Every finding on record at Alton Memorial Rehab & Therapy

Based on interview and record review, the facility failed to ensure adequate supervision of a dependent resident during care to prevent a resident from falling out of bed for 1 of 3 (R3) residents reviewed for accidents in a sample of 6. This failure resulted in R3 falling from bed causing a left hip fracture requiring surgical intervention. Findings include:R3's Face Sheet, not dated, documents R3 was admitted on [DATE] with the following diagnosis: Other pulmonary embolism without acute cor pulmonale (Primary, Admission), Paroxysmal atrial fibrillation, Heart failure, unspecified, Peripheral vascular disease, unspecified Irritable bowel syndrome, unspecified, Pain, unspecified, Weakness, Presence of automatic (implantable) cardiac defibrillator, Depression, unspecified, Type 2 diabetes mellitus without complications, Hyperlipidemia, unspecified, Essential (primary) hypertension, Atherosclerotic heart disease of native coronary artery without angina pectoris. R3's Care Plan, dated 04/09/2026, documents Category: Falls - I am at risk for falls.R3's Minimum Data Set, dated [DATE], documents R3 is cognitively intact and had a fall at the facility with major injury.R3's Fall Assessment, dated 4/9/2026, documents R3 is High Risk for Falls.R3's Incident Report documents on 04/13/2026 at 3:55 PM R3 had a witnessed fall in her room. Complained of pain to left hip. Pain scored a #5 on 1-10 pain scale with #4 Moderate Pain - Distressing, Miserable. Root Cause: resident slid off mattress while repositioning self. Intervention: provide alternate mattress; educate in safe bed mobility techniques. It also documents 04/14/2026 at 7:24 AM, documents called (Regional) hospital for update regarding patient. Reported to this nurse resident is being admitted to room, currently NPO (nothing by mouth) with surgery tentatively scheduled for today. Resident admitted with diagnosis of left femur fracture. R3's Pelvis and Left Hip Xray from outside company, dated 4/13/2026, documents X-RAY: Pelvis and left hip, five views. IMPRESSION:1. Suspicious for acute impacted subcapital left femoral neck fractureR3's Event Details documents on 4/13/2026 at 10:52 PM R3 had an unplanned transfer to (Regional Hospital) for a fall.R3's Left Hip Xray report from (Regional Hospital), dated 4/14/2026, documents Left Hip: Subcapital left femoral neck fracture.On 7/14/2026 at 9:34 AM V7, Certified Nurse Assistant (CNA), stated she witnessed R3's fall. V7 stated R3 had been sitting up for a while in the wheelchair awaiting her new air mattress to be installed. V7 stated once installed, R3 requested to sit on the side of the bed. V7 stated she assisted R3 to do so. V7 stated she made sure the mattress was deflated when sitting R3 on it. V7 stated she turned on the mattress to inflate. V7 stated she then turned and walked away from R3 to move the wheelchair across the room. V7 stated R3 leaned her head back, lifted her leg and went off the side of the bed onto the floor. V7 stated it happened really fast. V7 stated once the mattress started to inflate the fall happened. V7 stated she didn't have a gait belt on R3 because R3 was sitting on the bed. V7 stated R3 was able to go to the bathroom without gait belt and only a hand on her and transfer into the bed. V7 stated she had thought about the incident and was informed and educated she should not have left R3 sitting on the side of the bed unattended, air mattress training and fall prevention training. V7 stated she should have stayed until R3 laid down. V7 stated if R3 had said she wanted to lay down then V7 would have laid R3 down. On 7/14/2026 at 10:04 AM V6, Licensed Practical Nurse (LPN), stated she was called to R3's room by V7. V6 stated R3 was on the floor. V6 stated R3 was in a weird, twisted position partially under the bed. V6 stated R3 had an air mattress. V6 stated she performed an assessment and R3 did not initially complain of pain and was able to move extremities. On 7/15/2026 at 3:47 PM V13, Registered Nurse (RN), stated when a resident has an air loss mattress you do not sit them on the side of the bed. V13 stated it is not safe, the resident will fall. V13 stated the air moving through the mattress will cause the resident to fall. V13 stated at no time do you sit a resident unattended on the side of the bed when using an air loss mattress.On 7/15/2026 at 3:50 PM V11, CNA, stated you don't sit a resident on the side of the bed unattended. V11 stated it's not safe. V11 stated the air movement in the mattress will push the resident out of bed.On 7/15/2026 at 3:52 PM V12, CNA, stated when inflating or deflating the air mattress no one should be on it. V12 stated there are times when the mattress deflates and the resident is laying in the middle of the bed and you inflate it. V12 stated you stay with the resident until it's inflated. V12 stated at no time, regardless of the resident's balance, do you sit them on the side of the bed, unattended, with an air loss mattress. V12 stated the air in the mattress will flip them off the bed.On 7/15/2026 at 4:53 PM V14, Nurse Practitioner, stated she does not remember this fall. V14 stated when a resident is using an air loss mattress they are to be in the center of the bed for comfort and safety. V14 stated if a resident is sitting on the side of the bed, it is very possible the air mattress would cause them to fall out of the bed and get injured. 7/14/2026 @ 9:48 AM V15, Medical Director, stated she was notified by V16, RN, of R3 sliding out of bed and complaints of pain. V16 stated she ordered an x-ray, received results of suspicious femur fracture and resident sent emergency room for evaluation. V16 stated she is not aware of the cause of this fall. V16 stated the air mattress is made to surround you in bed. V16 stated the resident is in the middle of the of the mattress. The facility's Fall Management/Reduction Program, dated 9/24, documents PURPOSE: To provide guidelines to manage and attempt to reduce the incidence of resident falls. POLICY: All residents admitted to Long Term Care, Assisted Living residences will be assessed upon admission, quarterly and as needed for fall risk utilizing the MORSE Fall Risk Scale. Appropriate safety interventions, including potentially being placed in a Fall Reduction Program, will be implemented. A fall interdisciplinary team (IDT) will consist of nursing, therapy and other disciplines as appropriate. This team will meet at least weekly to review and make appropriate recommendations for residents who have fallen.The Rhythm Multi Alternating and Low Air Loss Pressure Relief System Manual, not dated, documents Push the AUTO FIRM button for fast inflation. Allow 4-7 min for full inflation. After the mattress is fully inflated, the caregiver can transfer the patient to the mattress. (Note: the mattress can be inflated while a patient is laying on it.)

Based on observation, interview and record review the facility failed to follow fall policy and procedures, and staff failed to use a gait belt when transferring a resident, for 1 (R2) of 3 residents reviewed for accidents. This failure resulted in a cognitively impaired resident (R2) being transferred to the emergency room after hitting her head. R2 had to get an EKG, blood work, head CT and chest x-ray. Using the reasonable person approach, this failure caused pain, discomfort and invasive interventions during an emergency room visit.Findings Include: R2's Resident Profile Report (Care Plan) dated 11/26/2025, documents R2 was at risk for falls and requires assistance with transfers and ambulation. The care plan states, Please ensure my bed is at an appropriate height at all times and call light is within reach. No documentation if gait belt should be used or how many staff to transfer R2 or mode of transfer. R2's Active Medication List documents Apixaban (blood thinner) 5 milligrams (mg) BID (twice a day) for treatment of AFIB. R2's Electronic Medical Record, dated 12/22/2025 no documentation of R2 fall in the shower or hitting her head on a handrail. R2's SBAR dated 12/22/2025 at 8:05 AM, V5, LPN (Licensed Practical Nurse) documents R2 had knees buckle approx. 12 hours ago where resident's face had come in contact with handrail in shower room resulting in dentures breaking. Resident has bleeding and pain noted to gums/mouth. NP (Nurse Practitioner) present and gave order to send R2 to ER (emergency room) for evaluation and treatment. R2 complained of mouth pain 8/10 on pain scale. Medications included Apixaban (blood thinner medication) 5 mg (milligrams) BID (twice a day.) On 12/23/2025 at 9:50 AM V5, Licensed Practical Nurse (LPN) stated she worked day shift on 12/22/2025 and arrived at the facility at approximately 7:00 AM. V5 stated received nurse report that R2 fell in the shower went to assess her. V5 stated R2 complained of mouth pain and assessed dry blood on R2's lip. V5 stated she notified the provider immediately and R2 was sent to the ER for further evaluation and treatment. V5 stated it was her understanding that the nurse (name unknown) didn't notify R2's provider that she hit her head when R2 fell on [DATE]. V5 stated when a resident falls at the facility the assigned nurse is to follow the facility's fall policy which includes assessing the resident and notifying the resident's provider of the fall immediately after the assessment then to document a post fall assessment and an SBAR if the resident goes to the ER. V5 stated she couldn't believe R2 wasn't sent to the ER after she fell because she is on a blood thinner, and she could have a brain bleed and needed to be assessed by a physician.On 12/23/2025 at 9:25 AM R2 sat up in a wheelchair in her room. V4, Certified Nurse Aide (CNA) pulled R2's shirt up for a skin assessed and a large purple bruise to right upper body was noted and a dried scab/abrasion to R2's right lip area as well. R2 stated she fell in the shower. R2 didn't recall what staff was in the shower when she fell or any specifics regarding the fall. R2 stated she hit her face on the rail, and she broke her teeth on the way down. R2 stated she was assessed at the hospital the next day and although her face hurt, she was ok. On 12/23/2025 at 10:04 AM V6, RN (Registered Nurse) stated she worked 7:00 AM to 11:00 PM on 12/21/2025 and was assigned to R2. V6 stated V7, CNA asked her to help transfer R2 from shower chair to her wheelchair in the shower room because V7 had attempted to multiple times but that R2's knees kept buckling and she needed assistance because R2 was weak. V6 entered the shower room and stood behind R2. V6 stated V7 stood R2 up and assisted her to stand to hold onto the grab bar and when she moved the shower chair from under R2 her knees buckled and her and V7 lowered R2 to the ground. V6 stated V7 didn't have a gait belt on R2 at the time of the transfer but she probably should have because R2 was so weak. V6 stated she assessed a small amount of blood on R2's mouth after they lowered her to the floor, but she didn't hear or see R2 hit her mouth on anything, and she was behind R2 so she wouldn't have seen her hit her mouth on the rail. V6 stated R2's dentures were broken at that time, and she assumed R2 cut her mouth on her broken dentures when she plopped on the shower floor while they lowered her to the floor. V6 stated V7 didn't tell her that R2 hit her mouth on the handrail until an hour after that and she had already assessed R2 and cleaned her mouth of the blood. V6 stated she didn't notify the provider that R2 fell because she didn't fall. V6 stated her and V7 assisted R2 to the floor and she didn't know she hit her mouth at that time. After V7 reported to her that R2 hit her mouth on the rail she still didn't report that to the provider because there was no bruising or injury sustained. V6 stated hindsight she should have reported the resident being lowered to the floor and that she hit her head because R2 is on a blood thinner and could have had a brain bleed. V6 stated she didn't assess neurological status after the fall and didn't take her vital signs either. R2's Emergency Department Records dated 12/22/2025 documents patient is a pleasant [AGE] year-old female who presents at the emergency room for evaluation fall yesterday. Apparently hit head, face. Has had some weakness. Physical exam: Jaw: tenderness and pain on movement present. Assessment: abrasion to lip, bruising to right upper extremity. Clinical impressions: contusion to face and generalized weakness. Patient had 12 lead EKG, blood work, head CT and chest x ray done in the ER. On 12/23/2025 at 10:22 AM V1, Administrator stated she had concerns regarding R2's fall and the lack of assessment, notification and the lack of post fall documentation from when R2 fell on the evening of 12/21/2025 in the shower room. V1 stated when a resident falls the assigned licensed nurse is responsible for assessing the resident and documenting the assessment in the resident's electronic medical record on a post fall assessment form and to notify the provider of the fall as well. V1 stated even if staff lower a resident to the floor that is still considered a fall because the resident changed planes. V1 stated she expected the nurse to assess the resident, document the assessment and then document that the provider was notified of the fall and what was ordered, if anything. V1 stated she reviewed R2's electronic medical record for the 12/21/2025 shower room fall and there was the assigned nurse was V6, and she didn't document anything regarding the fall in R2's medical record. V1 stated she was very concerned that R2 wasn't sent to the ER until 12 hours post fall because she's on a blood thinner and even though she's not a nurse she knew R2 could have a brain bleed and needed to be assessed by a physician. V1 stated R2 was transported to the ER on [DATE] at approximately 7:00 AM and had a head CT done and it was negative for a brain bleed. V1 stated R2 sustained bruises, and her dentures were broken during the fall in the shower. V1 stated she expects staff to use a gait belt, and she expected V7 to use one on R2, especially since she noted R2 was weak prior to the transfer. R2's Progress Note, dated 12/23/2025 V8, Nurse Practitioner (NP) documented at 7:19 AM she was notified that R2 had a fall the previous evening in which her face struck a bar in the shower room, resulting in broken dentures. The report further noted dried blood present on R2's lips, with complaints of jaw and facial pain. R2 complained of pain to her head, face and mouth. On 12/23/2025 at 1:20 PM V8, NP stated she was notified that R2 fell in the shower the night before on the morning of 12/22/2025 and she assessed R2's mouth was bleeding and stated since R2 is on a blood thinner medication she should have been assessed and transferred to the ER at the time of the fall. V8 stated she expected staff to follow the fall policies and procedures at the facility and to use a gait belt when transferring residents. V8 stated she expected staff to document an assessment of the fall and stated there was no documentation of the fall in R2's electronic medical record and no post fall assessments. V8 stated she wasn't notified that R2 fell and hit her mouth/head in the shower on 12/22/2025 and she would have expected staff to notify her of that because R2 was on a blood thinner and needed to be assessed by a physician in the ER immediately to rule out a brain bleed. The Facility's Fall Management/Reduction Program Policy, revised 9/24, documents once a fall occurs, it is important that an assessment and investigation occur to determine possible cause of the fall utilizing the designated form within the resident's medical record. A post fall evaluation is to be completed after any resident fall. Additionally, neuro checks per neuro check policy will also be completed. Neuro checks are to be completed with any fall at the following intervals: all falls in which the head was struck initial assessment, every 15 minutes x4, every 30 minutes x2, every hour x2, then once per shift for 72 hours. The Facility's Use of Gait Belt Policy revised 5/23 documents policy purpose: to provide guidelines to facilitate the safe transfer of the resident and prevent injury to the resident. Responsibility: it will be the responsibility of all nursing staff to follow this policy and procedure. Nursing personnel must have gait belts on their person at all times.

