21 documents R1 spilled hot coffee on herself and has a blistering scald burn to right hip. R1's Physician Wound Progress Note dated 8/11/21 documents R1 with a second degree burn on the right hip since 8/2/21 due to coffee spill onto her clothes by the resident. The same physician wound progress notes also document, Wound #1 status is Open. The wound is currently as a Full thickness Without Exposed Support Structures wound with etiology of 2nd degree Burn and is located on the Right Trochanter [one of the bony prominences toward the near end of the thigh bone]. The wound measures 30cm length X 5cm width X 0.1cm depth .There is medium amount of serous drainage noted. There is small (1 -33%) pink granulation within the wound bed. There is large (67 - 100%) amount of necrotic tissue within the wound bed including Adherent Slough . On 8/11/21 at 11:55 AM - 12:25 PM, R1 sat at the table with her upper body covered with a shawl and her eyes closed while V3 (Dementia Coordinator) attempted to feed her. During this interaction R1 did not move her arms or make any attempts to reach for any food or drink items in front of her. R1 refused to eat and provided minimal or no response when V3 asked questions. On 8/12/21 at 8:58 AM, R1 sat at the dining room table with eyes open, right arm and hand fixed at abdomen and left arm resting on her chest. R1 was able to move her left arm and hand when asked but movement was limited and left hand joints were arthritic appearing. V3 provided R1 with about a quarter cup of thickened coffee and R1 stated she could not pick up the cup. V3 assisted placing the cup in her hand and R1 was able to grasp the cup handle with 2 fingers only. R1 was visibly shaking when she lifted the cup to her lips. R1 required V3's 1:1 assistance to encourage her to maintain a grip on the cup and to bring it to her lips to drink the coffee. On 8/12/21 at 9:20 AM, V8 (Wound Nurse) provided a dressing change to R1's right hip. R1's wound appeared as a linear wound to the right lateral hip extending down the thigh. This wound was bright red around the edges with yellow tissue to the middle of the wound. V8 stated the original appearance right after the occurrence was fluid filled blisters which have since opened. On 8/12/21 at V12 (Nursing Assistant) stated, I was the one who gave her the coffee. She was yelling she wanted coffee. V12 stated she set a cup of coffee about 3/4 full in front of R1. V12 stated she did not assist R1 to drink the coffee and was not aware R1 required 1:1 supervision. On 8/12/21 at 9:50 AM, V10 (Occupational Therapist) stated he completed R1's first evaluation on 7/24/21 as a new admission. V10 stated he spoke with V14 (R1's Daughter) and found R1 was getting occupational therapy at home for her arm to work on feeding. V10 stated during his assessment R1 was found to have bilateral upper extremity impairments and her cognitive status made her ability to follow cueing difficult. V10 stated R1 was assessed as requiring 1:1 assistance for meals and needing to be hand fed which he recommended as a precaution during feeding. V10 stated R1 was not be left alone and cannot manage a cup of juice let alone a cup of hot coffee. V10 stated she should not have been given a cup of hot coffee because she cannot independently and safely manage a cup of coffee. V10 further stated so far therapy was working mainly on finger foods and was hoping to progress from there. On 8/11/21 at 9:57 AM, V4 (Dietary Manager) stated coffee is dispensed into thermal containers from a coffee machine and the thermal containers are brought to the dining rooms prior to meal service. V4 stated the temperature of the coffee dispensed from these machines are regulated and monitored by the company who performs monthly checks. V4 stated coffee is served between 150-180 degrees. On 8/11/21 at 9:57 AM, the temperature from the 2 coffee machines at the facility were 170.4 degrees Fahrenheit (F) in the pantry and 172.4 (F) in the kitchen. R1's Dietary Progress Note dated 7/26/21 documents R1's family stated R1 likes juice, coffee and milk at every meal. R1's Minimum Data Set, dated dated dated [DATE] documents R1 has moderately impaired cognition with a BIMS (Brief Interview for Mental Status) score of 9. The Antiscald.com burn exposure chart documents a 2nd degree burn will occur within 3 seconds of exposure at a temperature of 140 degrees.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance while resident was consuming coffee. This applies to 1 of 3 residents (R1) reviewed for supervision and assistance during meals in a sample of 11. This failure resulted in R1 sustaining a 2nd degree burn to her right hip. Findings include: R1's admitting progress note dated 7/24/21 documents R1 being admitted with diagnoses to include Agitation and Dementia with behavioral disturbances. This note documents V14 (R1's Daughter) reported R1 requires 1:1 assistance with meals due to loss of upper extremity movement. R1's Physician Order Sheet dated 7/26/21 documents mechanical soft diet with nectar thick liquids. R1's Occupational Therapy Plan of Care Assessment completed by V10 (Occupational Therapist) dated 7/24/21, documents R1 with medical history including Dementia and Motor Vehicle Accident (2020) with a Cervical Fracture. This assessment documents R1's prior status before admission as R1 was able to feed herself occasionally with left upper extremity due to a non-functioning right upper extremity; receiving occupational therapy at home to work on R1's right hand. The assessment section documents R1's current level of self feeding ability as maximum assistance (76 - 99%). The functional deficits section document R1's current level for eating as requiring substantial/maximal assistance - helper does more than half of the effort, helper lifts or holds trunk or limbs and provides more than half the effort. Precautions initiated include 1:1 feeding. A facility Final Incident Report dated 8/5/21 documents on 8/2/21 R1 was served coffee during lunch per her request and staff were checking on R1 from time to time. Staff then noticed R1's clothes were wet with coffee. At approximately 12:30PM R1 was noted with redness and fluid filled blisters to her right hip. R1 was complaining of pain to this area and was provided pain medications. The physician was contacted for orders which included [MEDICATION(S)] (topical antibiotic, which is used to treat or prevent serious infection on areas of skin with second or third degree burns) and to cover with a dressing. R1's Progress Note dated 8/2/21 documents R1 with a new burn to her right hip with an intact fluid filled blister measuring 28 X 5 centimeters. R1's Physician Progress Note dated 8/4/21 documents R1 spilled hot coffee on herself and has a blistering scald burn to right hip. R1's Physician Wound Progress Note dated 8/11/21 documents R1 with a second degree burn on the right hip since 8/2/21 due to coffee spill onto her clothes by the resident. The same physician wound progress notes also document, Wound #1 status is Open. The wound is currently as a Full thickness Without Exposed Support Structures wound with etiology of 2nd degree Burn and is located on the Right Trochanter [one of the bony prominences toward the near end of the thigh bone]. The wound measures 30cm length X 5cm width X 0.1cm depth .There is medium amount of serous drainage noted. There is small (1 -33%) pink granulation within the wound bed. There is large (67 - 100%) amount of necrotic tissue within the wound bed including Adherent Slough . On 8/11/21 at 11:55 AM - 12:25 PM, R1 sat at the table with her upper body covered with a shawl and her eyes closed while V3 (Dementia Coordinator) attempted to feed her. During this interaction R1 did not move her arms or make any attempts to reach for any food or drink items in front of her. R1 refused to eat and provided minimal or no response when V3 asked questions. On 8/12/21 at 8:58 AM, R1 sat at the dining room table with eyes open, right arm and hand fixed at abdomen and left arm resting on her chest. R1 was able to move her left arm and hand when asked but movement was limited and left hand joints were arthritic appearing. V3 provided R1 with about a quarter cup of thickened coffee and R1 stated she could not pick up the cup. V3 assisted placing the cup in her hand and R1 was able to grasp the cup handle with 2 fingers only. R1 was visibly shaking when she lifted the cup to her lips. R1 required V3's 1:1 assistance to encourage her to maintain a grip on the cup and to bring it to her lips to drink the coffee. On 8/12/21 at 9:20 AM, V8 (Wound Nurse) provided a dressing change to R1's right hip. R1's wound appeared as a linear wound to the right lateral hip extending down the thigh. This wound was bright red around the edges with yellow tissue to the middle of the wound. V8 stated the original appearance right after the occurrence was fluid filled blisters which have since opened. On 8/12/21 at V12 (Nursing Assistant) stated, I was the one who gave her the coffee. She was yelling she wanted coffee. V12 stated she set a cup of coffee about 3/4 full in front of R1. V12 stated she did not assist R1 to drink the coffee and was not aware R1 required 1:1 supervision. On 8/12/21 at 9:50 AM, V10 (Occupational Therapist) stated he completed R1's first evaluation on 7/24/21 as a new admission. V10 stated he spoke with V14 (R1's Daughter) and found R1 was getting occupational therapy at home for her arm to work on feeding. V10 stated during his assessment R1 was found to have bilateral upper extremity impairments and her cognitive status made her ability to follow cueing difficult. V10 stated R1 was assessed as requiring 1:1 assistance for meals and needing to be hand fed which he recommended as a precaution during feeding. V10 stated R1 was not be left alone and cannot manage a cup of juice let alone a cup of hot coffee. V10 stated she should not have been given a cup of hot coffee because she cannot independently and safely manage a cup of coffee. V10 further stated so far therapy was working mainly on finger foods and was hoping to progress from there. On 8/11/21 at 9:57 AM, V4 (Dietary Manager) stated coffee is dispensed into thermal containers from a coffee machine and the thermal containers are brought to the dining rooms prior to meal service. V4 stated the temperature of the coffee dispensed from these machines are regulated and monitored by the company who performs monthly checks. V4 stated coffee is served between 150-180 degrees. On 8/11/21 at 9:57 AM, the temperature from the 2 coffee machines at the facility were 170.4 degrees Fahrenheit (F) in the pantry and 172.4 (F) in the kitchen. R1's Dietary Progress Note dated 7/26/21 documents R1's family stated R1 likes juice, coffee and milk at every meal. R1's Minimum Data Set, dated dated dated [DATE] documents R1 has moderately impaired cognition with a BIMS (Brief Interview for Mental Status) score of 9. The Antiscald.com burn exposure chart documents a 2nd degree burn will occur within 3 seconds of exposure at a temperature of 140 degrees.

Based on interview and record review, the facility failed to ensure a resident did not experience trauma from a leg immobilizer resulting in the development of a pressure ulcer. The facility also failed to provide physician-ordered treatment to a resident's facility-acquired pressure ulcers. These failures resulted in R1 developing a Stage 4 pressure ulcer on the left lower leg requiring a vacuum-assisted wound closure device and seeking a plastic surgery consult for wound closure, and an unstageable pressure ulcer of the left ankle. This applies to 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 6. Findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR shows R1 was discharged from the facility on June 14, 2021 to the local hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 did not return to the facility. R1 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS (Minimum Data Set) dated April 12, 2021 shows R1 had moderate cognitive impairment, required limited assistance with eating, and extensive assistance with all other ADLs (Activities of Daily Living). R1 had functional range of motion impairment on one side of her upper and lower extremities and used a wheelchair for mobility. R1 had an indwelling urinary catheter and was frequently incontinent of stool. The MDS continues to show R1 was at risk for developing pressure ulcers and did not have one or more unhealed pressure ulcers at Stage 1 or higher upon admission. R1 was transferred to the local hospital on June 14, 2021 from the facility. Hospital documentation dated June 14, 2021 shows R1 was admitted to the local hospital with an unstageable pressure ulcer to the left lateral ankle measuring 1.7 cm length x 1.5 cm. width, and a Stage 4 pressure ulcer to the left lateral lower leg measuring 4 cm. length x 2.5 cm. width x 0.5 cm. depth with tendon exposed. Hospital documentation dated June 19, 2021 shows R1 was admitted to the hospital on June 14, 2021. Patient completed short course of antibiotics. [R1] was also found to have several pressure ulcers/wounds including a left lower extremity Stage IV with tendon exposed. General surgery was consulted and performed bedside debridement. Plastic surgery was also consulted and recommended wound VAC placement with follow-up in several weeks to evaluate for potential skin grafting. V5's (Registered Nurse/RN/Wound Nurse) skin assessment for R1, dated April 12, 2021 shows no open wounds. R1's skin assessment shows, Left lower extremity removable brace. Left posterior lower leg: mild redness noted under brace. Skin intact. On April 20, 2021 at 11:05 AM, V5 (RN/Wound Care Nurse) documented, Note: Treatment: [R1] has a new wound to her left lateral lower extremity possibly from her brace rubbing. Wound bed is 100% red with periwound bruising. Wound noted with small sanguineous drainage. Wound bed measures 3 x 3.5 x 0.1 cm. (centimeters). Writer cleansed wound bed with NSS (Normal Saline Solution), patted dry, and applied [honey wound gel], an ABD (Abdominal gauze pad), and wrapped with [rolled gauze]. On April 28, 2021, V6 (Wound Care Physician) documented, Initial Assessment. [R1] is a [AGE] year old female that has a trauma wound on the left lateral lower leg due to the left lower leg immobilizer since 4/22/21. The patient does complain of pain 9/10 (0 is no pain, 10 is greatest pain) and has tenderness when the wound is examined and when the dressing is changed.Wound #1 status is open. The wound is currently classified as a full thickness without exposed support structures wound with etiology of trauma, other and is located on the left, lateral lower leg. The wound measures 4 cm length x 3 cm width x 0.2 cm depth. There is a medium amount of serous drainage noted. There is small (1-33%) pink granulation within the wound bed. There is a large (67-100%) amount of necrotic tissue within the wound bed including adherent slough . On April 28, 2021, V6 (Wound Care Physician) ordered wound cleansing and dressings to include, Cleanse wound with ¼ strength Dakin's solution and then with NS (Normal Saline). Protect periwound with skin prep. Apply alginate to wound bed. Apply [MEDICATION(S)] agent to wound bed [honey gel]. Cover wound with ABD. Secure dressing with [stretch gauze]. Change daily. Change prn (as needed) for soiling and/or saturation. A review of the EMR shows V6's orders from April 28, 2021 were not started until May 4, 2021. V6 continued to treat R1 weekly at the facility from April 28, 2021 to June 9, 2021 with continuing treatment orders. The facility does not have documentation to show R1's lower leg wound received physician-ordered wound treatment on April 24, 25, 26, 2021, May 1, 2, 8, 9, 15, 20, 21, 22, 23, 29, and 30, 2021, and June 6, 2021. On April 29, 2021 at 6:55 AM, V5 (RN/Wound Care Nurse) documented, Treatment: Writer spoke with [R1's] surgeon (V8) about [R1's] left lower extremity immobilizer. Surgeon gave orders that immobilizer must be on at all times during transfers and when the patient is up in her wheelchair. He said the immobilizer does not need to be on while the patient is in bed. The EMR shows the following order dated April 28, 2021, Per ortho recommendation, left knee immobilizer to be on when up from bed/during transfers. Off when in bed. Nursing documentation on the April and May 2021 TARs (Treatment Administration Records) shows nursing initials acknowledging V8's order. The facility does not have documentation to show if R1's knee immobilizer was ever removed or for what period of time R1 was without the immobilizer. Prior to May 28, 2021, the facility does not have any documentation to show V8 (Orthopedic Physician) was notified of the worsening skin breakdown R1 was experiencing due to the knee immobilizer brace. On May 19, 2021 V6 (Wound Care Physician) documented R1's left lateral lower leg wound was worsening. The wound measures 6.5 cm. length x 3.5 cm width x 0.5 cm depth. V6 documented R1 developed a second wound on the left lateral malleolus (ankle) measuring 1.2 cm. length x 1.5 cm. width x 0.1 cm. depth. The wound margin is distinct with the outline attached to the wound base. There is a large (67-100%) amount of necrotic tissue within the wound bed including adherent slough. V6 also documented R1 Has a trauma wound on the left lateral ankle due to the left lower immobilizer since 5/19/2021. V6 ordered wound care for R1's second pressure ulcer, including cleaning with Dakin's solution and normal saline, honey gel, and covering with a dressing. The EMR shows an order dated May 21, 2021 for, Left lateral ankle. Cleanse with NSS, apply [honey gel] and alginate with dry dressing daily. The facility does not have documentation to show treatment to R1's left lateral ankle was completed as ordered on May 22, 23, 29, 30, and June 6, 2021. On June 2, 2021, V6 (Wound Care Physician) documented R1's left lateral lower leg wound had exposed tendon. V6 documented R1's left lateral ankle wound was worsening and measured 2 cm. length x 2 cm. width x 0.2 cm. depth. On July 19, 2021 at 1:53 PM, V1 (Administrator) and V2 (Director of Nursing/DON) said it is their expectation that residents receive wound care as ordered by the physician. V1 said the facility is frequently using agency nursing staff who don't complete wound care on the weekends when the wound care nurse is not present in the facility. V2 said missed wound care treatments have been a problem at the facility. V2 also said the facility had difficulties with R1's telehealth visits during May 2021 and several of R1's visits with V6 (Orthopedic Physician) were missed. On July 19, 2021 at 2:56 PM V6 (Wound Care Physician) said, [R1's] wounds were caused by trauma and pressure from the immobilizer brace. It is my expectation the facility staff administer wound care daily as I order it. I expect them to start the orders within a day or two of me placing the order. They should also have been documenting the time the brace was being removed and put back on, so we had a good idea if the pressure was being taken off the wound. [R1] did end up developing two pressure ulcers due to the immobilizer brace, and one of the wounds did end up having tendon exposed. On July 20, 2021 at 12:22 PM, (V8) (Orthopedic Physician) said, I was told by the facility on April 28, 2021 [R1] was developing a small wound under her brace. A small wound, such as a Stage 1 pressure ulcer is not uncommon in the elderly population while wearing an immobilizer brace, however, I expect the wound can easily be controlled and cared for by a wound care team and wound care physician. If the wound gets worse, I should be notified. The resident was supposed to follow up with us, a few weeks after April 28, 2021 via a telehealth visit. The facility never did that. Our records show four visits for [R1] during the month of May 2021 that were never logged onto via the telehealth phone number by the facility. We were never told the extent of [R1's] pressure ulcer from the brace. Had I been made aware the wound had progressed to the extent the wound did, and had the facility kept the telehealth appointments with us, I would have discontinued the immobilizer brace much sooner, and possibly avoided such a serious wound where the tendon became exposed. I've never seen a wound progress this bad while receiving wound care from a wound care team and a wound care physician. On June 2, 2021, I told the facility they could get rid of [R1's] brace, but still was not informed of the extent of the wound. I was never made aware the resident left the nursing home and was hospitalized . After [R1] left the facility, I saw the resident and she had a wound vac device over her wound and had a plastic surgery consult. I had given an order the facility could take the immobilizer brace off while the resident was in bed back in April. After seeing [R1's] wound, I don't see how they could have been removing the brace. They should have kept track of the amount of time the brace was off the resident and if the wound was worsening, they should have informed me.

Based on interview and record review, the facility failed to ensure a safe, obstacle-free dry environment for a resident transfer and failed to assist a resident's request for toilet use in a timely manner. This failure resulted in R1 tripping over a towel and sustaining a [MEDICAL CONDITION], requiring surgical intervention. This applies to 2 of 3 residents (R1, R3) reviewed for falls with injury in the sample of 3. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was readmitted to the facility in (MONTH) (YEAR). R1 was discharged to home on (MONTH) 20, (YEAR) and no longer resides at the facility. R1 had multiple [DIAGNOSES REDACTED]. R1's MDS (Minimum Data Set) dated (MONTH) 10, (YEAR) shows R1 had severe cognitive impairment, was totally dependent on two facility staff members for transfers and toilet use, required extensive assistance with bed mobility, locomotion on and off the unit, dressing, eating, personal hygiene, and bathing. R1 was frequently incontinent of urine, and always incontinent of stool. The facility's fall risk assessment dated (MONTH) 27, (YEAR) shows R1 was a high fall risk. The facility's Incident Report dated (MONTH) 4, (YEAR) shows: On 10/2/2018 at 7:37 PM, assigned CNA (Certified Nursing Assistant) (V4) reported to nurse on duty that resident had a fall incident. Nurse on duty immediately went to resident's room. Resident noted lying in a supine position on the floor with both arms and legs extended, near the right side of bed. Locked shower chair behind resident and platform walker on the side of the resident. Room was well-lit and clutter free. A towel was placed on floor as resident had just been given a shower. On assessment, resident able to do usual movements of both upper and lower extremities. No new bruises, skin tears, cuts, abrasions or skin issues noted. Resident alert, oriented x 3, verbally responsive. Denies any pain or discomfort. Denies hitting her head or any other body part. Denies headache, dizziness or light-headedness. Per resident, she was transferring from the shower chair to the bed when she slipped on the towel. R1's Incident Report dated (MONTH) 4, (YEAR) shows R1 did not complain of pain on (MONTH) 2, (YEAR). R1 complained of pain on (MONTH) 3, (YEAR). Physician orders [REDACTED]. Hospital documentation shows R1 had a right hip hemiarthroplasty surgery on (MONTH) 5, (YEAR). On (MONTH) 4, 2019 at 1:10 PM, V2 (DON/Director of Nursing) said, the shower chair was used as a transport device for R1 from the shower to R1's room. V2 said the facility's shower chair can act as a transfer device and a shower chair. V4 (CNA) was alone and attempted to transfer R1. The incident report shows R1 fell over a towel that was placed on the floor. V2 said, The towel should not have been there. (V4) made the decision because the floor was wet and she put the towel there to dry the floor. The cause of the fall was the towel. The resident had a history of [REDACTED]. The CNA should have been using a gait belt but the CNA said the resident was naked and she did not apply the gait belt to the resident because she didn't have clothes on. The CNA wanted to apply the clothes prior to using the gait belt but never got the chance. On (MONTH) 4, 2019 at 2:44 PM, V4 (CNA) said due to the length of time that had passed since the incident, she could not recall any specifics related to the incident and her written statement to the facility would be more accurate than an interview at this time. V4's written statement dated (MONTH) 2, (YEAR) shows V4 was alone in the room with R1 and the resident fell over a towel after her shower was given. V4 said in her statement: (R1) was standing up, moving to the bed, (V4) had just given shower. (R1's) feet were wet, so towel was placed on floor to keep from slipping on floor. As (R1) moved, foot got tripped on towel, patient went down slow. On (MONTH) 4, 2019 at 3:05 PM, V6 (Director of Therapy) said, R1 initially required a mechanical lift device for transfers but was upgraded to a one person, moderate assist with transfers on (MONTH) 28, (YEAR). V6 said R1 also used a platform walker. V6 said, Therapy recommendations to residents and facility staff are based on the fact the environment has been determined to be safe and free of water or obstacles such as towels. On (MONTH) 4 2019 at 4:53 PM, V5 (Physician) said R1 was at an extremely high risk for falling. V5 said, The fall definitely caused (R1's) fracture, resulting in the need for surgical repair. As a healthy person, I know I would not trip over the towels on the floor but she had a lot of medical problems. V5 said the combination of R1's medical condition and the towel on the floor caused R1's fall. The facility's Fall Prevention Policy dated (MONTH) (YEAR) shows: Policy: This facility is committed to minimizing resident falls and/or injury so as to maximize each resident's physical, mental and psychosocial well-being. While preventing all resident's fall is not possible, it is this facility's policy to act in a proactive manner to identify and assess those residents as risk for falls, plan for preventive strategies, and facilitate a safe environment as possible. The facility's Accident Prevention and Resident Supervision Policy, dated (MONTH) (YEAR) shows: Policy: This facility ensures to provide an environment that is free from hazards over which the facility has control and provides appropriate supervision and assistance devices to each resident to prevent avoidable accidents. This includes systems and processes designed to: 1. Identify hazards and risks; 2. Evaluate and analyze hazards and risks; 3. Implement interventions to reduce hazards and risks; and 4. Monitor for effectiveness and modify approaches as indicated; 5. Residents receive supervision and assistive devices to prevent avoidable accidents. Avoidable Accident means that an accident occurred because the facility failed to: Identify environment hazards and individual resident risk of an accident, including need for supervision; and/or evaluate/analyze the hazards and risks; and/or Implement interventions, including adequate supervision, consistent with a resident's needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident. 2. The EMR shows R3 was recently readmitted to the facility on (MONTH) 21, 2019 with multiple [DIAGNOSES REDACTED]. R3's MDS dated (MONTH) 28, 2019 shows R3 is cognitively intact, is able to eat with supervision, requires limited assistance with personal hygiene, and requires extensive assistance by facility staff with bed mobility, transfers between surfaces, locomotion on and off the unit, dressing, toilet use, and bathing. R3 is occasionally incontinent of urine and always continent of bowel. R3's POS (Physician order [REDACTED]. orally every day for her hypertension, and Xarelto (blood thinner) 10 mg. orally every day. On (MONTH) 5, 2019 at 9:35 AM, R3 was sitting in the wheelchair in her room. R3 had noticeable facial bruising around her bilateral eyes, nose, forehead and neck. R3 had a swollen area on her forehead over her left eye. R3 said she is only 25% weight-bearing due to a fall she sustained at home in (MONTH) 2019 and she is residing at the facility to receive therapy services. R3 said, On (MONTH) 29, I used the call light to ask for help going to the bathroom, and the CNA came and turned it off and said she would return in a minute. A minute turned into longer so I tried to go by myself. I take [MEDICATION NAME] four times a day for my liver [MEDICAL CONDITION], and it makes me have frequent bowel movements. Unfortunately, I don't get a lot of notice. When the urge strikes me I have to go now! I also take a diuretic, so I have to urinate frequently and if I don't get into the restroom, I will wet myself. I had to go so bad. I thought my wheelchair was closer to me than it was. I got up to get my wheelchair and then I felt weak and fell . They sent me to the hospital. I didn't need stitches, but I'm on a blood thinner so I bled a lot from my nose. They did a CT scan on my head and neck. Luckily I didn't damage my new hip. Hospital documentation dated (MONTH) 29, 2019 for R3's CT scan of the brain shows, prominent left frontal scalp hematoma, left frontal and periorbital soft tissue hematoma. On (MONTH) 5, 2019 at 9:51 AM, V7 (CNA) said, I came into the building to start my shift at 7:00 AM on (MONTH) 29. I was late that day. I saw (R3's) call light was on. I went in the room and turned off the call light. I told her to let me go punch in and check the schedule and I would be back. When I came back, they said she was on the floor and had fallen. I can't say exactly how much time had passed. I did not ask anyone else to help her when I turned off her call light. She is able to transfer herself from the wheelchair to the toilet, but she can't walk by herself. The facility provided documentation to show they reviewed their security camera footage which showed R3 turned her call light on at 7:06 AM and V7 (CNA) entered the room at 7:07 AM, turned off the call light, and left the room. At 7:17 AM facility staff standing outside R3's room heard R3 calling for help and at 7:18 AM, CNAs and nurses came to the room to assist R3 after falling. On (MONTH) 5, 2019 at 12:43 PM, V2 (DON) said, The facility does not have a call light policy. The staff is not supposed to turn off the call light until the need is met. The CNA should not have turned off (R3's) call light until she received the requested assistance.