Based on observation, interview and record review the facility failed to notify the provider of a fall with injury for 1 (R2) of 3 residents reviewed for accidents.Findings include: R2's Resident Profile Report (Care Plan) dated 11/26/2025, documents R2 was at risk for all and requires assistance with transfers and ambulation. Please ensure my bed is at an appropriate height at all times and call light is within reach. R2's SBAR dated 12/22/2025 at 8:05 AM, V5, LPN (Licensed Practical Nurse) documents R2 had knees buckle approx. 12 hours ago where resident's face had come in contact with handrail in shower room resulting in dentures breaking. Resident has bleeding and pain noted to gums/mouth. NP (Nurse Practitioner) present and gave order to send R2 to ER for evaluation and treatment. R2 complained of mouth pain 8/10 on pain scale. Medications included Apixaban (blood thinner medication) 5 mg (milligrams) BID (twice a day.) On 12/23/2025 at 9:50 AM V5, LPN stated she worked day shift on 12/22/2025 and arrived at the facility at approximately 7:00 AM. V5 stated received nurse report that R2 fell in the shower she went to assess her. V5 stated R2 complained of mouth pain and assessed dry blood on R2's lip, V5 stated she notified the provider immediately and R2 was sent to the ER for further evaluation and treatment. V5 stated it was her understanding that the nurse (name unknown) didn't notify R2's provider that she hit her head when R2 fell on [DATE]. V5 stated when a resident falls at the facility the assigned nurse is to follow the facility's fall policy which includes assessing the resident and notifying the resident's provider of the fall immediately after the assessment then to document a post fall assessment and an SBAR if the resident goes to the ER. V5 stated she couldn't believe R2 wasn't sent to the ER after she fell because she is on a blood thinner, and she could have a brain bleed and needed to be assessed by a physician.R2's Nurse Practitioner (NP) Progress Note, dated 12/23/2025, documents this fall was not reported to the provider until the oncoming nurse received report the following morning. The incident was not documented in R2's electronic medical record in a timely manner, and no nursing notes were available for review. R2 is prescribed Eliquis. Any reported or suspected head strike while on an anticoagulation warrants immediate transfer to the emergency department for evaluation, and at a minimum a STAT head CT. At 7:24 AM orders were given to send R2 to the emergency department, she was transferred via EMS. On 12/23/2025 at 1:20 PM V8, NP stated she wasn't notified R2 fell and hit her mouth/head in the shower on 12/22/2025 and she would have expected staff to notify her of that because R2 was on a blood thinner and needed to be assessed by a physician. V8 stated when she assessed R2 on the morning of 12/22/2025 R2's mouth was bleeding, so she knew R2 had an injury and she transferred R2 to the ER after assessing her. The Facility's Reporting of Injuries Policy, revised 12/25 documents purpose: to provide an orderly process for reporting injuries involving residents. Serious incidents, i.e., head injuries are to be reported to the physician at the time of occurrence. Be prepared in using the SBAR format, to report to the physician results of the assessment, including pertinent information relative to items such as medications. All charting should include notification of doctor.

Based on interview and record review, the Facility failed to ensure food was palatable for 4 of 4 residents (R4, R12, R32, R44) reviewed for nutritional services in the sample of 25.1- R4's Undated Face Sheet documents R4 was admitted to the facility on [DATE]. R4's Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively intact and is independent with eating. R4's Physician Order dated 3/27/2025 documents R4 has a Regular Diet. On 12/2/2025 at 11:35 AM R4 stated the food in the facility is terrible and tastes like s***. R4 stated residents have brought up the food issue regarding taste and temperature every month at resident council and the facility has failed to change things. R4 stated she eats in her room and every meal tray she receives is cold. R4 stated the food is well done and hard, the pasta is gummy, and everything is tasteless. R4 stated she had written a letter to the head chef regarding the food and the chef has discussed the resident's concerns and no changes to the food have been made. 2-R12's Face Sheet documents R12 was admitted to the facility on [DATE]. R12's Diet Order dated 11/13/25 documents Regular diet. R12's MDS dated [DATE] documented R12 was cognitively intact. On 12/2/2025 at 9:55 AM, R12 stated the food is her only complaint at the facility, and it is just not good. 3-R32's Face Sheet documents R32 was admitted to the facility on [DATE]. R32's Diet Order dated 11/10/25 documents Regular diet. R32's MDS dated [DATE] documented R32 was cognitively intact. On 12/2/25 at 10:16 AM, R32 stated the food is not good and is usually cold. 4-R44's Face Sheet documents R44 was admitted to the facility on [DATE]. R44's Diet Order dated 11/6/25 documents Regular diet. R44's MDS dated [DATE] documented R44 was moderately cognitively impaired. On 12/2/25 at 10:15 AM, R44 stated the food is always cold. The Facility's 3/20/25 Resident Council Meeting Minutes document, Milk – made up ahead of time – served and it's not cold. The Facility's 9/19/25 Resident Council Meeting Minutes document, Need good food b/c (because) we are still people even though we are old. The Facility's 10/23/25 Resident Council Meeting Minutes documents, The food is terrible. On 12/4/25 at 2:45 PM, V1, Administrator, stated R4 always complains about the food, but was not aware of any other residents having these complaints. The Facility's Meal Quality and Temperature Policy revised 1/2025 documents, Food and drinks are palatable, attractive, and served at a safe and appetizing temperature to ensure resident satisfaction and to meet nutrition and hydration needs.

Based on interview and record review the facility failed to ensure respectful handling and safeguarding of 2 (R3,R4) of 2 residents' personal clothing in the sample of 25. The loss of the resident's clothing demonstrates a failure to honor the resident's right to dignity and respect for personal belongings. Findings include:On 12/02/2025 3:28 PM, V10, R3's family member, stated she is happy with everything at the facility and with her father's care except that the facility has lost her father's clothes. She stated that has been an ongoing issue.On 12/4/25 at 1:30 PM, R3 and R4 both stated they are missing clothes for months. R4 stated that she has told V1, Administrator, and nothing has been found. R3 & R4 are both documented as being long term care residents of the facility.On 12/4/25 at 2:17 PM, V7, Laundry/Housekeeping Supervisor stated she only washes the clothes for the long-term residents. She stated they do not wash the short-term residents' clothes. She stated the families are responsible for washing the short-term resident's clothes. She stated the laundry is down in the facility in the basement. She stated the facility has a lost and found for clothes. She stated she is unaware that R3 and R4 are missing clothes.Resident council dated 12/19/2024 documents resident still missing six white t- shirts v- neck. Resident council dated 1/16/2025 documents missing clothing.Resident council dated 5/22/2025 documents resident wants to know when she is getting paid for her lost clothing.Facility policy dated March 2020 states: We provide laundry services for many residents and sometimes an item can be misplaced. We want to address this problem promptly so please notify your nurse or Social Worker immediately if a clothing item cannot be found.

Based on record review and interview that facility failed to evaluate and revise the care plan for 1 of 1 (R22) residents reviewed for care plans in a sample of 25.R22's Undated Face Sheet documents R22 was re-admitted to the facility on [DATE] and has a medical diagnosis of Hypertensive Disorder, Osteoporosis, Focal to Bilateral Tonic-Clonic Epileptic Seizures.R22's Minimum Date Set (MDS) dated [DATE] documents R22 is moderately cognitively impaired and needs partial/moderate assistance with sitting to standing, chair/bed to chair transfers, and toilet transfers.R22's Care Plan Last Reviewed 10/17/25 documents (R22) is at risk for falls. I require assistance with transfers and ambulation. Please ensure my bed is at an appropriate height at all times. Please ensure my call light is within reach when I am in my room. 8/28/25: call don't fall sign in bathroom; labs. I had a fall on 5/24/25 intervention: frequent observations/staff interaction when passing by and PLEASE CALL, DON'T FALL sign in room. I had a fall on 8/5/25 intervention brakes repaired, and extension added to brake handle.R22's MORSE Fall Risk Score dated 4/16/2025 documents R22 has a fall risk score of 50 and has a history of falls in the last 3 months.R22's MORSE Fall Risk Score dated 11/30/2025 documents R22 has a fall risk score of 50 and has a history of falls in the last 3 months.R22's Post Fall Evaluation dated 8/5/2025 documents: Nurse called to resident restroom he was sitting on floor with back against wall, no injuries to report. Interdisciplinary Team (IDT) after further investigation resident attempted to self-transfer and the brake on the wheelchair became loose causing resident to fall. Intervention: maintenance repaired wheelchair brakes and added an extension to the handle.R22's Post Fall Evaluation dated 8/28/2025 documents: Restroom call light came on, nurse answered light and observed res sitting on buttocks on floor between wheelchair (w/c) and wall with right arm between res and wall. Nurse asked res what happened, and he stated, he was trying to transfer self and slid down wall to floor, then pulled call light for assistance. Intervention education provided by nursing and therapy and Please Call, Don't Fall sign placed in the bathroom.On 12/4/2025 at 9:00 AM R22 showed this surveyor his wheelchair, no extension was noted to R22's wheelchair brake handle. R22 stated he does not remember having an extension to his brake handle. R22 stated he has not had a Call Don't Fall in his room or bathroom.On 12/4/2025 at 8:55 AM, No Call don't fall sign observed in R22's bathroom. No Please Call, Don't Fall signed observed in R22's room.On 12/4/2025 at 10:18 PM R22's wheelchair observed with V2, Assistant Director of Nursing (ADON), regarding extension to brake handle. V2 stated she does not see an extension. V2 stated she remembers a brake handle extension was an intervention in place for R22, however she was not working at the facility during the time of implementation.On 12/4/2025 at 10:23 AM observed R22's wheelchair and bathroom with V1, Administrator. V1 stated there are no extensions to R22's brake handles at this time and there is also no Call don't fall sign in R22's bathroom. On 12/4/2025 at 10:42 AM V1, Administrator, stated R22 previously had the fall interventions of the brake handle extension and the Call Don't Fall sign, however R22 had a medical decline and the fall interventions that are on his Care Plan are no longer appropriate and should be resolved. On 12/05/2025 8:34 AM V1 stated R22 previously transferred a lot on his own and after re-education. R22 no longer tries to transfer himself. V1 stated R22 is not considered a high fall risk anymore due to fall education provided to R22. V1 stated the fall interventions on R22's Care Plan are no longer appropriate and R22's Care Plan has not been updated to resolve the fall interventions due to human error. V1 stated she expects the facility to follow the Care Plan Policy. The Facility's Fall Management/Reductions Program Date Revised 9/24 documents Upon admission to the facility, all residents will be assessed using the MORSE Fall Risk Scale. At a score ABOVE 45, the resident is identified at a high risk for falls. The resident's Care Plan will be reviewed and updated as needed to reflect initiation or discontinuance of the Fall Program, including documentation of any fall and any safety measures used for the resident.The Facility's Care Planning Policy Date Revised 11/24 documents It is the responsibility of the Interdisciplinary Team (IDT) members and nursing staff to review and update the Resident Profile Care Plan when there is a change in the resident's condition, abilities, or preferences. This is also to be reviewed and revised as needed, with each MDS assessment.

Based on observation, interview, and record review the facility failed to implement current progressive interventions to prevent falls for 1 of 6 (R22) residents reviewed for falls in a sample of 25.R22's Undated Face Sheet documents R22 was re-admitted to the facility on [DATE] and has a medial diagnosis of Hypertensive Disorder, Osteoporosis, Focal to Bilateral Tonic-Clonic Epileptic Seizures.R22's Minimum Date Set (MDS) dated [DATE] documents R22 is moderately cognitively impaired and needs partial/moderate assistance with sitting to standing, chair/bed to chair transfers, and toilet transfers.R22's Care Plan Last Reviewed 10/17/25 documents (R22) is at risk for falls. I require assistance with transfers and ambulation. Please ensure my bed is at an appropriate height at all times. Please ensure my call light is within reach when I am in my room. 8/28/25: call don't fall sign in bathroom; labs. I had a fall on 5/24/25 intervention: frequent observations/staff interaction when passing by and PLEASE CALL, DON'T FALL sign in room. I had a fall on 8/5/25 intervention brakes repaired and extension added to brake handle.R22's MORSE Fall Risk Score dated 4/16/2025 documents R22 has a fall risk score of 50 and has a history of falls in the last 3 months.R22's MORSE Fall Risk Score dated 5/14/2025 documents R22 has a fall risk score of 60 and has a history of falls in the last 3 months.R22's MORSE Fall Risk Score dated 7/2/2025 documents R22 has a fall risk score of 65 and has a history of falls in the last 3 months.R22's MORSE Fall Risk Score dated 11/30/2025 documents R22 has a fall risk score of 50 and has a history of falls in the last 3 months.R22's Post Fall Evaluation dated 8/5/2025 documents Nurse called to resident restroom he was sitting on floor with back against wall, no injuries to report. Interdisciplinary Team (IDT) after further investigation resident attempted to self transfer and the brake on the wheelchair became loose causing resident to fall. Intervention: maintenance repaired wheelchair brakes and added an extension to the handle.R22's Post Fall Evaluation dated 8/28/2025 documents restroom call light came on, nurse answered light and observed res sitting on buttocks on floor between wheelchair (w/c) and wall with right arm between res and wall. Nurse asked res what happened and he stated, he was trying to transfer self and slid down wall to floor, then pulled call light for assistance. Intervention education provided by nursing and therapy and Please Call, Don't Fall sign placed in the bathroom.On 12/4/2025 at 9:00 AM R22 showed this surveyor his wheelchair, no extension was noted to R22's wheelchair brake handle. R22 stated he does not remember having an extension to his brake handle. R22 stated he has not had a Call Don't Fall in his room or bathroom.On 12/4/2025 at 8:55 AM No Call don't fall sign observed in R22's bathroom. No Please Call, Don't Fall signed observed in R22's room.On 12/4/2025 at 10:18 PM R22's wheelchair observed with V2, Assistant Director of Nursing (ADON), regarding extension to brake handle. V2 stated she does not see an extension. V2 stated she remembers a brake handle extension was an intervention in place for R22, however she was not working at the facility during the time of implementation.On 12/4/2025 at 10:23 AM observed R22's wheelchair and bathroom with V1, Administrator. V1 stated there are no extensions to R22's brake handles at this time and there is also no Call don't fall sign in R22's bathroom. On 12/4/2025 at 10:42 AM V1, Administrator, stated R22 previously had the fall interventions of the brake handle extension and the Call Don't Fall sign, however R22 had a medical decline and the fall interventions that are on his Care Plan are no longer appropriate and should be resolved. On 12/05/2025 8:34 AM V1 stated R22 previously transferred a lot on his own and after re-education, R22 no longer tries to transfer himself. V1 stated R22 is not considered a high fall risk anymore due to fall education provided to R22. V1 stated the fall interventions on R22's Care Plan are no longer appropriate and R22's Care Plan has not been updated to resolve the fall interventions due to human error.The Facility's Fall Management/Reductions Program Date Revised 9/24 documents Upon admission to the facility, all residents will be assessed using the MORSE Fall Risk Scale. At a score ABOVE 45, the resident is identified at a high risk for falls. The MORSE Fall Risk Scale will be completed by the nurse quarterly and as needed for noted condition changes or if resident has fallen and is not identified as a high risk for falls at time of fall. If, at any time, the MORSE fall risk assessment receives a total score above 45 and the resident is not already in the Fall Prevention/Reduction Program, the nurse will place the resident in the Program and update the Care Plan.