Based on interview and record review, the facility failed to ensure that residents received sufficient interventions to adequately manage pain; failed to anticipate resident's pain and develop interventions to address severe pain; failed to recognize pain in a cognitively impaired resident; failed to recognize and evaluate the existing pain for a resident These failures resulted in R1 suffering ongoing severe pain daily over a period 3 weeks. R1's pain interfered with his sleep and activity level, and hampered his ability to reach his full potential to progress in therapy. These failures also resulted in R20 being in pain with an undiagnosed right ankle fracture for a number of days before receiving treatment. This applies to 2 residents (R1, R20) out of 11 reviewed for pain in the sample of 23. The findings include: 1. R1 was admitted to the facility on [DATE] with multiple diagnoses, including effusion of joint and infection, according to the admission Minimum Data Sets ((MDS) dated [DATE]. R1 has pain "almost constantly" which affects his sleep and day-to-day activities according to the MDS dated [DATE]. R1 has impaired range of motion in his left knee due to an infection (status [REDACTED]. From 4/12/13 to 5/1/13 R1 had orders for PRN (as needed) pain medications but no orders for scheduled pain medication according to review of the physician order [REDACTED]. On 4/22/13, R1's pain medication order for [MEDICATION NAME] was changed from 5 mg-325 mg (2 tablets) to 10 mg-325 mg (1 tablet) every 4 hours as needed. This change resulted in a decrease in the amount of pain medication being given - from 650 mg of [MEDICATION NAME] to 325 mg per dose - at a time when R1 was experiencing severe pain. On 4/27/13, an order for [REDACTED]. E2 stated that the nurse should have clarified the order with the doctor because the new order for [MEDICATION NAME] resulted in less pain medication per dose. R1 suffered from severe pain daily at an intensity level of 7 - 10 (on a scale of 0 - 10) according to the MAR, Occupational Therapy notes, and/or Physical Therapy notes dated 4/13, 4/14, 415, 4/16, 4/17, 4/18, 4/19, 4/20, 4/21, 4/22, 4/23, 4/24, 4/25, 4/26, 4/27, 4/28, 4/29, and 4/30/13. R1 received PRN pain medication 2 - 7 times a day according to the MAR for April 2013. "Severe Pain" is described as a pain intensity of 7 -10 according to the MAR. Occupational Therapy notes dated 4/22/13 and 4/24/13 document that R1's pain appears to be affecting his activity tolerance and limits his activity. Occupational Therapy notes dated 4/26/13 and 4/29/13 document that R1 expresses anxiety over his pain level "which he perceives as his lack of ability for ADLs." Physical Therapy notes dated 4/18/13 document that R1's pain level was 9 and he refused some therapy because of increased knee pain. Physical therapy notes dated 4/23/13 and 5/1/13 document that R1's progress is limited due in part to pain. R1's pain prohibits him from participating in therapy per nursing, according to the Nurse Practitioner assessment dated [DATE]. R1 verbalized that he was experiencing 'excruciating pain' according to nursing notes dated 4/23/13. R1's care plan does not address R1's constant pain and does not provide interventions for providing a regular pain management regimen, nor does it provide interventions for providing pain medications prior to physical and occupational therapy. On 5/1/13 at 9:30 AM, R1 said that he was having a lot of pain in his left leg. R1 rated his pain at a level 8 on a scale of 0 - 10. R1 stated that he is in pain "all of the time" and that he cannot fully participate in therapy because of his pain. R1 said that his pain keeps him awake at night. R1 stated that his pain has gotten worse since he has been in the facility. R1 said he has no objection to taking regularly scheduled pain medication. On 5/1/13 at 10:10 AM, R1 stated that his pain level was still at a level 8, despite receiving [MEDICATION NAME] 10 mg-325 mg at 8:20 AM and [MEDICATION NAME] 25 mg at 9:25 AM (per the MAR). On 5/1/13 at 12:55 PM, Z4 (Occupational Therapy) stated that she has worked with R1 over the past week. Z4 said that R1 was experiencing "a lot of pain" prior to starting therapy on 4/22, 4/25 and 4/26/13. Z4 said that R1 was frustrated with the level of pain he was experiencing. The facility's policy titled "Pain Management" states that pain relief measures will be evaluated and documented in the progress notes and MAR (medication administration record." 2) R20, a [AGE] year old resident with multiple [DIAGNOSES REDACTED]. The description of the incident describes that on 4/4/13 at around 2:30pm R20 complained of right leg pain. Upon assessment, the leg was found to be swollen, slightly warm to touch with pain upon movement. Relief was achieved with rest and pain medication. The NP (nurse practioner) was contacted and an order for [REDACTED]. The right foot shows a hallux deformity with [MEDICAL CONDITION] changes." Documentation shows that R20 was seen by the NP on 4/3/13 and was told about R20 having on and off pain including bilateral leg pain. Orders were given for some labs and a new order for a [MEDICATION NAME] 12mcg every 72 hours. No further evaluation or assessment is documented. On 4/4/13 the NP saw R20 again with no new orders. R20 was allowed to rest in bed with the leg elevated. At 7pm the resident was reassessed and the right ankle area to the right foot was swollen, with slight warmth. R20 said she had pain with movement in the leg but she had general body ache at the same time. The physician was called and the order was received for the Xrays. Once results were obtained, R20 was sent to the hospital for evaluation. During routine record review it was noted that on three different dates, 3/16/13, 3/23/13, and 3/28, R20 had documentation of significant bruising to the right leg. On 3/16/13 the resident was "noted with purplish discoloration on the right anterior leg" measuring 7.5cm x 4cm. The NP was notified with no new orders given. Subsequent nurses notes document continuing complaints of pain in the legs and other areas. R20 was again found to have another bruise to the right lower leg on 3/23/13 at 6 am while being changed. The new area was described as being 5 x 8 cm, purplish in color surrounding it with approximately 1.5 x 3 cm blackish discoloration. R20 was unable to say what had happened. The treatment nurse was made aware. Diagrams of both areas indicate that they are on two different areas of the leg. The notes between 3/23/13 and 3/28/13 indicate continued brusing apparent on this area and periodic complaints of pain. On 3/28/13 a nurses note documents "still noted with purplish discoloration on right lower leg skin is intact. Also resident was noted with bruise on her right anterior foot." Investigation of these bruises of unknown origin were presented for 3/16/13 and 3/23/13. E2 the director of nursing (DON) was unable to provide any information for the 3/28/13 observations. During this time R20's complaints of pain were increasing. R20 who according to the most recent MDS (minimum data set) dated 3/12/13 has a cognitive score of 3 out of 15 and is not always able to specify the location of her pain. Though R20 was experiencing increasing pain and discomfort and at least three episodes of bruising of unknown origin in less than two weeks, comprehensive evaluation was not done to determine the extent of R20's injuries causing her prolonged discomfort. E2 was asked if there was any further documentation of evaluation by rehab, restorative, treatment nurse, nurse practioner or physician that would help find the cause of the injuries . Though the two investigative reports presented refer to input from the other disciplines, no documentation was available at this time.