Based on observation, interview, and record review, the Facility failed to follow physician prescribed therapeutic supplement order for 1 of 1 residents (R33) reviewed for nutritional services in the sample of 25.Findings include:1-R33's Face Sheet documents R33 was admitted to the facility on [DATE] with diagnoses including protein calorie malnutrition and end stage renal disease (ESRD).R33's Minimum Data Set (MDS) dated [DATE] documented R33 was cognitively intact, ambulated with wheelchair and walker, and was on a therapeutic diet.R33's Physician Order dated 10/30/25 documents Renal Diet.R33's Physician Order dated 10/6/25 documents Ensure High Protein three times daily.R33's Registered Dietitian Nutrition Evaluation dated 10/6/25 documents, Increased nutrient needs r/t (related to) ESRD as evidenced by dialysis treatment. Inadequate oral intake r/t loss of appetite/social/environmental circumstances as evidenced by physical finding. The nutrition intervention added was Ensure High Protein three times daily.R33's Care Plan Updated 10/9/25 documents, Supplements are ordered Ensure High Protein TID (three times daily). I am at risk for malnutrition.On 12/5/25 at 7:50 AM, R33 was sitting in dining room eating breakfast. There was no Ensure High Protein on her tray. R33 stated she receives the protein shakes with meals some of the time.On 12/5/25 at 8:10 AM, V8, Dietary Aid, was cleaning up after breakfast service and stated she was unsure whether R33 got an Ensure High Protein with breakfast today.On 12/5/25 at 8:15 AM, V9, Certified Nursing Assistant (CNA), stated she was unsure whether R33 got an Ensure High Protein with breakfast today, but R33 will often request them if she does not receive them.On 12/5/25 at 10:20 AM, V1, Administrator, stated the Facility does not have a policy regarding following physician orders, and they just follow them. She stated she will address R33's supplements not being given.

Based on observation, interview and record review, the facility failed to adequately staff the dietary department to ensure meals were served in a timely manner for 1 of 5 residents (R9) reviewed for food and nutrition services in the sample of 9. Findings include: R9's Physician Orders document R9 was admitted to the facility on [DATE]. R9's Face Sheet documents R9 has diagnoses including heart disease, peripheral vascular disease, and protein calorie malnutrition. R9's Minimum Data Set (MDS) dated [DATE] documented R9 was cognitively intact, independent with eating, and ambulated with wheelchair and walker. R9's Care Plan documents goal to improve nutritional status. R9's Physician Orders document 12/16/24 order for carbohydrate controlled diet. On 1/9/25 at 12:47 PM, R9 stated dinner is never on time and has recently received dinner as late as 6:30 PM and 6:35 PM. On 1/9/25 at 12:57 PM, V10, Certified Nursing Assistant (CNA) stated meal service tends to run slower in the evenings. On 1/9/25 at 2:40 PM, V16, Dietary Aid, stated he occasionally has to work by himself during meals and services the entire facility. On 1/9/25 at 2:50 PM, V15, Dietary Manager, stated sometimes meal trays are late, and it is more of a problem for residents who eat in their rooms because the dining room is served first. On 1/9/25 at 3:00 PM, V14, Activities Director, stated meal timing was previously discussed as a problem in the Resident Council Meeting. He was unsure if the issue has been resolved but was told the kitchen has been sending food a little later in effort to keep it hot. On 1/9/25 at 11:35 AM, V7, Licensed Practical Nurse (LPN), stated meals run late if there is only one person running the kitchen. On 1/9/25 at 11:37 AM, V11, CNA, stated meals are served late on occasion. On 1/9/25 at 11:48 AM, there was a posting on the steam table documenting breakfast is served from 7:30-8:00, lunch is served from 11:30-12:00, and dinner is served from 5:30-6:00. On 1/9/25 at 2:15 PM, V1, Administrator, stated she was unaware of any meals being served late. She stated the facility does not have a policy regarding acceptable time frames for meals, but should be base times on resident preference. On 1/9/25 at 4:20 PM, V1 stated she will address this issue. The Facility's Resident Council Meeting Minutes dated 11/19/24 document, Food needs to be on time. The Facility's Meal Times posting documents breakfast is served from 7:30-8:00, lunch is served from 11:30-12:00, and dinner is served from 5:30-6:00. The Facility's Dietary Schedule documents only one staff member was working during the dinner service on 12/7/24, 12/8/24, 12/13/24, 12/14/24, 12/15/24, 12/26/24, 12/27/24, and 1/6/25. The facility's 1/9/25 Census documents there are 54 residents living in the facility.

Based on interview and record review the facility failed to ensure all abuse investigations were reported to the designated representative and to other officials in accordance with State law, including State Survey Agency within five working days of the incident for 1 of 7 residents (R2) reviewed for reporting in the sample of 10. Findings include: On 1/2/2025 at 12:28 PM, V1, Administrator stated (V6), Licensed Practical Nurse LPN) was the nurse working the day (R2's) wet sheets were changed and the male certified nursing assistant (CNA) was (V7). V7 was the one who was working (R2's) hall. V1 stated, I did not get any statements or have any allegations of abuse related to (R2). I know the family was upset about (R2's) bed being wet but I do not have any statements or anything in writing voicing any other concerns, and nothing related to any abuse allegations. All abuse investigations for the past six months were requested and reviewed and there was no abuse investigation provided for R2. On 1/2/2024 at 12:43 PM, V7, Certified Nursing Assistant (CNA) stated, I laid (R2) gently on the bed and moved her feet over, covered her up and left the room. I never threw her on the bed or threw water at her. I tried to go back and clean up the water but (V6, LPN) told me not go into her room. On 1/3/2025 at 8:33 AM, R2 stated, I was good at the (Facility) until that staff member picked me up, slid me on the bed, swung my feet around and spilled water all over me and left me. I was afraid of him. He was rough with me. I was very upset, so I immediately called (V5, Family of R2) and told her what had happened. Nobody should be treated the way he treated me. I was scared to tell him about the water because of the way he was treating me. I feel like I was abused by him. On 1/3/2025 at 8:39 AM, V5, Family of R2 stated, I remember getting the call from my mom because she was frantic, and I asked her what was going on and she asked me to please come to the (Facility). It took me over an hour before I got there but when I got there my mom was still upset. When I walked into the room there was water all over the floor. I started cleaning up the water on the floor because I did not want anyone to fall. Then my mom told me a staff member threw her on the bed and spilled water all over her and left her. Now mind you, it took me an hour to get to my mom because I had to wait on my cousin, and here she is and when I went over to her the bed was soaked with water. I started stripping the bed and I went and got (V6, the nurse) and told him my mom was afraid of (V7) and he had me write everything down in a statement and he told me that staff member (V7) would not be providing care anymore to my mom. (V7) started to come into my mom's room and he told me he was going to finish cleaning everything but (V6) told him he could not go back into my mom's room. (V7) told me he had spilt the water I could see my mom shaking and I was happy (V7) was not going to provide care to my mom. But, then the next day (V7) was on the floor the next day giving care to my mom, so nothing happened. I did not want (V7) going into my mom's room after that incident because my mom was so upset and said she felt abused, and nobody should be treated the way (V7) treated her that day. On 1/3/2025 at 12:44 PM, V7, Licensed Practical Nurse (LPN) stated, I remember the family member (V5) coming to me and she was upset and told me there was water in her mom's room on the floor that she had cleaned up and her bed was wet. I went into the room and there was not any water on the floor but (R2's) bed was wet and damp. They told me they were upset with (V7's care) and did not want (V7) providing any care to (R2) and I told them to write down a statement. I called (V2) and she told me to call (V1). I called (V1) and I put the statement under (V1's) door because she was not here. I told both (V1) and (V2) that the family was upset and did not want (V7) providing care to (R2). I told (V7) he could not work (R2's) hall. Nobody asked me any other questions. R2's Medical Records were reviewed and there was no documentation related to any allegations of abuse made by R2. On 1/3/2025 at 3:07 PM, V1, Administrator stated she did not complete an investigation on (R2) and or put anything in place for (R2) or collect evidence to determine what actions the facility must follow, and or put in place for the protection of the residents in the facility. V1 also stated she did not report it because she stated she did not get any statements, and nothing was put under her door and did not realize it was not customer service. The Facility Resident Abuse/Neglect/Exploitation Policy with a revision date of 7/23 documents, To provide guidelines for identifying, investigation, and reporting resident abuse/neglect and exploitation including any reasonable suspicion of a crime toward the resident. It is the responsibility of the Administrator of each resident to monitor compliance of this policy. Department Managers and Supervisors must know, understand, and enforce this policy. All employees of (Facility) must know, understand, and abide by this policy. Every resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Resident must not be subject to abuse by anyone, including, but not limited to, resident staff, other residents, consultants or volunteers, other agencies serving the individual, family members or legal guardians, friends, or other individual. The Elder Justice Act of 2009 has mandated enhanced reporting requirements for crimes that occur in LTC (Long term Care) facility which are outlined in this policy. Any covered individual who received an allegation or suspects that there is a situation of abuse, neglect, or exploitation of a resident including a potential or actual criminal action shall immediate disrupt all perceived or observed abuse by yelling for help, activating the call lights and/or telling the person involved to stop. A covered individual may also contact the appropriate State agency- Department of Health and Senior Services (DHSS) Complaint Registry Unit. The Administrator will direct staff to complete an incident report and initiate investigation process. An investigation shall be initiated immediately. Any allegations must be fully investigated and self-reported to an appropriate State Agency. Upon receiving al allegation of abuse, the alleged perpetrator will be suspended/removed immediate from the resident, pending the investigation. Nursing Management or the Administrator will initiate the investigation and complete the Resident Abuse/Neglect Complaint Investigation Report.

Based on interview and record review the Facility failed to ensure all abuse allegation were thoroughly investigated for 1 of 5 residents (R2) reviewed for investigation of abuse in the sample of 10. Findings include: On 1/2/2025 at 12:28 PM, V1, Administrator stated, (V6, Licensed Practical Nurse LPN) was the nurse working the day that (R2's) wet sheets were changed and the male certified nursing assistant (CNA) was (V7). V7 was the one who was working (R2's) hall. V1 stated, I did not get any statements or have any allegations of abuse related to (R6). I know the family was upset about (R2's) bed being wet but I do not have any statements or anything in writing voicing any other concerns, and nothing related to any abuse allegations. All abuse investigations for the past six months were requested and reviewed and there was no abuse investigation provided for R2. On 1/2/2024 at 12:43 PM, V7, stated (R2) was very slow in her movements. (R2) did not like to move a lot, I helped her to transfer from her recliner to her wheelchair, and then her wheelchair to her bed, when I turned around a saw water on the floor. I did not see any water on (R2) nor did I see (R2) was wet. If I thought, she was wet I would have changed her right then. I always tried to be gentle with her and had no issues with her. I laid her gently on the bed and moved her feet over, covered her up and left the room. I never threw her on the bed or threw water at her. I tried to go back and clean up the water but (V6) told me not go into her room. On 1/3/2025 at 8:33 AM, R2 stated, I was good at the (Facility) until that staff member picked me up, slid me on the bed, swung my feet around and spilled water all over me and left me. I was afraid of him. He was rough with me. I was very upset, so I immediately called (V5) and told her what had happened. Nobody should be treated the way he treated me. I was scared to tell him about the water because of the way he was treating me. I feel like I was abused by him. I am afraid to go back to the facility. On 1/3/2025 at 8:39 AM, V5, Family of R2 stated, I remember getting the call from my mom because she was frantic, and I asked her what was going on and she asked me to please come to the (Facility). It took me over an hour before I got there but when I got there my mom was still upset. When I walked into the room there was water all over the floor. I started cleaning up the water on the floor because I did not want anyone to fall. Then my mom told me a staff member threw her on the bed and spilled water all over her and left her. Now mind you, it took me an hour to get to my mom because I had to wait on my cousin, and here she is and when I went over to her the bed was soaked with water. I started stripping the bed and I went and got (V6, the nurse) and told him my mom was afraid of (V7) and he had me write everything down in a statement and he told me that staff member (V7) would not be providing care anymore to my mom. (V7) started to come into my mom's room and he told me he was going to finish cleaning everything but (V6) told him he could not go back into my mom's room. (V7) told me he had spilt the water I could see my mom shaking and I was happy (V7) was not going to provide care to my mom. But, then the next day (V7) was on the floor the next day giving care to my mom, so nothing happened. I did not want (V7) going into my mom's room after that incident because my mom was so upset and said she felt abused, and nobody should be treated the way (V7) treated her that day. (R2) does not want to go back to the facility. I was hoping she would have more care but if that is the care she is getting them I am going to have her come home with me. On 1/3/2025 at 12:44 PM, V6, LPN stated, I remember the family member (V5) coming to me and she was upset and told me there was water in her mom's room on the floor that she had cleaned up and her bed was wet. I went into the room and there was not any water on the floor but (R2's) bed was wet and damp. They told me they were upset with (V7's care) and did not want (V7) providing any care to (R2) and I told them to write down a statement. I called (V2) and she told me to call (V1). I called (V1) and I put the statement under (V1's) door because she was not here. I told both (V1) and (V2) that the family was upset and did not want (V6) providing care to (R2). I told (V7) he could not work (R2's) hall. Nobody asked me any other questions. R2's Medical Records were reviewed and there was no documentation related to any allegations of abuse made by R2. On 1/2/2025 at 2:30 PM, V2, DON stated, I am not aware of any resident accidentally or intentionally having water on them and staff not cleaning it up and/or treating any resident rough. (V7) did call me and told me the family of (R2) had a family concern and I immediately told him to call (V1) because she is the one that needs to address any concerns. I never heard back from anyone, so I was not aware until today that there were any abuse allegations from (R2). Normally, if there are any abuse allegations that are supposed to go directly to the administrator where she will start an investigation. Usually, once the investigation is initiated, then I will help out with the investigation. On 1/3/2025 at 3:07 PM, V1 stated she did not complete an investigation on (R2) and or put anything in place for (R2) or collect evidence to determine what actions the facility must follow, and or put in place for the protection of the residents in the facility. No assessment was completed on (R2), and no interviews were conducted and/or no measures were put into place to ensure no future potential abuse occurred. V1 stated she was not aware there was any allegation of abuse made by (R2). The Facility Resident Abuse/Neglect/Exploitation Policy with a revision date of 7/23 documents, To provide guidelines for identifying, investigating, and reporting resident abuse/neglect and exploitation, including any reasonable suspicion of a crime toward the resident. It is the responsibility of the Administrator of each resident to monitor compliance of this policy. Department Managers and Supervisors must know, understand, and enforce this policy. All employees of (Facility) must know, understand, and abide by this policy. Every resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Resident must not be subject to abuse by anyone, including, but not limited to, resident staff, other residents, consultants or volunteers, other agencies serving the individual, family members or legal guardians, friends, or other individuals. The Elder Justice Act of 2009 has mandated enhanced reporting requirements for crimes that occur in LTC (Long term Care) facility which are outlined in this policy. Any covered individual who received an allegation or suspects that there is a situation of abuse, neglect, or exploitation of a resident including a potential or actual criminal action shall immediately disrupt all perceived or observed abuse by yelling for help, activating the call lights, and/or telling the person involved to stop. A covered individual may also contact the appropriate State agency- Department of Health and Senior Services (DHSS) Complaint Registry Unit. The Administrator will direct staff to complete an incident report and initiate investigation process. An investigation shall be initiated immediately. Any allegations must be fully investigated and self-reported to an appropriate State Agency. Upon receiving an allegation of abuse, the alleged perpetrator will be suspended/removed immediately from the resident, pending the investigation. Nursing Management or the Administrator will initiate the investigation and complete the Resident Abuse/Neglect Complaint Investigation Report.

Based on interview and record review the facility failed to provide timely and complete incontinent care for 5 of 5 residents (R13, R23, R24, R31, R33) reviewed for incontinent care in a sample of 33. This failure resulted in R23 laying in urine all night, feeling dirty, like a fool and embarrassed. Findings include: 1. R23's Care Plan, not dated, documents R23 is occasionally incontinent of urine of bladder and continent of bowel. Please provide frequent toileting and peri care after each incontinent episode, requires extensive assist with ADL's (activities of daily living), R23's Minimum Data Set, dated dated ,d+[DATE], documents R23 is alert and oriented x4, occasionally incontinent of urine, and requires assistance from staff for toileting. On 10/7/2024 at approximately 9:00 AM, observed V5, CNA, providing R23 incontinent care. R23 was incontinent of urine. V5 pulled back covers and opened R23's incontinent brief. V5's incontinent brief was heavily soiled with urine. V5 then cleansed R23's peri and groin area. V5 then assisted R23 over onto her right side. R23's gown, incontinent brief, incontinent pad and sheets were soaked with urine. R23's sheets were soaked up to her upper back. V5 removed the soiled incontinent brief revealing multiple deep, red indentations in skin. V5 then cleansed R23's left buttock. V5 then removed the urine soak sheets from the bed and rolled beneath R23. V5 then assisted R23 into the seated position on the side of the bed and put on R23's clothes and assisted R23 into the wheelchair. V5 did not cleanse all areas of incontinence. V5 did not cleanse R3's inner thighs and back. On 10/7/2024 at 8:50 AM, R23 stated she wanted to know why the girl did not come in and change her last night. R23 stated she has been wet all night. R23 stated the girl came in and gave her water last night but never checked her or cleaned her. R23 stated she told the girl she needed to be changed. R23 stated in the day she is up in her chair and able to use the toilet with help. R23 stated at night when she is in the bed, she loses all sense of control. R23 stated this makes her feel dirty, angry and embarrassed. R23 stated she doesn't want to lay in her own filth all night and she doesn't want to stink because of it. R23 stated it hurts laying in one position wet all night. R23 stated there is only 1 CNA, Certified Nurse Assistant, that cleans you when you are wet. R23 stated the others remove the depend and put another on you without cleaning you. R23 stated she shouldn't have to live like that. R23 stated they don't have enough staff. R23 stated she laid wet all night. R23 stated there was a time she had to have her roommate take her off the bedpan and clean her. R23 stated no one came. R23 stated she complains about it, but nothing is done. R23 stated she feels like a fool, like she is nothing. On 10/7/2024 at 9:08 AM, V5, CNA, stated she was informed (R23) did not void all night. V5 stated she thought it was odd because (R23) is a heavy wetter at night. On 10/101/2024 at 11:03 AM, V18, Nurse Supervisor, stated (R23) is alert and oriented x4. V18 stated if (R23) stated said she was laying wet all night this would be accurate statement. V18 stated if R23 stated she was embarrassed, angry, felt like a fool and felt pain from this this would be an accurate statement of how (R23) felt. V18 stated (R23) laying in urine all night and being soiled up to her head is a dignity problem. On 10/10/2024 at 11:47 AM, V23, Licensed Practical Nurse, stated (R23) is alert and oriented x4. V23 stated (R23) will tell you the truth. V23 stated if (R23) stated she was wet all night, and they didn't have staff this would be an accurate statement. V23 stated if she laid in urine for a long time, she would feel nasty and dirty. V23 stated if (R23) stated this is how she felt it would be accurate. On 10/8/24 at 1:30 PM, Resident Council was conducted, and R23, R24, R31, and R33 voiced multiple concerns with lack of staff and timeliness of incontinent care during this meeting. R23, Resident Council President, stated the facility does not have enough staff at night and she has laid in wet pants multiple times all night because she could not get any employees to clean her up. R23 stated her roommate R24 is a former CNA and R24 has assisted her with getting on the bedpan and has cleaned her up throughout the night because they could not get any staff to answer the call light. R23 stated she frequently must sit with wet pants for long periods of time due to staff not answering her call light or staff saying they will be back to change her, and then they don't return. R23 stated she frequently voices her complaints to administration, and they just blow smoke up her butt in response to her complaints. 2. R13's Care Plan, not dated, documents R13 and requires extensive too dependent of ADL care, incontinent of bowel and bladder. Provide peri care after episodes of incontinent remain clean and dry and minimize the risk of skin breakdown thru this next review period. R13's MDS, dated [DATE], documents R13 is moderately cognitively impaired, incontinent of bladder and bowel, and requires assistance from staff for toileting. On 10/9/2024 at 8:00 AM, observed V23, LPN, and V24, LPN, performed incontinent care and treatment. R13 was incontinent of urine and bowel. V23 and V24 opened R13's incontinent brief V24 rolled it between R13's legs. V23 and V24 then turned R13 on her right side. V24 rolled the soiled incontinent brief under R13. Using soap and water V24 wiped the stool from between R13's right and left buttocks. V24 then wiped the same area with a wet washcloth. V24 then changed her gloves and performed treatment to R13's pressure ulcer on right buttock. V24 then placed a clean incontinent brief under R13. V23 and V24 rolled R13 onto her left side and removed the soiled incontinent brief from beneath R13. V23 and V24 then fastened R13's brief and placed cover over R13. On 10/10/2024 at 11:03 AM, V18, Nurse Supervisor, stated she expects the staff to clean all wet areas. V18 stated if a resident is wet up to her back and neck those areas are to be cleaned as part of peri care. V18 stated if a treatment is performed, and the resident is incontinent of bowel and bladder the staff are to perform peri care and then complete the treatment. The facility's Perineal Policy, dated 10/22, documents Purpose: To provide guidelines for performing perineal care. Policy: Perineal care is to be done as needed for incontinence for residents who are unable to perform self-care. Perineal care is done to cleanse the perineum to prevent growth of bacteria, prevent skin breakdown and promote good personal hygiene. Standard precautions and sound aseptic technique will be used when performing peri-care. Policy: Perineal Care is to be done as needed for incontinence for residents who are unable to perform self-care. Perineal care is done to cleanse the perineum to prevent growth of bacteria, prevent skin breakdown and promote good personal hygiene. Practice: 10. Always work from the cleanest area to the dirtiest. Therefore, clean from urethra to the anal area (front to back) to prevent fecal matter from spreading from the anal area to the vagina or urethra using clean technique. Always gently pat dry (no scrubbing). Female Perineal Care 2. Expose perineal area. Gently cleanse the inner legs and outer peri area along the outside of the labia. 3. Cleanse outer labia from front to back. 4. Cleanse inner labia from front to back. 5. Gently open all skin folds and cleanse from front to back. 6. Cleanse and dry anal area. -- 3. R24's face sheet, print date of 10/9/24, documented R24 has diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia and aphasia following cerebral infarction, depression, multiple sclerosis, epilepsy, and hypertension. R24's MDS dated [DATE] documented R24 is cognitively intact. R24's MDS dated [DATE] documented R24 depends on a wheelchair for mobility and requires partial to moderate assistance to ambulate 10 feet. On 10/8/24, during the Resident Council meeting R24 agreed that she helps her roommate (R23) get on the bed pan at night and cleans her up due to staff not answering the call light. 4. R31's face sheet, print date of 10/9/24, documented R31 has diagnoses of malignant neoplasm of prostate, dysphasia following cerebral infarction, pulmonary hypertension, pleural effusion, emphysema, spinal stenosis, and atrial fibrillation. R31's MDS dated [DATE] documented R31 is cognitively intact, always incontinent of bowels, has an indwelling urinary catheter, and requires substantial to maximal assistance with toileting hygiene. On 10/8/24, during the Resident Council meeting R31 stated that there is not enough staff on any of the shifts and that the night shift is the worst. R31 stated that he has been dirty all night several times because he cannot get the CNAs to change him. 5. R33's face sheet dated 10/9/24 documented R33 has diagnoses of benign hypertensive heart, chronic kidney disease, congestive heart failure, morbid obesity, gout, atrial fibrillation, anemia, hypertension, and diabetes mellitus. R33's MDS dated [DATE] documented R33 is cognitively intact, always incontinent of bowel and bladder, and requires substantial to maximal assistance with toileting hygiene. On 10/8/24, during the Resident Council meeting R33 stated that she often must sit in her wet adult diaper due to the staff not answering her call light or answering it, stating they will be back to change her, and then they don't return. R33 stated she recently called for assistance to be changed at 7 am because she was wet. The CNA stated she would be back to change her, and she could not get anyone to change her adult diaper until 11:30 am. On 10/8/24 at approximately 2 PM, V5, CNA stated that sometimes she does find residents that are saturated with urine when she comes on duty in the mornings. On 10/10/24 at 11:06 AM, V18, Nurse Supervisor stated that she would expect the facility nursing staff to answer resident call lights within 5 minutes She would expect the nursing staff to immediately assist the residents with care needs and stated that it is absolutely not okay for a resident to be cleaning up another resident.