Based on observation, record review, and interview the facility failed to maintain an infection control system which: 1. Ensured residents at the facility did not acquire a high rate of infections at the facility, specifically[DIAGNOSES REDACTED] (clostridium difficile) and ESBL (extended spectrum beta lactamase) infections. 2. Developed an Infection Control Committee which identified, analyzed, and implemented interventions to decrease/eliminate facility acquired infections. 3. Ensured the infection control tracking log was accurate and complete. 4. Ensured contact isolation protocol was followed regarding isolating residents and discontinuing isolations. 5. Ensured contact isolation rooms and community bathrooms were cleaned/disinfected with the appropriate chemical agents to kill the infective[DIAGNOSES REDACTED] organisms. 6. Ensured facility staff was educated on the infective organisms of residents in isolation. 7. Ensured linens were not contaminated when being handled in the Laundry Dept. 8. Ensured residents with infections who needed isolation were cohorted with residents with the same infections. 9. Ensured facility staff washed their hands when needed. 10. Ensured glucose monitoring machines were disinfected after being used on residents who required blood glucose monitoring. Due to these failures E1 (Administrator) and E2 (Director of Nurses) were informed that an immediate jeopardy existed in the area of infection control. E1 and E2 were notified of the immediate jeopardy on [DATE] at 3:30 p.m. While the immediate jeopardy was removed on [DATE], the facility remains out of compliance at a severity level 2. Additional time is needed to monitor and evaluate the effectiveness of staff training and education, and correct implementation of policies and procedures. This is for 8 residents in the sample of 24 (R3, R14, R16, R10, R17, R21, R24, R4) and 13 supplemental residents outside of the supplemental sample (R141, R142, R47, R135, R92, R60, R41, R71, R26, R91, R125, R116, R97). This failure has the potential to affect every resident in the facility. The findings include: 1. Review of the facility's infection control logs for February, March, April, 2011 showed from [DATE] to [DATE] eleven residents (R141, R142, R47, R135, R24, R92, R3, R60, R14, R41, and R16) had[DIAGNOSES REDACTED] at the facility. Nine of the above eleven residents (R141, R135, R24, R92, R3, R60, R14, R41, and R16) acquired the[DIAGNOSES REDACTED] infections at the facility. This showed the facility had a 72% rate of[DIAGNOSES REDACTED] acquired infections from [DATE] to [DATE]. Review of the infection control logs showed of the 8 acquired[DIAGNOSES REDACTED] infections, 1 was acquired in Feb. 2011, 3 were acquired in Mar. 2011, and 4 were acquired in Apr. 2011. Review of the infection control logs from [DATE] to [DATE] showed 8 residents with ESBL infections of the urine. Two of the ESBL infections (R21 and R60) were community acquired and 6 of the ESBL infections (R71, R26, R91, R21 (second infection), R17, R125, and R60) were facility acquired. Of the 6 facility acquired ESBL's of the urine 3 of the infections were acquired in Feb. 2011, 1 was acquired in Mar. 2011, and 2 were acquired in Mar. 2011. Interview with E3 (Assistant Director of Nurses) on [DATE] at 1:30 p.m. noted E3 to say all of the residents who acquired[DIAGNOSES REDACTED] and ESBL at the facility had no signs and symptoms of[DIAGNOSES REDACTED] or ESBL before they acquired the infections. When E3 was asked why residents were acquiring infections at the facility, E3 stated, "I don't know." 2. Further interview with E3 noted E3 to say the facility had no Infection Control Committee at the facility which identified, analyzed, and developed interventions to decrease and/or eliminate facility acquired infections. 3. Review of the Infection Control Tracking Log showed the log to be inaccurate and incomplete. Review of the Infection Control Tracking Log dated ,[DATE] to [DATE] showed 9 resident in contact isolation. Five of the 9 residents (R135, R3, R47, R4, R14, R41, and R16) were identified occupying the wrong rooms. This log also showed R47 had been removed from isolation on [DATE]. R47 was observed in contact isolation on [DATE]. Review of the Infection Control Log dated [DATE] to [DATE] showed one resident (R10) was not listed on the log as being in contact isolation. R10 was observed in contact isolation for VRE ([MEDICATION NAME] resistant [MEDICATION NAME]) on [DATE] during the initial tour of the facility. Interview with E3 (Assistant Director of Nurses/Infection Control Nurse) on [DATE] at 1:30 p.m. noted E3 to say R10 had been placed in contact isolation on [DATE] for VRE of a coccyx wound. 4. Review of R16's nurses notes showed R16 was having LBM's (loose bowel movements) and showing signs and symptoms of[DIAGNOSES REDACTED] on [DATE]. Nursing documentation showed R16 had 8 LBM's on [DATE] which 4 LBM's were documented as being watery and foul smelling. Stool collection for[DIAGNOSES REDACTED] and antibiotic therapy was ordered. There was no documentation that R16 was placed into contact isolation for possible[DIAGNOSES REDACTED] on [DATE]. R16 was exhibiting signs and symptoms of[DIAGNOSES REDACTED] on [DATE] but according to the Infection Control Log R16 was not placed into contact isolation until [DATE] (2 days later). Review of the facility's policy on Clostridium Difficile Associated Disease (CDAD) showed, "Contact precautions should be used for CDAD residents with diarrhea." The policy also notes, "A resident is considered to have symptomatic CDAD when: 1. Resident exhibits clinical symptoms, eg., diarrhea, watery or unformed stools occurring more than 3 times per day above the norm for that resident. 2. Resident usually tests positive for both the [DIAGNOSES REDACTED]icile organism and its toxin. On [DATE] during the initial tour of the facility 6 residents were observed in contact isolation for[DIAGNOSES REDACTED] (R135, R3, R47, R14, R41, and R16). Review of documentation on R16's CNA Documentation Record for [DATE] showed R16 only had 4 BM's (bowel movements) from ,[DATE] to [DATE]. Interview with Z4 (Hospice CNA) on [DATE], Z3 (Hospice CNA) on [DATE], and E12 (CNA) on [DATE] noted all to say R16 was not having LBM's. All interviewed could not remember when R16 had a LBM. R16 remained in contact isolation until [DATE]. After review of the facility's Infection Control Log, observing residents in isolation for[DIAGNOSES REDACTED] without signs and symptoms, and questioning why residents remained in isolation for[DIAGNOSES REDACTED], the other 5 residents were removed out of contact isolation. R10 was removed out of isolation on [DATE]. R14 was sent to a nearby hospital on [DATE]. R41 was removed out of isolation on [DATE]. R3 was removed out of isolation on [DATE]. R135 was removed out of isolation on [DATE]. Review of CNA documentation and nurses notes showed all of these residents were asymptomatic of[DIAGNOSES REDACTED] and had gone more than 72 hours with formed stools. The facility's CDAD policy regarding discontinuation of isolation noted, "Contact precautions should continue until diarrhea ceases." It also noted, "If no episodes of diarrhea are noted x 48 hours, consult with Infection Control Coordinator and resident physician to discontinue... If no episodes of resident, physician to discontinue isolation." Telephone interview with Z1 on [DATE] at 1:35 p.m. noted Z1 to say, "Isolation for[DIAGNOSES REDACTED] should be discontinued when the resident has not had diarrhea for 3 days per isolation protocol." 5. On [DATE] E19 (Housekeeper) was observed cleaning/disinfecting R16's room. R16 was in contact isolation for[DIAGNOSES REDACTED]. E19 used a spray glass cleaner to wipe down R16's over bed table, dresser, bedside table, window sill and vent. E19 did not wipe down R16's bedrolls. E19 used a disinfectant bathroom cleaner to clean R16's toilet and a glass cleaner to clean the mirror and sink. After E 19 cleaned R16's room and bathroom E19 mopped R16's floor with water which contained a disinfecting floor cleaner. Review of the cleaning/disinfectant product labels and product literature showed none of the cleaning/disinfectant products were effective at killing C-Doff. Interview with E 24 (Housekeeping Supervisor) on [DATE] noted E 24 to say she did not know the cleaners/disinfectants the staff were using to clean/disinfect the residents' rooms did not kill the C-Doff organism. On [DATE] E21 (Housekeeper) was observed cleaning/disinfecting a community shower room in which R141 had just been given a shower. R141 is a resident who has[DIAGNOSES REDACTED] infection. E21 sprayed glass cleaner on the lower wall tiles and shower chair, then sprayed the lower wall tiles with a disinfectant bathroom cleaner. E21 mopped the floor with a disinfectant floor cleaner solution. Review of product literature showed the glass cleaner, the disinfectant bathroom cleaner, nor the disinfectant floor cleaner solution was effective at killing C-Doff. E21 did not wipe both grab bars, the shower faucet, the shower head, nor the shower room door knob. E21 did go back and use a hospital cleaner disinfectant with bleach (which kills C-Doff after 5 minute contact) on the shower chair, 1 grab bar, the door knob, and light switch, but did not use the product as directed. E21 sprayed the hospital cleaner disinfectant with bleach on the above mentioned items and immediately wiped the items with a dry cloth. This product required a 5 minute contact time to kill[DIAGNOSES REDACTED]. On [DATE] E23 (p.m. Housekeeper) was observed ineffectively cleaning a[DIAGNOSES REDACTED] contact isolation room. E23 mopped the floor with a floor cleaner solution that was not effective with killing[DIAGNOSES REDACTED]. On [DATE] E 23 was again cleaning/disinfecting a[DIAGNOSES REDACTED] contact isolation room. E24 (housekeeping supervisor) stood by to observe. E24 stated E23 was using a new product which was effective at killing[DIAGNOSES REDACTED]. Again E23 ineffectively cleaned the room. Product information did show the new product was effective at killing[DIAGNOSES REDACTED] but a 10 minute contact time was required. E23 was observed wiping the product right away after spraying. E 23 also used a hospital germicide disinfectant to mop the floor. Product literature showed the germicide disinfectant did not kill[DIAGNOSES REDACTED]. There was also a resident's wheel chair with plastic cushion and bedside commode in the room. These items were not cleaned/disinfected when the room was cleaned. On [DATE] E19, E25, and E26 were observed terminally cleaning a contact isolation room in which a resident had been removed from isolation who had[DIAGNOSES REDACTED]. The terminal cleaning was ineffective due to the resident's bathroom not being cleaned and the hospital disinfectant solution used was not effective in killing[DIAGNOSES REDACTED]. Interview with E24 (housekeeping supervisor) noted E 24 to say, "We won't clean the bathroom because R 35 didn't use the bathroom, she used a bedside commode and the residents in the adjoining room used the bathroom." Nursing staff was observed in their PIPE (personal protective equipment) leaning against the bathroom sink to wash their hands and staff used the bathroom to empty R135's bedside commode. E24 was informed the bathroom had to be disinfected. 6. Interviews with Housekeeping staff E19 on [DATE] at 11:45 a.m., E21 on [DATE] at 10:40 a.m., and E23 on [DATE] at 3:30 p.m. noted all to say they did not know why residents in contact isolation were in contact isolation. Each of the housekeepers were observed ineffectively cleaning either resident rooms with[DIAGNOSES REDACTED] or community shower rooms after a resident with[DIAGNOSES REDACTED] had been showered. Each housekeeping staff admitted that they are not trained/informed of the specific infective organism for which the resident is isolated. Interview with E24 (Housekeeping Supervisor) also disclosed that the housekeeping staff is not trained or informed of infective organisms requiring resident isolation. 7. On [DATE] during the general observations of the facility the Laundry Dept. was observed. E18 (Laundry Aide) was observed folding clean linen to be prepared for use on the residents beds. E18 was observed folding comforters and blankets. While E18 was folding the comforters and blankets, E18 was letting the comforters and blankets touch and drag on the floor. When the surveyor intervened and told E18 that she was contaminating the linens, E18 first denied that the linens were touching/dragging on the floor. E14 (maintenance supervisor) witnessed the linen touching/dragging the floor and also informed E18 the linen was contaminated. E 18's response was, "The housekeeper mopped the floor before she left so it's ok." E 18 had to be informed that the linen was now contaminated and had to be washed again. 8. R17 was listed on the infection control log as having positive (+) ESBL (Extended Spectrum Bata Lactamase) in urine, that is health associated. The date of onset was [DATE], the date resolved was [DATE]. The laboratory report of a urine culture collected on [DATE] and reported [DATE] showed Escherichia coli ESBL greater than 100,000 colonies/ml. with an antibiotic ordered for 7 days. E2 (director of nursing) was interviewed on [DATE] and review of facility policy: "Infection control, ESBL" revised [DATE] states that isolation contact precautions may be discontinued when the resident is no longer exhibiting signs and symptoms of active infection, or when re-culturing results are negative for ESBL. The policy also states that re-culturing is not routinely recommended, but if ordered, it should be done 72 hours after discontinuation of antibiotic therapy or when in the judgement of the physician the resident is no longer infected. A resident is considered clear after two negative cultures are obtained, each one week apart." E2 said that the facility rule is to have 2 negative cultures to be removed from isolation. R 17 had two urinalysis test done on [DATE]- one at 06:00, and one at 13:30 both were negative and used to remove R17 from isolation. These tests were not done according to policy -one week apart. Another part of this policy is that residents with ESBL will have their own room or be cohorted with a resident with the same infection. R17 had this infection 2 months in a row, and her roommate has not had this infection. -R24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] R24 was transferred to room [ROOM NUMBER]. On [DATE] R24 was seen by physician for protrusion of tissue of colononostomy site (with colostomy) and stool specimen collected, stool output noted loose, slimy and greenish. On [DATE] stool specimen result was positive for[DIAGNOSES REDACTED], and R24 placed on [MEDICATION NAME]. [MEDICATION NAME] was discontinued and [MEDICATION NAME] started four times a day for 14 days. R24 remained in room [ROOM NUMBER] and placed on isolation for[DIAGNOSES REDACTED]. R 24's roommate (R117) was alert and oriented to person with periods of confusion. R24 and R117 remained roommates residing in the facility's cognitively impaired unit until R24 expired on [DATE]. Interview with E3 (Infection Control Nurse) on [DATE] at 5:dpm, E3 said he assumed that since R24 had a colostomy the[DIAGNOSES REDACTED] was contained. E3 said he did not consider that both residents were cognitively impaired, he should have placed R24 in a private room or with another resident with[DIAGNOSES REDACTED]. Review of the facility's Clostridium Difficile Associated Disease (CDAD) policy and procedure dated [DATE] documents for treatment of [REDACTED]. Cohort symptomatic[DIAGNOSES REDACTED] residents only with other symptomatic[DIAGNOSES REDACTED] residents. Review of the facility's isolation surveillance tracking log dated [DATE] shows R24 was positive for health associated (facility acquired) CDC on [DATE]. 