3. R24's face sheet, print date of 10/9/24, documented R24 has diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia and aphasia following cerebral infarction, depression, multiple sclerosis, epilepsy, and hypertension. R24's MDS dated [DATE] documented R24 is cognitively intact. R24's MDS dated [DATE] documented R24 depends on a wheelchair for mobility and requires partial to moderate assistance to ambulate 10 feet. On 10/8/24, during the Resident Council meeting R24 agreed that she helps her roommate (R23) get on the bed pan at night and cleans her up due to staff not answering the call light. 4. R31's face sheet, print date of 10/9/24, documented R31 has diagnoses of malignant neoplasm of prostate, dysphasia following cerebral infarction, pulmonary hypertension, pleural effusion, emphysema, spinal stenosis, and atrial fibrillation. R31's MDS dated [DATE] documented R31 is cognitively intact, always incontinent of bowels, has an indwelling urinary catheter, and requires substantial to maximal assistance with toileting hygiene. On 10/8/24, during the Resident Council meeting R31 stated that there is not enough staff on any of the shifts and that the night shift is the worst. R31 stated that he has been dirty all night several times because he cannot get the CNAs to change him. 5. R33's face sheet dated 10/9/24 documented R33 has diagnoses of benign hypertensive heart, chronic kidney disease, congestive heart failure, morbid obesity, gout, atrial fibrillation, anemia, hypertension, and diabetes mellitus. R33's MDS dated [DATE] documented R33 is cognitively intact, always incontinent of bowel and bladder, and requires substantial to maximal assistance with toileting hygiene. On 10/8/24, during the Resident Council meeting R33 stated that she often must sit in her wet adult diaper due to the staff not answering her call light or answering it, stating they will be back to change her, and then they don't return. R33 stated she recently called for assistance to be changed at 7 am because she was wet. The CNA stated she would be back to change her, and she could not get anyone to change her adult diaper until 11:30 am. On 10/8/24 at approximately 2 PM, V5, CNA stated that sometimes she does find residents that are saturated with urine when she comes on duty in the mornings. On 10/10/24 at 11:06 AM, V18, Nurse Supervisor stated that she would expect the facility nursing staff to answer resident call lights within 5 minutes She would expect the nursing staff to immediately assist the residents with care needs and stated that it is absolutely not okay for a resident to be cleaning up another resident. Based on interview and record review the facility failed to provide timely and complete incontinent care for 5 of 5 residents (R13, R23, R24, R31, R33) reviewed for incontinent care in a sample of 33. This failure resulted in R23 laying in urine all night, feeling dirty, like a fool and embarrassed. Findings include: 1. R23's Care Plan, not dated, documents R23 is occasionally incontinent of urine of bladder and continent of bowel. Please provide frequent toileting and peri care after each incontinent episode, requires extensive assist with ADL's (activities of daily living), R23's Minimum Data Set, dated 8/20, documents R23 is alert and oriented x4, occasionally incontinent of urine, and requires assistance from staff for toileting. On 10/7/2024 at approximately 9:00 AM, observed V5, CNA, providing R23 incontinent care. R23 was incontinent of urine. V5 pulled back covers and opened R23's incontinent brief. V5's incontinent brief was heavily soiled with urine. V5 then cleansed R23's peri and groin area. V5 then assisted R23 over onto her right side. R23's gown, incontinent brief, incontinent pad and sheets were soaked with urine. R23's sheets were soaked up to her upper back. V5 removed the soiled incontinent brief revealing multiple deep, red indentations in skin. V5 then cleansed R23's left buttock. V5 then removed the urine soak sheets from the bed and rolled beneath R23. V5 then assisted R23 into the seated position on the side of the bed and put on R23's clothes and assisted R23 into the wheelchair. V5 did not cleanse all areas of incontinence. V5 did not cleanse R3's inner thighs and back. On 10/7/2024 at 8:50 AM, R23 stated she wanted to know why the girl did not come in and change her last night. R23 stated she has been wet all night. R23 stated the girl came in and gave her water last night but never checked her or cleaned her. R23 stated she told the girl she needed to be changed. R23 stated in the day she is up in her chair and able to use the toilet with help. R23 stated at night when she is in the bed, she loses all sense of control. R23 stated this makes her feel dirty, angry and embarrassed. R23 stated she doesn't want to lay in her own filth all night and she doesn't want to stink because of it. R23 stated it hurts laying in one position wet all night. R23 stated there is only 1 CNA, Certified Nurse Assistant, that cleans you when you are wet. R23 stated the others remove the depend and put another on you without cleaning you. R23 stated she shouldn't have to live like that. R23 stated they don't have enough staff. R23 stated she laid wet all night. R23 stated there was a time she had to have her roommate take her off the bedpan and clean her. R23 stated no one came. R23 stated she complains about it, but nothing is done. R23 stated she feels like a fool, like she is nothing. On 10/7/2024 at 9:08 AM, V5, CNA, stated she was informed (R23) did not void all night. V5 stated she thought it was odd because (R23) is a heavy wetter at night. On 10/101/2024 at 11:03 AM, V18, Nurse Supervisor, stated (R23) is alert and oriented x4. V18 stated if (R23) stated said she was laying wet all night this would be accurate statement. V18 stated if R23 stated she was embarrassed, angry, felt like a fool and felt pain from this this would be an accurate statement of how (R23) felt. V18 stated (R23) laying in urine all night and being soiled up to her head is a dignity problem. On 10/10/2024 at 11:47 AM, V23, Licensed Practical Nurse, stated (R23) is alert and oriented x4. V23 stated (R23) will tell you the truth. V23 stated if (R23) stated she was wet all night, and they didn't have staff this would be an accurate statement. V23 stated if she laid in urine for a long time, she would feel nasty and dirty. V23 stated if (R23) stated this is how she felt it would be accurate. On 10/8/24 at 1:30 PM, Resident Council was conducted, and R23, R24, R31, and R33 voiced multiple concerns with lack of staff and timeliness of incontinent care during this meeting. R23, Resident Council President, stated the facility does not have enough staff at night and she has laid in wet pants multiple times all night because she could not get any employees to clean her up. R23 stated her roommate R24 is a former CNA and R24 has assisted her with getting on the bedpan and has cleaned her up throughout the night because they could not get any staff to answer the call light. R23 stated she frequently must sit with wet pants for long periods of time due to staff not answering her call light or staff saying they will be back to change her, and then they don't return. R23 stated she frequently voices her complaints to administration, and they just blow smoke up her butt in response to her complaints. 2. R13's Care Plan, not dated, documents R13 and requires extensive too dependent of ADL care, incontinent of bowel and bladder. Provide peri care after episodes of incontinent remain clean and dry and minimize the risk of skin breakdown thru this next review period. R13's MDS, dated [DATE], documents R13 is moderately cognitively impaired, incontinent of bladder and bowel, and requires assistance from staff for toileting. On 10/9/2024 at 8:00 AM, observed V23, LPN, and V24, LPN, performed incontinent care and treatment. R13 was incontinent of urine and bowel. V23 and V24 opened R13's incontinent brief V24 rolled it between R13's legs. V23 and V24 then turned R13 on her right side. V24 rolled the soiled incontinent brief under R13. Using soap and water V24 wiped the stool from between R13's right and left buttocks. V24 then wiped the same area with a wet washcloth. V24 then changed her gloves and performed treatment to R13's pressure ulcer on right buttock. V24 then placed a clean incontinent brief under R13. V23 and V24 rolled R13 onto her left side and removed the soiled incontinent brief from beneath R13. V23 and V24 then fastened R13's brief and placed cover over R13. On 10/10/2024 at 11:03 AM, V18, Nurse Supervisor, stated she expects the staff to clean all wet areas. V18 stated if a resident is wet up to her back and neck those areas are to be cleaned as part of peri care. V18 stated if a treatment is performed, and the resident is incontinent of bowel and bladder the staff are to perform peri care and then complete the treatment. The facility's Perineal Policy, dated 10/22, documents Purpose: To provide guidelines for performing perineal care. Policy: Perineal care is to be done as needed for incontinence for residents who are unable to perform self-care. Perineal care is done to cleanse the perineum to prevent growth of bacteria, prevent skin breakdown and promote good personal hygiene. Standard precautions and sound aseptic technique will be used when performing peri-care. Policy: Perineal Care is to be done as needed for incontinence for residents who are unable to perform self-care. Perineal care is done to cleanse the perineum to prevent growth of bacteria, prevent skin breakdown and promote good personal hygiene. Practice: 10. Always work from the cleanest area to the dirtiest. Therefore, clean from urethra to the anal area (front to back) to prevent fecal matter from spreading from the anal area to the vagina or urethra using clean technique. Always gently pat dry (no scrubbing). Female Perineal Care 2. Expose perineal area. Gently cleanse the inner legs and outer peri area along the outside of the labia. 3. Cleanse outer labia from front to back. 4. Cleanse inner labia from front to back. 5. Gently open all skin folds and cleanse from front to back. 6. Cleanse and dry anal area.

Based on interview, record review, and observation the facility failed to ensure residents are free from significant medication errors for 1 of 6 (R195) residents reviewed for medication administration in a sample of 33. A delay of 6 days in getting the antibiotic started to treat UTI as ordered by the Physician Assistant caused R195 to become confused, have abdominal pain, increased leg pain, and missed some therapy sessions. Findings include: R195's face sheet, print date of 10/8/24, documented R195 was admitted to the facility on [DATE] with diagnoses of displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, Sjogren syndrome with peripheral nervous system involvement, Parkinson's disease, anemia, obstructive sleep apnea, and rheumatoid arthritis. R195's MDS (Minimum Data Set) dated 9/4/24, documented R195 is mildly cognitively impaired. R195's Physician Progress Notes by V31 PA (Physician Assistant) dated 9/27/24 at 8:51 AM documented, TI (urinary tract infection). Urine cx (culture) growing out ESBL (extended spectrum beta-lactamase). 9/27 - 1 week course of ciprofloxacin ordered. R195's Urine Culture Report dated 9/26/24 documents, urine culture positive for klebsiella pneumoniae ESBL. V31, PA documented on this report start ciprofloxacin 500 mg 1 tab (tablet) po (by mouth) BID (two times a day) for times 7 days for UTI with a start date of 9/27/24. R195's Nurse Progress Note dated 10/2/24 at 3:41 PM documents, UA (urinalysis) results sent to MD 9/27/24 with order returning to start Cipro. Order entry was delayed until 10/2/24 for ABT (antibiotic). MD and family aware. ABT started at this time. R195's Physical Therapy Treatment Encounter note dated 9/18/24 documented, patient participated in gait training and ambulated 50 feet with CGA (contact guard assist)/Min assist (minimal assistance) using a FWW (front wheeled walker) with cues. R195's Physical Therapy Note dated 9/19/24 documented, (R195) participated in gait training using front wheeled walker, CGA, and ambulated 250 feet with close w/c (wheelchair) follow. R195's Physical Therapy Note dated 9/24/24 documented, patient with decreased performance with blood in urine and procedure this date to drain fluid as patient had distended abdomen. Patient required increased assistance this date due to fatigue. R195's Occupational Therapy Note dated 10/2/24 documented, patient seen extended time today secondary to having difficulty attending to task and following automatic instructions. Wife present and concerned. Patient alert and oriented x 1. Patient requiring increased time to initiate and complete tasks. Patient required max to near total assist to don bilateral tie shoes. Patient demonstrated poor sitting balance. Patient not following instructions to complete transfer to chair with front wheeled walker. Patient required mod assist to complete SPT (stand pivot transfer) from bed to wheelchair. Nurse informed of status and reports patient has irregular labs and has a call out to MD. R195's physical therapy note dated 10/2/24 documented COTA (Certified Occupational Therapy Assistant) reports increased confusion from patient. This clinician arrived at patient with wife appearing distressed. Patient's wife reports antibiotic for UTI was ordered 9/27 but was never started. Wife also reports she was told there were abnormal labs, but only had the report for hemoglobin. Wife reports catheter had been removed but was reinserted. Spoke with nurse to ask about patient being seen. Nurse said to return later as she needed to straight cath (catheterization) patient and scan bladder. Min (minimal) assist for supine to sit with assist using leg lifter during sit to supine. Patient utilizing bed rails. Verbal instruction for hand placement for ease of transfer. CGA for sit to stand from bed with verbal instruction for correct hand placement. This progress notes documented patient walked zero feet when R195 received physical therapy on 10/2/24. On 10/7/24 at 9:15 am R195's wife V28 stated the facility did not get R195's antibiotic started when it was order for a UTI. V28 stated there was a delay of 6 days in getting the antibiotic started and R195 was confused, having abdominal pain, increased leg pain, and missed some therapy sessions due to the UTI not being treated as ordered by the Physician Assistant. V28 stated she met with V2 DON (Director of Nursing) and V2 stated there was a miscommunication causing the antibiotic not getting administered when it was ordered. On 10/9/24 at 10:40 am V2 DON stated there was a medication error with R195's cipro order due to miscommunication between the nurse and the Physician Assistant. V2 stated the facility did complete a medication error report and a QAPI (Quality Assurance Performance Improvement) on R195's medication error. The facility medication incident report, print date of 10/8/24, documented R195's medication error was discovered by the facility on 10/2/24 for R195's antibiotic was ordered to be started on 9/27/24. This incident report documented antibiotic delayed start for UTI. R195's MARS (medication administration records) dated 9/24 and 10/24 documented R195 had an order for oxycodone 5mg prn (as needed) every 4 hours on admission 9/17/24. These MARS documented R195 only received the oxycodone on 9/23/24, 9/27/24, 10/1/24, and 10/2/24 when R195 was exhibiting symptoms of a UTI. R195's MAR dated 10/1/24 documented R195's first dose of ciprofloxacin was ordered on 9/27/24 was not administered until 10/2/24. On 10/9/24 at 10:45 am V28 (R195's wife) stated R195 is going home tomorrow because the insurance company will not pay for anymore therapy services. V28 stated she filed an appeal with the insurance company, and it was denied. V28 stated the 6-day delay in R195 receiving the antibiotics for the UTI due to the miscommunication caused R195 to miss therapy for multiple days because R195 was having pain, confused, and unable to participate in therapy. V28 stated instead of treating the UTI due to the miscommunication with the antibiotics the facility nurses were just administering oxycontin to R195 for pain. V28 stated the oxycontin caused R195 to be zoned out. R195 stated he was having pain in his lower abdomen and his upper leg during this time, and he was unable to do therapy. V28 stated she is very upset because R195 did not receive as much therapy as he needed due to the delay in getting the antibiotic started. V28 stated she believes R195 would be more prepared to go home if R195's UTI would have been treated when it was ordered. On 10/9/24 at 11:05 am V26 PTA (Physical Therapy Assistant) stated she has been treating R195 since admission and there was a period R195 was not able to participate in therapy due to an increase in pain and confusion. On 10/9/24 at 11:06 am V27 PT (Physical Therapist)/Therapy Manager stated R195 did not have any pain when she completed his initial therapy evaluation. V27 stated then there were a few days R195 did have a lot of pain and some confusion so R195 was not doing very well in therapy or unable to participate in therapy during those day. V27 stated the therapy documentation shows R195 was doing good in therapy up until 9/23/24, was walking 175 feet, then on 9/24/24 R195 had decreased performance, blood in his urine, and abdominal distention. V27 stated on 9/26/24 R195 complained of a lot of pain and could not participate in therapy on this day. V27 stated she spoke to R195's nurse on 9/26/24 and requested a doppler study and held off on therapy until the results came back. V27 stated the doppler results came back negative on 9/27/24 and R195 did received some therapy on 9/27/24 but R195 was unable to walk in therapy on 9/27/24. V27 stated R195 was only able to walk 10 feet in therapy on 9/30/24. V27 stated on 10/1/24 R195 was still having pain and only walked 30 feet in therapy. V27 stated on 10/2/24 R195 had increased confusion, was unable to walk in therapy, and only participated a little due to a UTI. V27 stated R195 was still confused on 10/3/24 and could not due therapy on this day but R195 was better on 10/4/24 and was able to walk 75 feet. V27 stated R195 did not have any confusion on 10/7/24 and he had a great day in therapy on 10/7/24. The facility Nursing Practices Policy and Procedure dated 1/24 documented Purpose: To establish guidelines for properly obtaining physician orders and processing these orders. Scope: Level 2 policy affecting licensed nursing personnel. Responsibility: It is the responsibility of the licensed nurse to understand and comply with this procedure. It is the responsibility of the nurse manager to maintain, enforce and monitor the procedure. It continues, telephone and verbal orders should be documented in the resident's electronic medical record then read back to the ordering physician/independent practitioner for verification.

Based on observation, interview, and record review, the facility failed to properly store medications and ensure expired medications were discarded when appropriate. This has the potential to affect all 45 residents living in the facility. Findings include: On 10/7/2024 at 9:43 AM, the facility's East Wing Medication Storage Room was inspected. The refrigerator in the medication room contained the following medication: 1. A Dulcolax suppository with expiration date 1/20/2023. 2. Two Acetaminophen 650mg suppositories with expiration date 4/2024. The East Wing medication room also had the following medication: 3. A large bottle of stool softener with expiration date 3/2022. On 10/7/2024 at approximately 9:50 AM, V4, Licensed Practical Nurse, LPN stated the medication in the storage rooms is stock medication. V4 stated the Dulcolax and Acetaminophen suppositories and the stool softeners are stock medication and can be used for everyone as long as they have an order and no allergies. V4 stated expired medications are not to be used and are to be destroyed. On 10/10/24 at 10:06 AM, V32, LPN stated the medicine room and medication storage room stores the stock, over the counter medication. V32 stated the Senna tablets, Acetaminophen and Dulcolax suppositories are stock medication and can be used for all residents. V32 stated if the medication is expired it is destroyed immediately. V32 stated they have a person stocks the medication, and they check the expiration date. On 10/10/2024 at 11:03 AM, V18, Nurse Supervisor stated (V33), Central Supply, is the central supply person. V18 stated at the end of last month, she has helped with checking the meds. V18 stated she is not sure of why the expired meds were there. V33 stated she is not sure if the medication was taking out of the cart and placed on the shelf or what. V33 stated the nurses check the carts and V33 checks the medicine room and medication room when he stocks. V18 stated he checks all the meds for expired medication at time. V18 stated when the medications are expired, he alerts the nurse, and they destroy them. On 10/10/2024 at 11:47 AM, V23, LPN stated when medications are expired on the cart they are removed and destroyed. V23 stated the medication is not placed back in the medication rooms they are destroyed. V23 stated the pharmacist checks the carts and the medication guy checks the medication rooms for expiration medications. The facility's Pharmacy Services and Procedure Manual, dated 12/1/22, documents Procedure: 4. The facility should ensure medications and biologicals: (1) have an expired date on the label; (2) have been retained longer than manufacture or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. The CMS Long-Term Care Facility Application for Medicare and Medicaid dated 10/7/2024, documents total residents 45.

Based on observation, and interview the facility failed to ensure a resident was treated with dignity and had needs met timely for 1 of 3 (R23) residents in a sample 33 observed for dignity. Findings include: R23's Care Plan, noted dated, documents R23 is able to make her needs known, pleasant to talk to and can communicate needs with staff. R23's Minimum Data Set, dated dated ,d+[DATE], documents R23 is alert and oriented x4 occasionally incontinent of urine and requires assistance from staff for toileting. On 10/7/2024 at approximately 9:00 AM, observed V5, CNA, providing R23 incontinent care. R23 was incontinent of urine. V5 pulled back covers and opened R23's incontinent brief. V5's incontinent brief was heavily soiled with urine. V5 then cleansed R23's peri and groin area. V5 then assisted R23 over onto her right side. R23's gown, incontinent brief, incontinent pad and sheets were soaked with urine. R23's sheets were soaked up to her upper back. V5 removed the soiled incontinent brief revealing multiple deep, red indentations in skin. V5 then cleansed R23's left buttock. V5 then removed the urine soak sheets from the bed and rolled beneath R23. V5 then assisted R23 into the seated position on the side of the bed and put on R23's clothes and assisted R23 into the wheelchair. V5 did not cleanse all areas of incontinence. V5 did not cleanse R3's inner thighs and back. On 10/7/2024 at 8:50 AM, R23 stated she wanted to know why the girl did not come in and change her last night. R23 stated she has been wet all night. R23 stated the girl came in and gave her water last night but never checked her or cleaned her. R23 stated she told the girl she needed to be changed. R23 stated in the day she is up in her chair and able to use the toilet with help. R23 stated at night when she is in the bed, she loses all sense of control. R23 stated this makes her feel dirty, angry and embarrassed. R23 stated she doesn't want to lay in her own filth all night and she doesn't want to stink because of it. R23 stated it hurts laying in one position wet all night. R23 stated there is only 1 CNA, Certified Nurse Assistant, that cleans you when you are wet. R23 stated the others remove the depend and put another on you without cleaning you. R23 stated she shouldn't have to live like that. R23 stated they don't have enough staff. R23 stated she laid wet all night. R23 stated there was a time she had to have her roommate take her off the bedpan and clean her. R23 stated no one came. R23 stated she complains about it, but nothing is done. R23 stated she feels like a fool, like she is nothing. On 10/7/2024 at 9:08 AM, V5, CNA, stated she was informed (R23) did not void all night. V5 stated she thought it was odd because (R23) is a heavy wetter at night. On 10/101/2024 at 11:03 AM, V18, Nurse Supervisor, stated (R23) is alert and oriented x4. V18 stated if (R23) stated said she was laying wet all night this would be accurate statement. V18 stated if R23 stated she was embarrassed, angry, felt like a fool and felt pain from this this would be an accurate statement of how (R23) felt. V18 stated (R23) laying in urine all night and being soiled up to her head is a dignity problem. On 10/10/2024 at 11:47 AM, V23, Licensed Practical Nurse, stated (R23) is alert and oriented x4. V23 stated (R23) will tell you the truth. V23 stated if (R23) stated she was wet all night, and they didn't have staff this would be an accurate statement. V23 stated if she laid in urine for a long time, she would feel nasty and dirty. V23 stated if (R23) stated this is how she felt it would be accurate. The facility's Resident Handbook, dated March 2020, documents Resident Rights: These are your rights as a resident of a Long-Term Care Community in Illinois as provided by the centers for Medicare and Medicaid Services (CMS) and the Illinois Department of Public Health (IDPH). You have the right to privacy in medical treatment, personal care, telephone and mail communications, visits with family and meetings in groups. You should be treated with consideration and respect, with full recognition of your dignity and individuality.

Based on record review and interview, the facility failed to complete the periodical comprehensive Minimum Data Set Assessments in the required time frame for 3 of 3 (R16, R23, R28) residents reviewed for resident assessments in a sample of 33. Findings include: 1. R28's Face Sheet, not dated, documents that R28 was admitted [DATE]. R28's Minimum Data Set (MDS), dated [DATE], documents Quarterly Assessment. Signed 8/23/2024. The facility provided a form that documents (R28) Target date: 8/9/2024, Submission and Processing date:10/8/2024. Warnings: Record submitted late. The submission date is more than 14 days after Z0500B on this new assessment. 2. R23's Face Sheet, not dated, documents that R23 was admitted [DATE]. R23's Minimum Data Set (MDS), dated [DATE], documents Quarterly Assessment. Signed 9/4/2024. The facility provided a form that documents (R23) Target date: 8/20/2024, Submission and Processing date: 10/8/2024. Warnings: Record submitted late. The submission date is more than 14 days after Z0500B on this new assessment. 3. R16's Face Sheet, not dated, documents that R16 was admitted [DATE]. R16's Minimum Data Set (MDS), dated [DATE], documents Quarterly Assessment. Signed 9/4/2024. The facility provided a form that documents (R28) Target date: 8/21/2024, Submission and Processing date: 10/8/2024. Warnings: Record submitted late. The submission date is more than 14 days after Z0500B on this new assessment. On 10/9/2024 at 1:32 PM, V29, MDS Coordinator stated that she is not sure why the assessments are indicating that they are overdue. On 10/9/2024 at 1:40 PM V30, Corporate Director of Reimbursement stated that the assessments were submitted late and this is why it was indicated that the assessments were overdue. The facility's Minimum Data Set Protocol, dated 10/23, documents Purpose: to provide directions for the completion of Resident Assessment Instrument (RAI) in a consistent, accurate manner that complies with the requirements set forth in the Long-Term Care Facility Resident Assessment Instrument User Manual. This includes the Minimum Data Set (MDS), Version 3.0, Submission: Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 +14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B +14 days).

Based on record review, and interview, facility failed to ensure sufficient nursing staff to provide nursing and related services to meet the residents' needs safely and in a manner promotes each resident's rights, physical, mental, and psychosocial well-being. This failure has the potential to affect all 33 residents residing in the facility. R23's Care Plan, not dated, documents R23 is occasionally incontinent of urine of bladder and continent of bowel. Please provide frequent toileting and peri care after each incontinent episode, requires extensive assist with ADL's (activities of daily living), R23's Minimum Data Set, dated dated ,d+[DATE], documents R23 is alert and oriented x4 occasionally incontinent of urine and requires assistance from staff for toileting. On 10/7/2024 at approximately 9:00 AM, observed V5, CNA, provide R23 incontinent care. R23 was incontinent of urine. V5 pulled back covers and opened R23's incontinent brief. V5's incontinent brief was heavily soiled with urine. V5 then cleansed R23's peri and groin area. V5 then assisted R23 over onto her right side. R23's gown, incontinent brief, incontinent pad and sheets were soaked with urine. R23's sheets were soaked up to her upper back. V5 removed the soiled incontinent brief revealing multiple deep, red indentations in skin. V5 then cleansed R23's left buttock. V5 then removed the urine soak sheets from the bed and rolled beneath R23. V5 then assisted R23 into the seated position on the side of the bed and put on R23's clothes and assisted R23 into the wheelchair. V5 did not cleanse all areas of incontinence. V5 did not cleanse R3's inner thighs and back. On 10/7/2024 at 8:50 AM, R23 stated she wanted to know why the girl did not come in and change her last night. R23 stated she has been wet all night. R23 stated the girl came in and gave her water last night but never checked her or cleaned her. R23 stated she told the girl she needed to be changed. R23 stated in the day she is up in her chair and able to use the toilet with help. R23 stated at night when she is in the bed, she loses all sense of control. R23 stated this makes her feel dirty, angry and embarrassed. R23 stated she doesn't want to lay in her own filth all night and she doesn't want to stink because of it. R23 stated it hurts laying in one position wet all night. R23 stated there is only 1 CNA, Certified Nurse Assistant, that cleans you when you are wet. R23 stated the others remove the depend and put another on you without cleaning you. R23 stated she shouldn't have to live like. R23 stated they don't have enough staff. R23 stated she laid all night. R23 stated there was a time she had to have her roommate take her off the bedpan and clean her. R23 stated no one came. R23 stated she complains about it, but nothing is done. R23 stated she feels like a fool, like she is nothing. On 10/8/24 at 1:30 PM, Resident Council was conducted, and R23, R24, R31, and R33 voiced multiple concerns with lack of staff and timeliness of incontinent care during this meeting. R23, Resident Council President, stated the facility does not have enough staff at night and she has laid in wet pants multiple times all night because she could not get any employees to clean her up. R23 stated her roommate R24 is a former CNA and R24 has assisted her with getting on the bedpan and has cleaned her up throughout the night because they could not get any staff to answer the call light. R23 stated she frequently must sit with wet pants for long periods of time due to staff not answering her call light or staff saying they will be back to change her, and then they don't return. R23 stated she frequently voices her complaints to administration, and they just blow smoke up her butt in response to her complaints. On 10/7/2024 at 9:08 AM, V5, CNA stated she was informed (R23) did not void all night. V5 stated she thought it was odd because (R23) is a heavy wetter at night. On 10/101/2024 at 11:03 AM, V18, Nurse Supervisor stated (R23) is alert and oriented x4. V18 stated if (R23) stated said she was laying wet all night Because no one came in and there were no staff this would be accurate statement. V18 stated if (R23) stated she was embarrassed, angry, felt like a fool and felt pain from this this would be an accurate statement of how (R23) felt. V18 stated (R23) laying in urine all night and being soiled up to her head is a dignity problem. On 10/10/2024 at 11:47 AM, V23 stated (R23) is alert and oriented x4. V23 stated (R23) will tell you the truth. V23 stated if (R23) stated she was wet all night, and they didn't have staff this would be an accurate statement. 49494 On 10/8/24 at 1:30 PM, Resident Council was conducted. R23, R24, R31, and R33 voiced multiple concerns with lack of staff during this meeting. R24's face sheet, print date of 10/9/24, documented R24 has diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia and aphasia following cerebral infarction, depression, multiple sclerosis, epilepsy, and hypertension. R24's MDS dated [DATE] documented R24 is cognitively intact. R24's MDS dated [DATE] documented R24 depends on a wheelchair for mobility and requires partial to moderate assistance to ambulate 10 feet. On 10/8/24, during the Resident Council meeting R24 agreed that she helps her roommate R23 get on the bed pan at night and cleans her up due to staff not answering the call light. R31's face sheet, print date of 10/9/24, documented R31 has diagnoses of malignant neoplasm of prostate, dysphasia following cerebral infarction, pulmonary hypertension, pleural effusion, emphysema, spinal stenosis, and atrial fibrillation. R31's MDS dated [DATE] documented R31 is cognitively intact, always incontinent of bowels, has an indwelling urinary catheter, and requires substantial to maximal assistance with toileting hygiene. On 10/8/24, during the Resident Council meeting R31 stated that there is not enough staff on any of the shifts and that the night shift is the worst. R31 stated that he has been dirty all night several times because he cannot get the CNAS to change him. R33's face sheet dated 10/9/24 documented R33 has diagnoses of benign hypertensive heart, chronic kidney disease, congestive heart failure, morbid obesity, gout, atrial fibrillation, anemia, hypertension, and diabetes mellitus. R33's MDS dated [DATE] documented R33 is cognitively intact, always incontinent of bowel and bladder, and requires substantial to maximal assistance with toileting hygiene. On 10/8/24, during the Resident Council meeting R33 stated that she often must sit in her wet adult diapers due to the staff not answering her call light or answering it, stating they will be back to change her, and then they don't return. R33 stated that she recently called for assistance to be changed at 7 am because she was wet, the CNA stated she would be back to change her, and that she could not get anyone to change her adult diaper until 11:30 am. On 10/8/24 at approximately 2:00 PM, V5, CNA stated that sometimes she does find residents that are saturated when she comes on duty in the mornings. On 10/10/24 at 11:06 AM, V18, Nurse Supervisor stated she would expect the facility nursing staff to answer resident call lights within 5 minutes, she would expect the nursing staff to immediately assist the residents with care needs and stated that it is absolutely not okay for a resident to be cleaning up another resident. The facility staff plan policy and procedure dated 3/20 documented the purpose is to establish written guidelines to assist nursing management in determining adequate staffing to provide safe resident care. It is the responsibility of all nursing management (Director of Nursing, Assistant Director of Nursing, Supervisors and Nurse Managers) to understand and enforce this policy. Responsibility: It is the responsibility of this community to provide sufficient staff with appropriate competencies and skills to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Policy: The provision of safe care to every resident should be the focus for determining the number and competency level of direct caregivers based on the resident's needs within the community and to make sure staffing information is readily available in a readable format to residents and visitors at any given time. The community census, acuity and diagnosis of the resident population will be considered based on the facility assessment. Basic staffing guidelines will be followed for assigning direct care nursing staff on each shift of duty. The need for additional staff should be assessed using established guidelines that are reflected in the practice statement of this policy. It continues, direct care staffing: 1. The staffing plan should be based upon general staffing guidelines. The staffing schedule is developed by the nursing office and available to the staff at least two weeks in advance. 2. Each shift staffing is determined by staffing guidelines using resident acuity, census and staff availability. Nursing Supervisors will evaluate upcoming shift staffing to ensure adequate staffing. 3. The information shall reflect staff absences on that shift due to call outs and illnesses. The actual hours will be updated on the staffing sheet after the start of each shift. It continues, 7. If the acuity for a specific nursing unit requires adjusted staffing, examples of acuity measures to be considered are: a. Number of residents that require full assistance. b. Number of residents with continuous monitoring devices, c. Number of new admissions within the past twenty-four hours. It continues, 11. Providing care includes, but is not limited to assessing, evaluating, planning, and implementing resident care plans and responding to residents' needs.