9. Observation blood sugar testing on [DATE] at 6:30a.m., E35 performed testing for R116 at 6:30a.m.; E35 wiped the blood glucose-testing machine with a Hospital Cleaner Disinfectant Towels with Bleach for less than 20 seconds. Manufactures' directions are: to clean and disinfect the meter, wipe with towel until completely wet let stand for 2 minutes. After completion of the test, E35 removed her gloves and placed the meter on the treatment cart, did not wash hands and went to R97 for glucose testing. E35 placed on gloves wiped, the meter for approximately 30 seconds performed the test removed the gloves placed the meter on the cart no hand washing done. E35 went to R4 who is in isolation for Methicillin Resistance Staph Aureus (MRSA) of the urine. E35 placed on gloves and went into the isolation room and performed the glucose testing, removed the gloves, and placed the meter on the cart. E35 did not wash hands after the procedure. E35 went to R10 to perform the glucose testing wiped the meter waited approximately 40 seconds and went to R10 to perform the glucose testing. E35 performed the same process of not washing hands and placing the meter on the cart. E35 did not have alcohol base on the cart nor did she use soap and water after procedures. Interview with E35 after the observations, E35 stated she knew she was suppose to wait 2 minutes for the cleaning and disinfecting of the glucose meter and stated she forgot to wash her hands. E35 was not aware of any special requirements for residents who are in isolation. The facility has identified 34 residents in the facility that receives blood sugar monitoring. Four of the 34 residents have infections for which the facility states require contact isolation: R4 (MRSA) of the urine. R10 [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE) of the wound R21 Extended Spectrum Beta Lactamase (ESBL) of the urine and R41 with Clostridium Difficile ([DIAGNOSES REDACTED]). 10. The facility designates residents with coexisting chronic diseases such as diabetes, arthritis, cancer ,COPD, anemia , as high risk for developing infections. A review of the facility's policy and procedure on blood Glucose monitoring dated ,[DATE] documents hand hygiene and gloves point #2 and #3 change gloves between each resident contact, perform hand hygiene immediately after removal of gloves and before touching other medical supplies intended for on all residents. The facility presented the training provided to E35 on [DATE]. The training documents the care and maintenance of the glucometer. The training failed to incorporate the cleaning and disinfection of the glucometers. The immediate jeopardy for the above referenced F-tag was abated by 9:00 am on [DATE]. Due to the nature and severity of breach in the infection control practices all staff are being educated to the appropriate practices and are identified as such throughout this abatement. In order to assure that every person in the respectable job classifications have in fact gotten the required training the following is done every shift: A cross referencing of all employees is done daily by comparing the employees already inserviced to the schedule of each department. No employee will be allowed to work without receiving the appropriate education. The following has been put into place related to the Nursing Department: The Peri Care and Catheter policy was revised on [DATE] Changes made to the policy are as follow: o The policy previously did not specify that the catheter tubing should be cleaned. The new policy states that after the peri area is cleaned the area at the catheter site should be cleansed with a clean washcloth moistened with soap and water. The C.N.A. or nurse will start from the point of insertion and clean towards the bag. o C.N.A.'s and nurses have worked have been educated on this change as of [DATE]. No one can work without this education. o Proper catheter care is being spot checked daily by our wound care nurse or designee for four weeks and then reassessed for frequency thereafter. Wound care nurses were trained on [DATE] and [DATE]. On [DATE], the policy related to cleaning of the glucometer between residents was revised to reflect the manufacturer's recommendation of air-drying for two minutes in between resident use. The product used for cleaning the glucometer's is Dispatch with Bleach. o The nurses performing this procedure have been educated, as of [DATE]. No one can work without this education. On [DATE], the policy for cleaning shared equipment such as scales, mechanical lifts, shower chairs, etc., was revised to assign the responsibility of cleaning this equipment in between resident use to the C.N.A. The policy states that Dispatch with bleach will be used. All this equipment has been terminally cleaned as of 6am on [DATE] by the night shift housekeeping staff member who has been trained to do so RN. The C.N.A.'s have been inserviced on [DATE] to clean this equipment after each resident use using Dispatch with Bleach by the infection control nurse and cannot work without this education ? A policy was developed on [DATE] regarding isolation/surveillance tracking. A tracking log was developed and will be updated on a daily basis by the Infection Control Nurse or designee and will be reviewed at the weekly infection control committee meeting for any trends, clusters or anything unusual. Recommendations as it relates to the tracking log will be referred to the QI Committee for their recommendations. The log includes the following information: ? Name of resident & Room # ? Date of admission ? Type of infection/isolation ? Health Associated or community acquired ? Date of onset ? Treatment ? Next culture due/comments ? Effective [DATE], no residents on isolation will be cohorted with residents who are not on isolation under any circumstances. The Infection Control policy has been updated to reflect this. The nurses have been educated on this practice and cannot work without this education. ? Inservicing has been done as follows o Handwashing o Effectiveness/non-effectiveness of hand sanitizer (hand sanitizer not effective for[DIAGNOSES REDACTED]) o Proper use of PPE o Proper Peri Care and catheter care o Disinfecting glucometer's in between resident use, using Dispatch with bleach wipes and the necessity of air-drying for two minutes (as per the manufacturer's recommendation) before using for the next resident. o Dedicated equipment is now provided for residents on isolation. This equipment includes blood pressure cuff, stethoscope, thermometer, pulse oximeter, if applicable and glucometer, if applicable. - o All residents in isolation were given their own dedicated equipment on [DATE] II. (BP cuff, stethoscope, thermometer and puIse oximeter and glucose machine if indicated). This equipment is place In a plastic bag with the resident's name on the bag and kept at the bedside. The presence of this equipment is being monitored by the night shift Supervisor on a daily basis and he/she is recording the findings on a monitoring log which is kept in the nursing office. Any missing dedicated equipment will be replaced immediately. The equipment is kept in the medical supply room. Placing this equipment in the isolation rooms initially will be the responsibility of the admitting nurse or by the nurse on duty when a current resident is placed on isolation. Inservicing has taken place on this change in practice. The following has been put into place related to the Housekeeping Department: ? The following policies have been revised/developed: o On [DATE], the policies related to terminal cleaning of[DIAGNOSES REDACTED] rooms, cleaning of an occupied[DIAGNOSES REDACTED] room have been revised to include that all[DIAGNOSES REDACTED] rooms must be cleaned using Dispatch with bleach. o On [DATE] step by step procedures were developed for the aforementioned policies as well as generalized room cleaning and generalized isolation room cleaning. These procedures have been translated into Spanish as well. o On [DATE], the Housekeeping Supervisor was re-educated on the following by an outside consultant Generalized cleaning of resident rooms, cleaning of isolation rooms (with particular emphasis on[DIAGNOSES REDACTED] rooms), terminal cleaning of isolation rooms (with particular emphasis of[DIAGNOSES REDACTED] rooms), and cleaning of shower beds. o The Housekeeping Supervisor, inserviced the day shift Housekeeping staff prior to them beginning their shift. Beginning on [DATE], the ,[DATE] Housekeeping staff on duty was inserviced on generalized cleaning of resident rooms, cleaning of isolation rooms (with particular emphasis on[DIAGNOSES REDACTED] rooms), terminal cleaning of isolation rooms (with particular emphasis of[DIAGNOSES REDACTED] rooms), and cleaning of shower beds. On [DATE], all day shift housekeeping staff on duty, were inserviced on theses same topics prior to beginning their work day. No housekeeping staff members will be allowed to work until they have received this same education. The 3 ~ 11 Housekeeping staff on duty on [DATE] were inserviced after a telephone conference with the sales rep This inservice training was translated in Spanish by the Housekeeping Supervisor A sign has been posted at the employee time clock informing all housekeeping staff that they must report to their supervisor for training before beginning their shift. This sign is written in both English and Spanish. ? On [DATE], a policy regarding the cleaning of shower beds was developed. This policy states that shower beds will be disinfected with Dispatch with bleach. ? All Housekeeping personnel that have worked were also educated on the following: o Handwashing Inservicing has taken place o Proper use of PPE Inservicing has taken place o Shower Bed Cleaning Inservicing has taken place ? Miscellaneous: o Beginning on [DATE], daily Spot check monitoring is being done by the Housekeeping Supervisor on the following: ? Generalized cleaning of isolation rooms ? Shower rooms and shower bed cleaning ? treatment of [REDACTED]. ? Handwashing Beginning on [DATE], daily spot checks of 10 resident rooms are being done to assure compliance with the policies and procedures. This will continue for the next four weeks and then reassessed for frequency thereafter. The Housekeeping Supervisor will turn in the completed spot check log to the facility's Administrator. The Administrator will randomly check 5 rooms per day and observe the actual cleaning of those rooms to ensure compliance. o Effective [DATE], housekeeping staff will be scheduled on the night shift to ensure continuity of safe infection control procedures 24 hours per day, 7 days per week. Other items put in place: ? An Infection Control Committee was created and met on [DATE]. This Committee will meet on a weekly basis on an ongoing basis. This Committee consists of: o Facility Infection Control Nurse o Director of Nursing o Administrator o Active Rehab Representative o C.N.A. o Therapy o Housekeeping Director o Medical Director o Wound Care Nurse o Dietary Manager o Social Service Director Staff members from all departments that have been on duty have been educated on handwashing and the proper use of PPE. Inservicing is ongoing and staff who have not received training will not be allowed to work. A sign has been placed by the time clock. By [DATE], families/significant others were contacted for all residents who are on isolation and education to those loved ones has taken place either in person or verbally by phone until they are able to come in to be personally trained. The Social Service Department will be responsible for contacting the family members of any new admissions with isolation/new onset isolations to inform them that they must receive education regarding the isolation precautions prior to visiting. A note will be placed on the 24 hour report, as well as in the progress notes, by Social Services to notify nursing that this training must take place. The Social Workers were educated by the Administrator and are currently performing this task. As of [DATE] the disciplinary process related to breaches in infection control practices are no longer following the process of verbal warning, written warning, 3-day suspension and termination. It is now a 2-step process, the first step being 3-day suspension and then termination. Union stewards have been notified. All equipment that could potentially be used by another resident i.e. shower beds, shower chairs, mechanical lifts, scales, etc. were terminally cleaned on [DATE] by the Housekeeping staff using Dispatch with Bleach. C.N.A.s have been educated that all shared equipment must be cleaned using Dispatch with Bleach between residents A second shower bed has been borrowed from another facility and a new one ordered in order to assure that residents not having[DIAGNOSES REDACTED]icile do not use a shower bed/chair of residents that do have[DIAGNOSES REDACTED]icile. On Saturday, [DATE] and Sunday, [DATE], every room including offices and closets has been terminally cleaned with Vlrasept, effective in killing[DIAGNOSES REDACTED]. Two chairs with fabric upholstery, were discovered in isolation rooms. On [DATE], these chairs were double bagged and removed from the resident rooms. In accordance with manufacturer's recommendations obtained bye-mail from Mike Dunbar of Am-San, the chairs were brought outside, and soaked in a solution of one part bleach to ten parts water for ten minutes. The chairs were then double bagged and disposed of in the garbage dumpsters. The family members of new admissions will be informed upon admission that if they would like to bring in personal furniture from home, it can only be leather or vinyl. The Medical Director has been educated on our practices and has read and signed off on our new isolation policies and procedures on [DATE].