Based on interview and record review the facility failed to ensure a safe transfer for 1 of 3 residents (R2) reviewed for falls in the sample of 13. This failure resulted in R2 sustaining a large, abrasion/laceration on her right calf while being transferring without the use of a gait belt and needing wound care. Findings include: R2's Physician Order Sheet for May, 2024 documents a diagnosis of abnormal weight loss, hereditary hemochromatosis, unspecified severe protein calorie malnutrition, alcoholic hepatitis without ascites, chronic obstructive pulmonary disease, disorder of iron metabolism, irritable bowel syndrome with diarrhea, body mass index 19.9 or less, adult, arthropathic psoriasis, monoclonal gammopathy, ankylosis, spondylitis lumbar region. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact for decision making of activities of daily living. I use a wheelchair and a walker and have no impairment on my upper and/or lower extremities. R2's Resident Profile Page dated 4/5/2024 documents, I have a goal of increasing my independence. I am at risk for falls. I require assistance with transfers and ambulation. My goal is to reduce the risk factors that contribute to my fall risk and to minimize the risk of injury related to my fall throughout this review. My goal is to discharge home independently with home health. I am five foot seven and weigh 87 pounds. I have a risk for skin breakdown. I have a risk for skin breakdown. I received skin tear to right lower leg from transfer. Treatment orders in place and improvement noted at discharge. R2's Physician Note SBAR (Situation, Background, Assessment and Recommendation) dated 4/1/2024 at 10:00 AM, documents, I was called to patients' room at approximately 9:30 AM, because she was yelling in pain. The CNA informed me that her skin on her right leg got bumped during transfer. DON assisted me down to her room and patient's right calf had skin tear 7 x 4 cm (centimeters) in size. CNA informed me that she was transferring her from the wheelchair to the bed and the patient started to slide out of her wheelchair and she was able to put her on the bed before she slid on the floor. Patient stated she felt as if her leg hit the footboard and blood was spotted there. I assisted the DON with wrapping the patient's leg to control drainage. Patient is lying in bed, call light in reach. Incident report made. R2's Wound Assessment Report dated 4/2/2024 documents wound length 9.9 x 5 (width) x 0.2 cm3 (depth) for right calf. L (length) x w (width) = 49.5. The facility photograph dated 4/2/2024 was reviewed and shows a large area or chunk of skin that was affected and discolored, taking up a large portion of the leg. R2's Progress Note dated 4/18/2024 at 10:20 PM, documents, I was called to a patient's room at approximately 9:30 PM, because she was screaming in pain. The CNA (certified nursing assistant) informed me that her skin on her leg ripped and was bleeding tremendously. DON (Director of Nursing) assisted me down to her room and patient right calf has skin peeling and hanging off. CNA informed me that she was transferring her from the wheelchair to the bed and the patient started to slide out of her wheelchair and she was able to put her on her bed before she slid on the floor. Patient stated that she felt as if her leg hit the footboard and blood was spotted on her. I assisted the DON with wrapping the patient's leg to control drainage. On 5/7/2024 at 3:07 PM, V4, Registered Nurse (RN) stated, (R2) was very pleasant, but she was not here very long. She fell before I started my shift. (R2) I believe had the incident with her calf on the day shift. (R2's) skin was very fragile. (R2) did have a good size wound to her calf. On top of that, she was very tiny, hardly weighed anything and was a smoker which are all things that contribute to healing of wounds. I believe she left here shortly after and was still getting wound treatment. On 5/7/2024 t 3:51 PM, V8, Nurse Practitioner stated, (R2's) skin was paper thin and there was an incident that she did sustain an injury from a transfer. I would expect all transfers to be safe and I am not sure what or how it happened, but she got a bad skin tear/abrasion on her leg. I would expect all things to be clear, so no resident is injured when being transferred. On 4/9/2024 at 3:00 PM, V9, Certified Nursing Assistant (CNA) stated, I gave (R2) a shower, and then put her in the wheelchair and took her into her room. (R2) is a one assist. I then I put the walker in front of her and she stood and then (R2) started to fall, and I grabbed her leg where she would not fall on the ground, and I yanked her, and she hit her leg on the side of bed. I guess (R2) hit the bed frame with her leg, because there was blood there on the bedframe at the end of the bed. (R2) did not give me chance to get a gait belt. I did not use a gait belt on (R2) when I was transferring her. On 5/9/2024 at 9:51 AM, V6, Licensed Practical Nurse (LPN) stated, I remember the aid (V9) came and got me and told me that while she was transferring (R2) from the chair to the bed, she hit her leg and got a skin tear to her right calf, and the skin was peeling. (R2) had hit her left at the bottom of the bed and her leg had scraped the foot board. I went and got (V2) and it was bleeding profusely, and we stopped the bleeding and bandages the area. We did not take a photo because of the blood but I believe the NP saw her the next day and they took a photo. R2's Wound Assessment Report dated 4/2/2024 documents wound length 9.9 centimeters x 5 (width) cm x 0.2 cm3 (depth) for right calf. LxW= 49.5). R2's Wound Report dated 4/18/2024 at 10:33 AM, documents wound 9.0 length x 4.7 x 0.1 cm3 (L x W = 42.3) On 5/9/2024 at 3:11 PM, V2, Director of Nursing stated, I would expect staff to follow the facility policy for transfers and for staff to use a gait belt for transferring all residents unless there was a medical contradiction for the use of a gait belt. (R2) did not have a medical contraindication. (R2) should have been transferred with a gait belt. I was not told a gait belt was not used on (R2) when she had the injury. I would have expected staff to dress her after her shower and use the gait belt to transfer her. The Gait Belt/Transfer Policy with a revision date of 5/2023 documents, To provide guidelines to facilitate the safe transfer and ambulation of the resident and prevent injury to the resident or employee. It will be the responsibility of all nursing staff to follow this policy and procedure. It is the policy of (Facility) to provide gait/transfer belts to nursing staff responsible for transfers and ambulation and for staff to use them when appropriate.