A. Based on observations, interviews and record reviews, the facility failed to -Identify and analyze all the risk factors and causes of residents' falls, and ensure interventions used were effective. -Monitor for the effectiveness of the interventions and change/modify the interventions as necessary to prevent recurrence for residents assessed as high risk for falls. This is for 2 of 24 sampled residents (R11 and R21) and 5 residents out of the sample (R39, R43, R89, R91 and R124) who were assessed as high risk for falls with decreased cognition. These failures resulted in R11 experiencing 17 avoidable falls in the facility from 4/3/10 through 4/20/11. The fall on 4/20/11 resulted in R11 sustaining a fracture of the right Humorous. E1 (Administrator) and E2 (DON) were notified of an immediate Jeopardy existing at F323 on 05-13-11 at 6:15 P.M. While the immediate Jeopardy was removed on 05-20-11, the facility remains out of compliance at severity level 2. Additional time is needed to monitor and evaluate the effectiveness of the training and education of the staff, policy and procedure. This applies to 1 of 3 residents in the sample (R11). This has the potential to affect 132 residents who are assessed as "high risk for falls." The findings include: 1) Review of the most recent Minimum Data Set ((MDS) dated [DATE] shows that R11 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This MDS shows R11 is unreviewable and able to make his needs known. R11's 4/29/11 MDS and Care Area Assessment (CAA) identified the resident requiring extensive assistance with transfers, ambulation, toileting, hygiene, dressing and activities, and utilizes a walker/wheelchair for ambulation. R11's 4/29/11 fall assessment and CAA's identified him as high risk for falls, increase in cognitive impairment, and decline in activities of daily living (ADL) and mobility. Observations on 5/10/11 at 11:30 A.M. R11 was in his wheelchair using his left arm to wheel himself into the 300 dining room, R11's right arm was in a blue sling that was not applied properly. E 49(CNA) stated R11 had fallen and broken his right arm and the sling is to be worn all times. On 5/11/11 at 12:30 P.M. R11 was leaving the 300 dining room using his left arm to wheel himself out of the 300 dining room, right arm sling not applied correctly, only top half of the arm. On 5/19/11 R11 was observed attempting to transfer himself to his bed, chair alarm sounding, no staff responding. Interview with E1 (Administrator) on 5/12/11 at 9:35 A.M., E1 stated the Quality Assurance(QA) Committee meets quarterly, last meeting was held April 1st. At the April 1st meeting the QA concerns identified were 1) 30 day turn around from the hospital and 2) advanced directives. The QA discussed falls and the number of incidents but no particular resident was identified as a concern. Interview with Z1(Medical Director) on 5/20/11 at 1:30 P.M., Z1 said he attends QA every three months but he has not discussed or identified a concern with falls. Interview with Z2 (Pharmacist) on 5/20/11 at 1:50 P.M., Z2 said she does look at the residents medication to evaluate if any of the medications are contributing to their falls. Z2 said she has not identified any one specific resident with a concern. A review of the facility's incident reports, R11 fell in the facility 16 times with minor injuries from 4/3/10 through 4/20/11, the fall on 4/20/11 resulted in R11 sustaining a fracture of the right Humorous. - R11 found on the floor 10 times, unwitnessed falls on the following dates: 4/3/10, 4/8/10, 4/21/10, 12/18/10, 2/11/11, 2/12/11, 2/24/11, 3/20/11, 4/7/11, and 4/21/11. The fall on 4/21/11 R11 sustained a fracture to the right humorous. -5/25/10 -witnessed fall in dining room pushing himself off the wheelchair and wheelchair moved back because wheelchair brakes were unlocked. -7/22/10- witnessed fall , R11 observed to stand up in wheelchair and tried to sit back but the wheelchair moved back and he missed it. -12/18/10- witnessed fall at nurses station- standing up in wheelchair, went to sit back down and wheelchair moved-resident fell to floor. -2/14/11- witnessed fall, staff transferring resident to bed from wheelchair and he slipped, falling to floor. -2/28/11- witnessed fall to floor- attempting to transfer self from bed to wheelchair -3/8/11-witnessed fall- slipped out of wheelchair -3/29/11- witnessed fall- resident attempting to transfer himself from chair to wheelchair. On 5/13/11 E2 said the fall committee meets monthly and looks at the number of falls in the facility but no particular resident has been a concern. E2 said the pharmacist reviewed R11's medications in March but did not have a concern. R11's POA was making an appointment with the neurologist related to his Parkinson's disease but then the POA went on vacation and R11 has not been to the appointment. R11's falls occurred mainly when he attempted to transfer without assistance and not lock the wheelchair brakes. On 4/11/11 R11's care plan was updated to include to "re-educate resident to lock wheelchair brake," but this is unrealistic because of his cognitive status, he cannot remember to lock the wheelchair brakes. R11's fall care plan did not include up-dated interventions after each fall nor were the falls analyzed to find the root cause in an attempt to prevent further falls. During a 5/17/11 interview with E50 (nurse), E50 said R11 is high risk for falling and he should be on a one to one. When his alarm goes off we can't get to him fast enough before he falls, it is to late, he has already fallen. Interview with E41 (CNA) on 5/16/11, E41 said she is R11's primary care taker during the A.M. shift and R11 does not usually fall when she is on duty. R11 needs assistance with transfers and toileting, he has a bed and chair alarm. Review of the facility's Accident Prevention and Resident Supervision policy and procedure dated 9/7/09 documents the following: Facility ensures to provide an environment that is free from hazards over which the facility has control and provides appropriate supervision and assistance devices to each resident to prevent avoidable accident. This includes systems and processes designed to: 1. Identify hazards and risks; 2. Evaluated and analyze hazards and risks; 3. Implement interventions to reduce hazards and risks;and 4. Monitor for effectiveness and modify approaches as indicated; 5. Residents receive supervision and assistive devices to prevent avoidable accidents. In review of the facility's list of residents that are high risk for falls and accidents that was provided to surveyors, resident's fall care plans, facility's incident reports, and observations shows the facility has not implemented or followed their policy and procedure for falls and accidents. 2) R21 was admitted to facility 3/10/11 after a recent cerebral vascular accident resulting in left sided weakness and unsteady balance. R21 also developed a urinary tract infection (UTI) requiring isolation precautions 4/07/11 - 4/25/11. R21's 3/27/11 Minimum Data Set assessment (MDS) and Care Area Assessment (CAA) identified the resident as requiring extensive assist with transfers, ambulation, toileting, hygiene and dressing activities. R21's 3/20/11 fall assessment and 3/27/11 Care Area Assessment (CAA) identify the resident as a high risk for falls, have poor judgement and insight and left sided weakness. R21's care plan and incident reports document 4 separate fall incidents between 3/29/11 and 5/09/11 (3/29/11, 4/04/11, 4/08/11 and 5/09/11). - 3/29/11 at 11:25AM while being assisted by E36 (CNA), in the toilet room, R21's knees became weak and sustained a fall. - 4/04/11 at 2:45PM R21 was left alone on the toilet by her CNA (E39) and fell to the floor. - 4/08/11 at 7:30PM R21 sustained a fall while being assisted by E40 (CNA) with a transfer from bed to wheelchair. - 5/09/11 at 6:30AM R21 fell while attempting to get to the toilet by herself. R21's fall care plan did not include updated interventions between 3/30 and 5/09/11 in an attempt to prevent further falls. R21's fall care plan failed to address the current UTI and urgent sensation to void. During a 5/13/11 interview with E38 (nurse), and a 5/18/11 interview with E41 (CNA), surveyor was told that R21 requires assist with ambulation and toileting. R21's 5/13/11 fall assessment states the resident has unsteady balance with sitting, standing and ambulating and decreased coordination and strength. R21's 5/09. 5/10 and 5/11/11 nursing progress notes include that the resident requires assistance with transfers and activities of daily living. R21 was observed 5/13/11 at 9:28AM and again 5/20/11 at approximately 11:15AM independently ambulating in her room without any assistance or assistive devices. 3) On 5/13/11 surveyor observed 13 unsupervised residents in the first floor television room from 9:37AM - 10:00AM, including R3, R39, R43, R89, R91 and R124. At 10:00AM, E37 (CNA) arrived to monitor the television room. E37 stated that her assignment today was to feed residents and then to monitor the television room in between meals. E37 said that at 9:45AM she went downstairs to break until 10:00AM after feeding residents. Record review of R3, R39, R43, R89, R91 and R124's current care plan and fall risk assessments, and 5/14/11 interview of E2 and 5/13/11 interview of E37, validated that these residents are cognitively impaired, require extensive assist with 1 or 2 staff for all activities of daily living, and require supervision related to being a fall risks. 4) During the survey E2 (DON) was asked multiple times for a complete list of residents identified as being high risk for falls. On 5/19/11 E2 provided surveyors with a list that identified 132 of facility's 137 in house residents as being high risk for falls. E2 said that almost every in house resident is a high risk for falls related to decreased cognition, age and medical conditions. The "Fall Risk Assessment" used by facility through 5/10/11 was generic, un-individualized and number coded 8 questions. The total sum at the end determined if a fall risk but no analysis of possible causes or recommendations to prevent further falls are included. Facility took the following steps to abate the Immediate Jeopardy. FACILITY ABATEMENT PLAN: 1. What corrective Actions taken for those residents alleged to have been affected by the deficient practice are: The resident identified has been reassessed and the following interventions have been put into place: a. Anti thrust cushion and non-slip pad were added to the wheelchair seat for better positioning on 5/16/11. b. On 5/18/11 physical therapy evaluated the appropriateness of the above stated wheelchair interventions/adjustments and concurred. c. A new Bowel and Bladder diary was initiated on 5/16/11 to see if a scheduled toileting program would be appropriate. d. The resident has been provided with a tippy cup at his bedside to prevent spillage, which will prevent slipping on fluids spilled on the floor on 5/17/11. e. Addition of new medication, Requip 0.25 PO BID started on 5/17/11. f. 1:1 monitoring for one week with a detailed diary of his activity to see if a pattern of agitation can be established was added to this plan on 5/18/11. Sitter responsibilities have been developed. g. On 5/18/11 the resident's care plan was updated to include increased participation in activity programming and all of the above. Besides the immediate interventions above an appointment was made by the son for June 30th with Dr. Goodman, Neurologist to reassess this resident as it related to his Parkinson's disease. The son has been updated as to the current plan of care as of 5/17/11. 2. How the facility identified other residents having the potential to be affected by the same deficient practice: Due to the acuity and age of our residents, all of our residents have the potential to be affected by this deficient practice. All residents that have had a fall in the last thirty days have had a review of their medical record for appropriate interventions and follow-up. These residents were reviewed at the fall ' s Committee Meeting held on May 16, 2011, and all care plans have been adjusted accordingly. 3. What measures will the facility take or will the facility alter to ensure that the problem will be corrected and will not reoccur? 1. All residents who have had a fall in the last thirty (30) days have led a review of their medical record and care plans updated where necessary. 2. A weekly fall committee meeting will be held every Friday to discuss these cases and any new fall that occur. 3. All residents assessed to be at risk for falls will be identified with a falling star. This falling star will be placed next to the resident's name on the name Signage outside the resident's room, on the resident's wheelchair (if applicable), and on the resident's armband. 4. The Medical Director will be informed and will participate on the fall ' s committee meetings on a monthly basis. His attendance will be the last Friday of the month. 5. When appropriate, resident education related to gait training, strengthening, proper use of assistive devices, etc. will be provided by the therapy department for residents undergoing skilled therapy. If not receiving skilled therapy, this education will be provided by the restorative nurse based upon therapy recommendation. 6. A complete review of the process by which resident incidents were evaluated and recommendations made for all falls has been done. Changes to this process are as follows: ? The supervisor/charge nurse on duty at the time of the fall is responsible for ascertaining why the resident fell with a recommendation for an immediate intervention. If the intervention requires C.N.A. attention, the nursing instructions in the PDA will be updated by the supervisor/charge nurse accordingly so that the C.N.A.'s are aware of the change. ? All interventions related to the fall are communicated for 72 hours via the 24 hour report by the supervisor/charge nurse. ? The 24 hour report is reviewed by all supervisors/charge nurses on every shift and in the morning at the morning at the morning meeting with all department managers Monday through Friday. On weekends the supervisors/charge nurses review this report and assure that interventions are being maintained. ? Within 72 hours the Restorative Nurse will review the supervisors/charge nurse intervention/recommendations for appropriateness and adjust accordingly. ? Pertinent assessments and vital signs are taken for 72 hours and recorded in the medical record. ? The Restorative Nurse is responsible for updating the plan of care within 72 hours. ? If upon the DON's review, it is determined that the fall was preventable, disciplinary action will follow if appropriate, and/or the root cause of the fall has been removed/eliminated. ? If there has been more than 1 fall in a 2 month period, the physiatrist will be asked to evaluate the resident and make recommendations. This has also been done for the list of residents that had fallen within the last 30 days. ? All falls that result in a fracture, or any fall wherein a causative factor cannot be determined, shall be referred to the corporate consultant. ? Previously the Director of Nursing completed all Comprehensive Fall Assessments. This responsibility has been shifted to the Restorative Nurse who will be able to prioritize this task. The Director of Nursing will review the finalized investigation and make any recommendations if necessary. ? Falls committee will now meet weekly verses monthly. Two meetings to review fall took place this week on 5/16/11 and 5/20/11. ? ? ? 4. Quality Assurance plans to monitor facility performance to make sure corrections are achieved: ? ? Falls committee will meet weekly to review previous cases cited in this POC as well as all new incidents. ? All falls incidents/accidents will be discussed Monday through Friday with the management team and reviewed on the weekends with the supervisors/charge nurses. ? The DON/Administrator will review and sign the incident reports of all accidents. Particular emphasis will be placed on review of the intervention put into place. ? The results/findings of the weekly falls meeting will be reported to CQI committee monthly for review for 6 months then quarterly to assure compliance. B. Based on observation, interview and record review the facility failed to provide an environment free of accident hazards by removing hazardous chemicals from resident access and assuring oxygen storage area is properly monitored and maintained to prevent liquid oxygen tanks from leaking in the oxygen storage room amongst several other full tanks, assuring staff are trained on proper oxygen handling to prevent injuries, and assuring all vents arere free of sharp edges The findings include: On 5/13/11 at 11AM and again 11:30AM, surveyor observed a partially full aerosol can of a disinfectant placed on the top of the toilet tank in the adjoining toilet room between rooms 215 and 217. 5/10/11 at 11:31AM, E36 (CNA), told surveyor that R55 in room 217 is forgetful and will attempt self ambulation in her wheelchair and R95 is confused and requires supervision. The aerosol disinfectant label and material safety data sheet (MSDS), contain a warning to keep out of reach of children. Causes eye irritation. Flammable. Contents under pressure. Keep away from heat, sparks and open flames. Do not puncture or incinerate container. Label includes ingestion may result in ethanol poisoning. On 5/10/11 during the initial tour, surveyor observed a large cylinder of liquid oxygen leaking large amounts of oxygen up in the air causing a build up of frost around fill valve on the tank. This leaking oxygen tank was sitting amongst several full oxygen liquid tanks in the 200 wing oxygen storage room. Facility staff were unaware of leaking tank until notified by surveyor. E2 (DON), stated that facility staff are supposed to remove the leaking oxygen tanks out of the facility on to the patio and leave it there until it stops leaking. Surveyor observed E24 (house keeping supervisor), touch the frost around the leaking fill valve on the tank with her bare hands. Facility policy and procedure for "Precautions at a glance - use of liquid oxygen" states that "Do not touch frosted portions of liquid oxygen system. Liquid oxygen is extremely cold. When touched, liquid oxygen or parts of the system in contact with liquid oxygen can cause frostbite or cryogenic burns." On 5/11/11 E2 presented surveyor with a signature page of the staff inserviced 5/10 and 5/11/11 on proper handling of liquid oxygen tanks. E24 was not inserviced. During the general observation of the facility on 5/11/11 with E14 (Maintenance Supervisor) sharp edges were noted on the vents in all rooms observed. These rooms included: Room 300, the bathroom next to room 304, room 207, room 331, room 303, room 201, room 230, room 100, and room 110. The sharp edges to these vents were observed in the residents rooms and bathrooms. These vents are were low to the floor but there was enough space between the floor and the vent for residents to possibly injure their feet and/or toes on the sharp edges. Interview with E14 (maintenance supervisor) on 5/11/11 noted E14 to say, "All of the vents in the facility are of this type. We probably need to put some protective covers on the vents to cover the sharp areas." During the general observation of the facility on 5/11/11 large, round, cylinder container of disinfectant wipes was found on a ledge in the facility's 300 wing small dining room. Information on the label noted, "keep out of reach of children" and also noted information regarding caution of getting solution in the eyes. E14 stated, "These wipes should not be in here." On 5/19/11 at 9:55 a.m. the oxygen storage room was checked with E9. While in the oxygen room a hissing sound was audible. Upon checking the large liquid oxygen tanks one of the tanks was noted still on and running and dispensing oxygen at 2L/min. E9 stated, "This oxygen tank should not be running while in this room." C. Based on observation, interview and record review the facility failed to provide adequate meal supervision of 1 sampled residents (R9), with oral - pharyngeal dysphagia on aspiration precautions and thickened liquids. The example includes: R9 was admitted [DATE] with [DIAGNOSES REDACTED]. R9's 5/09/11 speech therapy evaluation included: requires training supervision and skills practice to specific feeding / swallowing techniques. Impaired swallowing and chewing, often requires reminders for correct consistencies and / or is non-compliant! Small bites and sips. R9's care plan includes requires swallow/feeding protocol, aspiration precautions and video fluoroscopy swallow study (VFSS). Monitor for gagging, regurgitation of food and fluids through nares, clearing throat, coughing, vomiting or watery eyes. Observe for signs and symptoms of aspiration pneumonia and assist resident with feeding and hydration. R9's current physician diet orders include pureed feedings with honey thickened liquids. On 5/10/11 R9 was observed seated at a table in the 200 wing small dining room with other residents for lunch meal. All of the tables in this 200 wing dining room contained individual glasses and a pitcher of water (thin consistency) and coffee. The nurse aide served all the residents at R9's table and then left to serve other tables. R9 was served his pureed meal without any thickened liquids. R9 was observed to pour himself a full glass of thin consistency water from the table pitcher and ingest 3/4 of the glass before the nurse aide noticed it. The nurse aide then removed his glass of water and handed R9 a container of honey thickened water. R9 became very upset and refused to eat anymore of his lunch after the thin water was taken from him. R9 consumed less than 10 % of his lunch meal. On 5/10/11 E1 and E2 both told surveyors that R9 is non-compliant with thicken liquids. E1 said that while at his prior nursing home, R9 fell while trying to get his hidden stock of thin water in his closet. R9's current care plan does not include his non-compliance with thickened liquids. R9's nursing progress notes 5/07 through 5/10/11 did not include any diet non-compliance behaviors.

Based on direct observation, staff interview, record review and interview of Z7 (physician) the facility failed to appropriately assess one of 24 sampled residents, R10, for pain. The facility: --failed to consistently provide quantitative measurements as well as provide pain characteristics (sharp, dull, aching, etc) of pain levels, --failed to provide alternative measures for pain relief when it became obvious that pain medication as administered was ineffective, -- failed to develop and implement a care plan with realistic objectives and time frames for monitoring the resident's pain status and effectiveness of the pain medication when administered, --failed to assess R10 for the possible causes of the pain. --failed to notify R10's physician of the lack of effectiveness of the pain medication when administered. These failures resulted in R10 experiencing prolonged pain over several days. Findings include: R10 was admitted from an area hospital to the facility on [DATE] with [DIAGNOSES REDACTED]. Prior to being admitted to the hospital, R10 lived in her own home in the community with a care giver. On 5/10/11, during the initial facility tour R10 was observed in her room in bed positioned on her back. The resident was crying, moaning, groaning ,had facial grimacing and saying "Hail Mary's " (prayers) . When the surveyor asked E38 (nurse) if the resident had had any recent pain medication, E 38 replied that the resident was on scheduled pain medication and hadn't received any yet. E38 stated that R10 had received [MEDICATION NAME] at 2:00PM, and [MEDICATION NAME] at 2:00PM. E38 did admit that the resident had prn (as needed) pain medication, but didn't offer any to R10. On 5/11/11 at 11:42 AM R10 was again observed in bed laying on her back with facial grimacing, saying " please help me " and saying "Hail Mary's". E 16 (nurse) was in the room, but did not respond at all to the resident. When ultimately asked by the surveyor if he thought that the resident needed pain medication or other assistance, E16 stated that the resident had just received pain medication. The surveyor had observed E16 administer [MEDICATION NAME] 100 mg and [MEDICATION NAME] 25 mg to the resident approximately 10 minutes earlier. When interviewed by the surveyor E 16 stated that the physician had not been notified of resident' s continued pain. On 5/11/11 at 2:40 PM R10 was still positioned on her back and was heard moaning. When asked what was wrong, R10 was unable to say what was wrong other than to say that she was in pain. The resident stated that she had not been repositioned and wanted to be repositioned. The surveyor obtained staff to reposition the resident onto her side. Once repositioned, R10 stated that she felt better and stopped moaning. R10 has two Pain Assessments, both dated 5/17/11. Both assessments contain different information that has the potential to affect the resident's pain and comfort levels. Assessment #1 indicated that it was the initial assessment. Assessment #2 indicated that it was an "Other" type of assessment done due to recurrent pain. Both documented that the resident did appear to be in pain. R10's first assessment of 5/17/11 indicated that the pain level was at 2-3 or mild. Assessment #2 from 5/17/11 indicated that the resident's pain level was at 4-5 or moderate. Assessment #1 indicated that the physician was not notified for pain medication and Assessment #2 indicated that the physician was notified about R10's pain and pain medication was initiated 5/16/11. Both 5/17/11 assessments for R10 give different indications of the resident having nonverbal/non cognitive signs of pain. In Assessment #1 the area that indicates what causes or increases pain was blank. Assessment #2 identified repositioning as a cause of increased pain duration and or variation. Assessment #1 listed repositioning and medication as pain relievers while Assessment #2 listed only medication as relieving pain. Assessment #1 listed calling the physician and pain medication as the "Plan" and Assessment #2 listed only pain medication as the "Plan". Review of R10's record revealed a care plan for pain developed on 5/5/11. The identified goal was that R10 would be free of pain through the next review (which was scheduled for 8/3/11). Interventions developed for R10 were: --Observe/assess for all pain or discomfort --respond immediately to complaint of pain --Provide/offer alternate non-pharmacologic pain relief methods such as distraction, provide light music, positioning for comfort, heat, ice. --Observe and document resident's response and effectiveness of pain regimen. Notify physician if pain is unrelieved by current pain regimen --Observe for non-verbal indicators of pain such as facial grimacing, moaning, groaning, crying, anxiety, agitation, restlessness, [MEDICAL CONDITION]. R10's record 5/4/11 through 5/12/11 did not contain any documentation/verification that pain relief measures other than medication was offered or attempted, did not contain consistent documentation of the resident's response to and the effectiveness of the pain regimen that was implemented for the resident, didn't document pain characteristics and failed to document/verify that R10's physician was notified of the resident's current and consistent pain and lack of effectiveness of the ordered pain medication. On 5/11/11 at 4:25 PM Z8 (Family) was interviewed and stated that R10 has had pain due to her [MEDICAL CONDITION]. Z8 stated that R10 ' s current pain medication doesn't ' last long enough and needs to be scheduled more often. Review of R10's physician's order [REDACTED]. --[MEDICATION NAME] 10 mg by oral route 5 times per day at 6 AM, 10 AM, 2 PM, 6 PM, 10 PM --[MEDICATION NAME] 25 mg 1 capsule by oral 3 times per day with meals at 8 AM, 12 PM, 5 PM --[MEDICATION NAME] 300 mg by oral once daily at bedtime every day at 9 PM --[MEDICATION NAME] 100 mg by oral route 2 times per day every day at 6 AM , 2 PM --[MEDICATION NAME] 5 mg-325 mg 1 tablet by oral every 4 hours as needed for severe pain --[MEDICATION NAME] 2 mg 1 tablet by oral route 2 times per day every day at 9 AM, 5 PM. --Flector 1.3% Adhesive Patch apply 1 patch (180) mg by topical route 2 times per day to shoulders. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. R10 did not receive prn [MEDICATION NAME] for her pain on 5/10/11 even after the observation of the resident's pain was made by both the surveyor and E38. Review of R10's nursing note from 5/4/11 through 5/13/11 and the medication administration records for the same dates indicated that the nursing staff did not consistently provide documentation of the severity/measurement/characteristics of the pain. R10's record did not contain documentation/verification that staff had assessed the resident for other possible causes of the resident's continued pain symptoms. Additionally, R10's record did not contain any documentation of those alternative measures to be used in pain relief as indicated in the care plan. On 5/12/11 at 5:00 PM Z7 (R10's physician) was interviewed by phone. During the interview Z7 stated that R10 has an order for [REDACTED]. Z7 informed the surveyor that she had not been contacted by facility staff re: R10's pain medication not being effective. Z7 stated that if pain was increasing or at a high level, or the pain medication was not working, the resident would need to be reevaluated for the effectiveness of the pain medication. Z7 continued on to say that she also had been unaware of R10's possible psychological distress. According to Z7, R10 is a new patient for her and when she sees the resident, R10 is sometimes lethargic and doesn't talk much. As stated by Z7, R10 has Chronic Encephalitis, some confusion and multiple medical problems that could contribute to her signs of mental distress. Z7 denied having been contacted by family or staff regarding the resident's mental or emotional status, but did say that R10 should be evaluated by a psychiatrist or psychologist. After the interview with the surveyor, Z7 assessed R10. As a result, an additional pain was ordered medication was increased to include [MEDICATION NAME] 10 mg/325 mg 1 tablet by oral route three times daily on schedule: 9:00AM, 1:00PM, and 5:00PM. R10 received the first dose of the medication at 9:00AM on 5/17/11. When observed in the afternoon at approximately, 2:30PM the resident was observed sleeping calmly in a reclining chair at the bedside. R10 was observed sleeping in bed on 5/18/11 at approximately 11:45AM. R10 was also placed on palliative care (specialized care focused on the pain, symptoms and stress of serious illness) by the physician.

Based on observation, record review and interview, the facility failed to: 1) Identify, assess and provide care and services to 1 of 24 sampled residents (R21) and three supplemental residents (R136, R137, and R 51) with incontinence to achieve or maintain as much normal urinary function as possible. 2) Provide appropriate care and services for residents with or without an indwelling urinary catheter to prevent urinary tract infections to the extent possible for 5 of 24 sampled residents (R4, R8, R14, R16, and R21). The findings include: 1)a) R21 was admitted to facility 3/10/11 after a recent [MEDICAL CONDITION] resulting in left sided weakness and unsteady balance and with a urinary tract infection [MEDICAL CONDITION], Extended Spectrum Beta Lactamase (ESBL). R21's 3/10/11 UTI is documented on infection tracking log as resolved 3/15/11. R21 went out to the hospital 3/15 through 3/20/11 with elevated blood sugars and [DIAGNOSES REDACTED]. R21 was placed under isolation precautions 4/07/11 - 4/25/11. R21's 4/27/11 urine culture was positive for ESBL and her 5/15/11 urine culture was positive for gram negative bacilli. R21's MDS's documented a decline in urinary continence between 3/27/11 "occasionally" incontinent (scored 1), and 4/10/11 "frequently" incontinent (scored 2). R21's 3/20/11 bowel and bladder assessment included that R21 has a good potential for improving or achieving urinary continence. The assessment was not comprehensive or individualized; it did not address R21's genital - urinary diagnosis (Disorders of Urethra and Urinary tract) and recent UTI's. The assessment only identified functional cause for urinary incontinence and did not include any individualized plan to address the incontinence. During 5/17/11 4:22PM interview, E9 (bowel and bladder restorative nurse) stated that prior to this survey the resident voiding diaries were not comprehensive with times of day and number or type of urinary incontinence. The prior diaries were by shift number of times incontinent. The diary also did not identify if the incontinence was small amount from leaking followed by voiding on toilet or total urinary incontinence. E9 also stated that on 5/17/11 at midnight R21 was just started on a 3 day voiding diary, R21 is frequently incontinent of urine and that R21's 4 fall incidents between 3/29 and 5/09/11 were all due to toileting needs. R21's care plan and incident reports document 4 separate fall incidents between 3/29/11 and 5/09/11 (3/29/11, 4/04/11, 4/08/11 and 5/09/11). - 3/29/11 at 11:25AM while being assisted by E36 (CNA), in the toilet room, R21's knees became weak and sustained a fall. - 4/04/11 at 2:45PM R21 was left alone in the toilet by her CNA (E39) and fell to the floor. - 4/08/11 at 7:30PM R21 sustained a fall while being assisted by E40 (CNA), with a transfer from bed to wheelchair. - 5/09/11 at 6:30AM R21 fell while attempting to get to the toilet by herself. R21's fall care plan did not include up-dated interventions 3/30 - 5/09/11 in an attempt to prevent further falls. R21's fall care plan failed to address the UTI and potential for urgency sensation to void. R21 was not identified as requiring a re-assessment of her toileting needs until after the 5/09/11 fall. As of 5/16/11, R21 had still not had her bladder incontinence/toileting needs re-assessed. R21's current care plan included a 4/11/11 problem "Potential for UTI with period of bladder incontinence." The interventions included initiate a bladder diary and analyze but as of 5/16/11 R21's urinary incontinence had not been re-assessed since 3/20/11. 1)b) Review of R51's toileting restorative program plan of care shows R51's [DIAGNOSES REDACTED]. R51's bladder diary shows on 5/6/11 from 7:00am- 3:00pm - incontinent 2X's, 3:00pm- 11:00pm - incontinent-incontinent 2X's. R51's bladder diary continues to document each shift the number of times she was incontinent until 5/12/11 but the diary does not document the time of the day the incontinence occurred. R51's urinary incontinent assessment dated [DATE] documents she can identify the need or urge to void, able to use call light, able to go to toilet, and requires assistance with ambulation and transfers. R51's plan of care documents: scheduled toileting plan, assist to toilet upon rising, after breakfast, before lunch, after lunch, before dinner, after dinner, at bedtime and as needed. R51's type of incontinence is identified as overflow and wears adult diapers. Interview with R51 on 5/16/11 at 10:00am, R51 said she knows when she has to go to the bathroom and is embarrassed when she urinates on herself but she needs help to get to the toilet. Interview with E 41(CNA)on 5/16/11 at 10:30am, E41 said R51 wears adult diapers but she tells me when she needs to go to the bathroom. R51 is not on any type of scheduled toileting. R51's urinary incontinence care plan does not include an assessment or interventions to assist in identifying reversible causes of incontinence. The information obtained from the bladder diary does not document the specific time of day R51 is incontinent, only how many times she is incontinent per shift. 1)c) Review of R136's toileting restorative program plan of care shows R136's [DIAGNOSES REDACTED]. R136's bladder diary shows on 3/11/11 from 7:00am-3:00pm - incontinent 1X, 3:00pm-11:00pm - incontinent-incontinent 3X's. R136's bladder diary continues to document each shift the number of time she was incontinent until 3/13/11 but the diary does not document the time of the day the incontinence occurred. R136's urinary incontinent assessment dated [DATE] documents she can identify the need or urge to void, able to use call light, able to go to toilet, and requires assistance with ambulation and transfers. R136's plan of care documents: scheduled toileting plan, assist to toilet upon rising, after breakfast, before lunch, after lunch, before dinner, after dinner, at bedtime and as needed. R136 has been identified as having functional incontinence and wears adult diapers. Interview with E49 (CNA)on 5/16/11 at 11:30am, E49 said R136 wears diapers but she will let me know when she needs to go to the bathroom. R136 is on scheduled toileting; in the morning, before and after meals. R136's urinary incontinence care plan does not include an assessment or interventions to assist in identifying reversible causes of incontinence. The information obtained from the bladder diary does not document the specific time of day R136 is incontinent, only how many times she is incontinent per shift. 1)d) Review of R137's toileting restorative program plan of care shows R137's [DIAGNOSES REDACTED]. R137's bladder diary shows on 5/6/11 from 7:00am-3:00pm - incontinent 2X's, 3:00pm-11:00pm - incontinent-incontinent 3X's. R137's bladder diary continues to document each shift the number of time he was incontinent until 5/12/11 but the diary does not document the time of the day the incontinence occurred. R137's urinary incontinent assessment dated [DATE] documents he can sometimes identify the need or urge to void, able to go to toilet, aqnd requires assistance with ambulation and transfers. R137's plan of care documents: scheduled toileting plan, assist to toilet upon rising, after breakfast, before lunch, after lunch, before dinner, after dinner, at bedtime and as needed. R137 has been identified as having functional incontinence and wears adult diapers. Interview with E 51 (CNA)on 5/16/11 at 9:30am, E51 said R137 wears diapers but he will let me know when he needs to go to the bathroom. R137 not on a scheduled toileting program, I toileted him on a regular bases; in the morning, before and after meals. R137's urinary incontinence care plan does not include an assessment or interventions to assist in identifying reversible causes of incontinence. The information obtained from the bladder diary does not document the specific time of day R137 is incontinent, only how many times she is incontinent per shift. Interview with E9 (Restorative Nurse) on 5/13/11 at 4:40pm, E9 stated the facility does a 3-day bladder diary on each resident upon admission. The facility gathers information relating to their incontinence which includes a review of hospital records, labs, medications, cognitive status, history and interviews with resident and staff. There is no resident on a formal Bowel and Bladder program, only scheduled. There are 26 residents in the facility on scheduled toileting. The scheduled toileting is patterned with the events of the day, i.e. meals (before/after). The residents need to hold their urine for at least an hour and there is no resident who would be a good candidate. The voiding diaries document how many times a shift the residents are incontinent, not specific times of incontinence. This is a problem with the new computer system and the staff is unable to document the specific times of day, only shifts. I am unable to develop specific toileting programs for the incontinent residents. Review of the facility's Bowel and Bladder policy and procedure, no date, documents: having assessed the factors that could affect incontinence, and completed the diary, the type of incontinence should be determined and the appropriately management of incontinence should be developed. Review of the census and conditions (HCFA-672) shows the facility has 72 residents out of 137 residents who are occasionally or frequently incontinent bowel and 97 residents out of 137 residents who are occasionally or frequently incontinent of bladder. 2) R8 was readmitted to facility 4/22/11 with a newly inserted [MEDICATION NAME] tube and a urethral stent. R8 has [DIAGNOSES REDACTED]. R8's 4/24/11 bowel and bladder assessment includes presence of indwelling urinary catheter due to [MEDICAL CONDITION]. History of UTI's, Diabetes Mellitus, Urinary Disorder, Kidney output obstruction and gross hematuria. R8 was on isolation through 4/23/11 with a MDRO UTI. 5/10/11 during initial tour R8 was observed alert and oriented X 3 with a [MEDICATION NAME] tube connected to a leg drainage bag. R8 told surveyor that he wears a leg drainage bag during the day hours and a regular urinary catheter drainage bag at night. R8 pointed toward his bedside cabinet to show his night time drainage bag. Surveyor observed a used urinary catheter drainage bag with tubing attached to R8's bedside cabinet drawer handle. The drainage bag tubing with connection hub were laying directly on the floor. R8's May 2011 physician order [REDACTED]. Facility Urinary catheter insertion, maintenance and prevention of catheter associated UTI, includes: "Maintain closed drainage system, disconnection of drainage tube from catheter is prohibited and "DO NOT rest the drainage bag on the floor." On 5/13/11 at 1:10 PM E10 (wound nurse) stated that facility protocol is to change indwelling urinary catheter drainage bags once a month and as needed. E10 said that drainage bag changes are not documented in the resident's medical record. E10 also said that R8 was readmitted to facility 4/22/11 therefore his drainage bag would probably not be changed until 5/22/11. 2) On 5/11/11 at 9:35 a.m. E10 (RN- Wound Care Nurse) was observed performing peri care/catheter care to R14. E10 sprayed R14's perineal area with peri wash 3 times and wiped R14 peri area each time with a clean washcloth. With the last washcloth after wiping R14's peri area E10 wiped R14 catheter tubing one time approximately 3 inches down from R14's urethral opening. E10 did not spray or wipe the area at R14's urethral opening or the tubing at/or in close proximity to the urethral site. Review of R14's lab work showed R10 had history of urinary tract infections. On 5/13/11 Z3 (Hospice CNA) was observed providing standby assist while E10 (RN - wound care nurse) was performing wound care treatment to R16. After the wound, care was completed Z3 performed peri care/catheter care to R16. Z3 used a wet cloth and wiped R16 perineal area from back to front several times. Z3 did not wipe R16's urethral site or the catheter tubing. Z3 did not stop wiping R16 urethral/perineal area from back to front until surveyor and E10 intervention. Interview with E10 at this time noted E10 to say Z3 was performing the peri care/catheter care incorrectly. Review of R16's lab work showed R16 had history of urinary tract infections. On 5/11/11 at 10:15 A.M. E34(CNA) was observed conducting indwelling catheter care for R4 whom has a history of urinary tract infections. E34 washed R4's perineum using warm soap and water -wiping from perineum to rectum several times, no rinsing. E34 turned R4 over and washed her fecal soiled buttock , no rinsing. E34 used the same warm soap and water to cleanse R4's catheter tubing. E34 started at the insertions site of the catheter wiping back and forth 2-3 times, no rinsing. Interview with E2(DON) on 5/12/11 at 11:00 A.M., E2 said "all staff has been inserviced on proper technique for cleansing of indwelling catheters." Review of the facility's policy and procedure for indwelling catheter care documents to observe the following: *wash perineum well with soap and water, taking care to wash from front to back; using one area of washcloth per washing stroke;rinse well using the same procedure. *cleanse area of catheter insertion well, using soap and water and being careful not to pull on catheter or advance further into urethra; rinse with warm water using same procedure. *wash catheter itself by holding on to catheter at insertion site, wash with one stroke downward from meatus, rinse using same procedure.