Based on interview, observation, and record review, the facility failed to ensure Dietary Staff wear appropriate hair and beard nets, failed to perform proper hand hygiene and/or wear gloves, and failed to check temperatures of food, including all diets (regular diets, special diets, and pureed foods) prior to serving to residents, to prevent contamination and foodborne illness. This failure has the potential to affect all 52 residents living in the facility. The findings include: On 2/1/24 at 2:20 PM, R1, stated, The food is horrible, I wouldn't feed it to my dog. It's usually between warm and cold. The outside may be warm, but the inside is cold. It comes from the hospital, and by the time we get it, it has cooled down. On 2/5/24 at 8:00 AM, V6, Food Service Director, stated All of the food at the facility is produced at the hospital and transported in hot boxes via hospital van, to the facility, it is unloaded, and is placed in a plug-in warmer. The facility's dietary department will prep the food, such as pureed, etc., as needed for special meals, and the cart is brought up to the floor's dining room steamtable/food line. The food is then plated for residents in the dining room first, and then to the residents in their rooms. The food is plated and placed on a non-warming cart and transported to the resident rooms. We try to follow the dietary menu as best we can unless there is a special diet a resident needs. There is a list of alternatives available 24-hours a day, with some exceptions. We are not going to cook chicken strips and fries in the middle of the night. On 2/5/24 at 8:17 AM, Breakfast was being served to residents sitting in the dining room, and then to the resident rooms. There were four breakfast trays on a non-warming plastic cart being delivered to residents by V7, Certified Nursing Assistant (CNA), including R3's and R4's. The breakfast plates on cart were partially covered by a plastic cover. On 2/5/24 at 8:18 AM, V7, stated, We only do four trays at a time and deliver the trays to their rooms. On 2/5/24 at 8:19 AM, R4, was eating her food as soon as the tray was delivered. R4, stated, No the food is not warm anymore. It comes from the hospital, and it is never warm. The food is usually not cold, but definitely not warm. On 2/5/24 at 8:33 AM, R3's breakfast tray was seen delivered (from 8:17 Cart), which took 16-minutes to get to R3 after the tray was placed on cart. On 2/5/24 at 8:35 AM, The last breakfast tray was delivered to R1. On 2/5/24 at 8:43 AM, R1, stated, The sausages are a little bit warm, not actually cold, but could be hotter. On 2/5/24 at 8:55 AM, R3, had just finished her breakfast was delivered at 8:33 AM. R3 stated, The food wasn't very warm, it wasn't exactly cold, but it could have been warmer. When my food isn't warm enough, I send it back and they will microwave it. I have had to do with eggs especially. Most of the time the food is not warm. On 2/5/24 at 9:43 AM, R5 stated, I eat in my room, and I am the last one to get a tray. The food is good, but it is always cold when I get it. They do have a big list of things I can pick from if I don't like the meal served, but even the alternatives are cold. On 2/5/24 at 11:28 AM, the lunch food was delivered to the 200-hall dining room by V11, Patient Dining Associate, via an open plastic non-warming cart, with food in metal pans and covered with either plastic wrap or aluminum foil. V11 placed the food containers on the steamtable/serving station. V11 had a cap on his head with no hairnet on, with a long ponytail going down his back, and a full beard on his face with no beard net. V11's hair was outside his cap and when V11 would bend over, his ponytail was seen flopping over his shoulder. V11 had gloves on as he passed out utensils to residents sitting at tables. On 2/5/24 at 11:42 AM, V11 did not doff his gloves and said he had to go downstairs to get the pureed food. V11 left the dining room with his gloves on. On 2/5/24 at 11:44 AM, V11 came back to the dining room with metal containers of food, and still had his gloves on, then took off the wraps over the food, and started plating the food, using the same gloves. V11 was seen using the microwave several times with his gloves on, then going back to the serving line to plate food. On 2/5/24 at 11:48 AM, V11 was seen putting creamy chicken soup into a bowl and walking over to the microwave and microwaving the soup, then would deliver soup to the resident without checking the temperature or letting the soup sit prior to delivering it to the resident. No resident was seen scalding or burning themselves with the soup. On 2/5/24 at 11:50 AM, R6 was served a plate of food at the dining room table, with his friend (V10) next to him. R6 had no utensils to eat with and nothing to drink. R6 picked up his plate and put it to his face and began eating with his fingers. V10 went to a table and got R6 some utensils, and asked V7 if she could get R6 a drink, V7 stated He's on my list and I'll get to him. It was approximately ten minutes later before V7 brought R6 a glass of tea, and after R6 was finished eating his meal. On 2/5/24 at 12:08 PM, V11 stated, The Chicken Soup wasn't heated up downstairs when I got it, is why I am microwaving it. It was brought up that way. I microwave the soup until it boils, then it should be hot enough. On 2/5/24 at 12:10 PM, V5, Dietary Manager, stated, We should temp our food when it arrives from the hospital and before serving it to the residents. You mean he didn't temp the food, even with (V6) standing there? Everything on the steamtable should be cooked, heated, and ready to serve to the residents. There is a list of alternatives if a resident requests something different. On 2/5/24 at 12:14 PM, V6, Food Service Director, stated, Everything on the steamtable should be heated and ready to serve. What I would have done is taken the chicken soup back downstairs and heat it up properly, then bring back up to the steamtable. On 2/5/24 at 2:50 PM, V5, Dietary Manager, stated, (V11) does not have a Food Handlers Certificate. (V11) did have a cap on his head, and I thought was sufficient. What if a man is bald or has a crew cut haircut, do they have to wear a hairnet? On 2/5/24 at 3:30 PM, R1 stated, I am the president of the Resident Council, and we have meetings the first week of every month. The number one complaint, tenfold, is about the food in this facility. It is basically a little bit of everything about the food, the taste, the amount, and the temperatures. It is just not good when we get it. They tend to microwave it all the time. The Activity Director is part of all the meetings, so I know she is aware of these issues but not sure who she tells. I know I personally have talked to (V1, Administrator) about this, so you may want to ask her. On 2/5/24 at 3:42 PM, V13, Activity Director, stated, After each resident council meeting, I will give any concerns/complaints to the department head to follow-up with. I know for dietary; I gave the issues to (V5). Anything needs to be done with Dietary, needs to go through (V5, and V6). I know they have been trying to work on it and are changing things for the residents. On 2/5/24 at 3:50 PM, V1, Administrator, stated, We have changed the menu, and the alternatives list, and I try to get feedback from the residents and then go back to dietary and talk to them. I know we are pushing the alternative menu and for the residents to eat in the dining room. On 2/5/24 at 3:58 PM, V5 stated, If I get a complaint, I pass it on to my manager (V6). We meet with the residents and discuss the issues. We have changed our menu now about ten times and have a lengthy alternative menu for residents to choose from. On 1/6/24 at 1:15 PM, V5, Dietary Manager, stated, I have been on the staff to check temps like they are supposed to. I'm not sure why there was soup wasn't warmed up on the steamtable. I can't believe (V11) was heating things in a microwave, and then not checking the temperature again to see how hot it was. Sounds like there is a lot of education has to be done. The Facility's Resident Council Meeting Minutes, dated 11/9/23, documented, Dietary: New menu coming out, maybe better choice of food. The Facility's Resident Council Meeting Minutes, dated 12/14/23, documented, Dietary: Can't eat the food, meat is overdone. If you had a dog, it won't eat it. Lots of times it is cold. They have soup day after day and the vegetables are not done. The Facility's Resident Council Memorandum, dated 12/14/23, documented, Issue: Meat is overdone, vegetables not done, lots of time it's cold. Response: Working on new menu and with the Chef to improve food quality. Meat is more tender, vegetables are softer. Nursing is working to staff appropriately to serve meals in a timelier manner. The Resident Council Meeting Minutes, dated 1/11/24, documented, Dietary: Snacks at the desk, but not better food. Any special meals: Better food. The Facility's 100-Hall and 200-Hall dining room steamtable temperature checklist were reviewed with multiple dates and meals missing a temp check: The Facility's 200-Hall/West Hall Temperature Log and Checklist, dated from January 2024 until current date (2/6/24), documented temperatures were checked on 1/14/24 for Breakfast and Lunch only, 1/15/24 for Breakfast and Lunch only, on 1/19/24 for Breakfast and Lunch only, on 1/22/24 for Breakfast only, on 1/25/24 for Breakfast only, on 1/26/24 for Breakfast only, on 1/28/24 for Dinner only, on 1/29/24 for Breakfast only, on 1/30/24 for Breakfast only, on 2/1/24 for Breakfast only, on 2/5/24 for Breakfast and Lunch only, on 2/6/24 for Breakfast only. The 2/5/24 Lunch temperature check was seen being done after residents were served their meals. The Facility's 100-Hall/East Hall Temperature Log and Checklist, dated from January 2024 until current date (2/6/24), documented temperatures were checked on 1/1/24 for Breakfast and Lunch only, on 1/2/24 for Breakfast and Lunch only, on 1/3/24 for Breakfast only, on 1/5/24 for Breakfast and Lunch only, on 1/8/24 for Breakfast and Lunch only, on 1/9/24 for Breakfast and Lunch only, on 1/10/24 for Breakfast and Lunch only, on 1/11/24 for Breakfast and Lunch only, on 1/13/24 for Breakfast and Lunch only, on 1/14/24 for Breakfast and Lunch only, on 1/15/24 for Breakfast only, on 1/16/24 for Breakfast and Lunch only, on 1/17/24 for Breakfast and Lunch only, on 1/19/24 for Breakfast and Lunch only, on 1/22/24 for Breakfast, Lunch, and Dinner, on 1/23/24 for Breakfast and Lunch only, on 1/24/24 for Breakfast and Lunch only, on 1/25/24 for Breakfast and Lunch only, on 1/27/24 for Breakfast and Lunch only, on 1/30/24 for Breakfast only, on 1/31/24 for Breakfast only, on 2/2/24 for Breakfast only, on 2/5/24 for Breakfast, Lunch, and Dinner, on 2/6/24 for Breakfast and Lunch. The Facility's Food Handling Guidelines Policy, undated, documented, Temperatures of food shall be monitored using accurate thermometers (32 +/-2 degrees Fahrenheit). The Director of Food and Nutrition Services and the Executive Chef are responsible for the execution and monitoring of CCPs and records associated with safe food handling procedures. The individual responsible for maintaining these records should initial the form(s) weekly and indicating proper procedures have been followed. Hands should be scrubbed following appropriate hand washing techniques according to facility/community policy (e.g., after toilet use, between food preparation tasks, before putting on gloves, etc.). Single use disposable gloves are worn when preparing foods will not be cooked again (ready-to-eat foods) and while serving food. Gloves are to be placed over clean hands. Gloves are changed between tasks or if punctured or ripped. Hands are washed after gloves are removed. Cooking: Food must be cooked to the minimum safe internal temperature listed in the chart below and the final cooking temperature will be recorded. Food heated in the microwave must reach an internal temperature of 165 degrees Fahrenheit at all parts. Food should be rotated or stirred halfway during cooking process and left to stand covered for two minutes after cooking to assure appropriate temperature throughout the product. Hot Holding Temperatures: Foods should be held hot for service at a temperature of 135 degrees Fahrenheit or higher. Foods should be covered during hot holding whenever possible to minimize the effects of evaporative cooling on the surface. Monitor the temperatures of food held in a hot holding box by checking at least one pan of food every two hours. Temperatures of hot food in service will be documented; Patient service during traditional meal periods: at the beginning of service and either middle or end of service on the Webtrition Taste Temperature Log. Room Service style patient dining program: at the beginning of service and every two hours thereafter. The Resident Census and Conditions of Residents, CMS 671, dated 2/5/24, documents the facility has 52 residents living in the facility.

Based on record review and interview the facility failed to provide adequate assistance during toileting for one resident (R2) of 3 residents reviewed for falls in the sample of 3. This failure resulted in R2 being sent to the hospital with head laceration, requiring 6 sutures, and subdural hematoma. Findings include: 1. R2's Resident Admission History dated 12/21/22 documents R2 admitted from an acute care hospital for skilled services. R2's history documents a diagnosis in part traumatic subdural hemorrhage without loss of consciousness, history of falls. R2's Minimum Data Set (MDS) dated [DATE] documents that R2 is moderately cognitively impaired with a Behavior Interview of Mental Status (BIMS) of 8. R2's MDS documents that R2 requires limited assistance and one-person physical assistance for transfers, and toileting. R2's undated Resident Profile Report documents ADL's (Activity of Daily Living) requires min/mod assist with cares. R2's profile report documents R2 is at risk for falls due to history of falls. R2's report documents that R2 had a fall on 12/22/22 with no injuries. Intervention bed in lowest position with thick black mat next to bed. R2's report documents that R2 fell on [DATE] and sent to the emergency room for evaluation and returned. Intervention: moved closer to nurses' station for better supervision. R2's Post fall evaluation dated 12/22/22 documents that R2 has an unwitnessed fall on 12/22/22 at 14:30 PM. R2's evaluation documents that nurse heard R2 yelling for help. R2's post fall evaluation documents that R2 was on the floor parallel to the bed. R2 stated she slid of the side of her bed. R2's evaluation documents that R2 had no injuries. IDT reviewed fall and R2 was trying to get up from bed to sit in wheelchair and slid off the bed which was in the lowest position, no injuries. Intervention: thick black mat placed next to bed with bed in lowest position. R2's post fall evaluation documents mental status: forgets limitations. Morse Fall Risk score 75. R2's Post Fall Evaluation dated 12/29/22 documents on 12/27/22 at 13:47PM R2 was heard screaming for help from bathroom. R2 was lying face first on the bathroom floor. R2's evaluation documents that R2 was bleeding from forehead sent to emergency room for evaluation. R2's evaluation documents R2 stated was reaching for toilet paper. R2's emergency department notes dated 12/27/22 documents that R2 received 6 sutures to laceration to forehead. Cat Scan of head documents small acute right sided subdural with stable left sided subdural. R2's emergency department notes document the physician spoke with neurosurgery who recommended Levetiracetam 500 Milligram (MG) twice a day and repeat Cat scan in 6 hours with transfer to trauma center. Notes document local hospital closed to all transfers including trauma. Notes document the physician contacted neurosurgery at another trauma center, who stated given well appearance and small bleed think reasonable to get repeat cat scan in 6 hours and if no changes discharge with outpatient neurosurgery follow up assuming no changes. Notes document repeat cat scan did not document any changes so R2 discharged back to the nursing home. On 1/17/2023 at 9:30AM V5, Certified Nursing Assistant (CNA) stated that she had taken R2 into the bathroom. V5 stated that she left R2 in the bathroom. V5 stated that R2 was to be assist of one with gait belt for toileting. V5 stated that she did not find R2 on the floor. V5 stated that she was not aware that R2 had a previous fall. On 1/17/2023 at 9:52AM, V4, Nurse Practitioner stated she was at the facility at the time of R2's fall. V4 stated that R2 was lying on the floor in the bathroom, with a cut to her head and her head bleeding. V4 stated that R2 was conscious and sent to the hospital for evaluation. V4 stated that R2 received sutures and did have a subdural hematoma. On 1/17/2023 at 11:51AM V6, Physical Therapist stated she had worked with R2 one or two times after admission. V6 stated R2 had balance issues and very forgetful. V6 stated R2 did not have good safety skills. V6 stated she worked with R2 on a transfer due to a fall she had when reaching for toilet paper. V6 stated that R2 did not have the range of motion to lift her arms up and could not reach the toilet paper. V6 stated that she assumed staff stayed with her in the bathroom due to the lack R2's balance, and safety skills. On 1/17/2023 at 11:58AM V8, CNA stated she would not leave a resident in the bathroom alone if resident identified high risk for falls. On 1/17/22 at 1:09 PM V3, Director of Nursing (DON) stated that every resident has a fall assessment on admission. V3 stated that R2 was not on a fall reduction program. On 1/17/2023 at 2:48PM V1, Administrator stated she would expect the facility to follow policies and procedures in regards to fall prevention. V1 stated she would not expect residents identified at high risk for falls that require assistance to be left in the bathroom alone. On 1/18/2023 V10, Physician stated as a general rule if a resident has had falls and is at a high risk for falls, fall precautions have to be in place. V10 stated R2 should have provided physical assistance in the bathroom. The facility policy dated 3/19 revised, documents appropriate safety interventions, including potentially being place in a fall reduction program, will be implemented. The facility policy documents a score above 45, the resident is identified at high risk of falls. A fall reduction program will be initiated. The policy documents in addition, a resident may be place in the Fall management/Reduction program at any time the Fall IDT or nursing supervisor feels it would be beneficial such as if there is a change in condition that may increase a resident's fall risk. Update the care plan accordingly. The policy documents the Fall Management /Reduction Program (a score above 45) requires the following: to alert staff to the increased fall risk by communication in shift reports and in the care plan. It is also denoted in the resident's electronic record denoting high fall risk status. Other safety interventions specific to the individual resident will be implemented as deemed appropriate by the nurse or supervisor and added to the care plan.

Based on observation, interview and record review, the facility failed to ensure fall interventions are implemented and provide supervision for safety for 1 of 4 residents (R28) reviewed for falls in the sample of 29. This failure resulted in R28 sustaining multiple falls with multiple fractures. Finding includes: R28's Morse Fall Risk Score, dated 10/30/2022, documented that she was at high risk for falls. R28's Minimum Data Set, dated dated [DATE] documented that R28 was rarely or never understood cognitively, that she required limited to extensive assistance of 1 staff member for activities of daily living, and that her balance was not steady and that she was only able to stabilize with staff assistance while moving from seated to standing position. R28's Post Fall Evaluation, dated 10/30/2022, documented, Morse Fall Risk Score: 80. It continues, Team Meeting Notes: Writer is notified about fall. Immediately, writer goes to see Patient. Writer sees patient laying with left side on the fall at the hallway. Patient is helped to stand with maximum assist. Patient is unable to explain situation; unable to confirm or decline head hitting the floor. Patient consistently complains of general pain; mad reference to shoulder and head upon assessment. No apparent skin injury gait is weak and unsteady. Patient is helped back to wheelchair. (Power of Attorney) is informed; Resident is transferred to ER (emergency room ) for evaluation. (V14, R28's Physician) is notified. It continues, Intervention: will notify family regarding recommendation for sitter. Resident will be monitored at the nurse's station for better supervision. (V14, R28's Physician and Power of Attorney) aware. R28's Post Fall Evaluation, dated 11/01/2022, documented, Member was observed sitting on the floor facing the door looking down at floor. She was holding her forehead with her (left) hand and when (Nurse) assessed the area (Nurse) noted a hematoma to (left) forehead, involving eyebrow with a small laceration within the hematoma and a scant amount of blood present. No other injuries were noted. Resident was assisted up to her manual wheelchair per 1 assist and was able to bear weight with out (complaint of) pain. It continues, She was brought to the nurse's station for supervision and an ice pack was applied to the hematoma. It continues, Intervention: if resident becomes anxious and restless, place in recliner at the nurse's station for close supervision, thick black mat next to bed when in bed in the lowest position. (V14, R28's Physician and Power of Attorney) aware. R28's Hospital Record, dated 11/01/2022 to 11/04/2022, documented, (Computerized tomography) Pelvis (without) contrast. Result date 11/01/2022. It continues, Impression: Non displaced fracture through the left lateral sacral body extending to the sacroiliac joint. R28's Care Plan, dated 11/15/2022, documented, I am at risk for falls related to my (history) of falls. Please ensure my bed is at an appropriate height at all times. Ensure my call light is within reach when I am in my room. Round on me as needed to ensure I do not need assistance with ambulation. My goal is to reduce the risk factor that contribute to my fall risk and to minimize the risk of injury related to my falls throughout this review period. On 11/28/2022 at 12:31 PM, R28 was lying in bed asleep. The bed was in the lowest position but there were no floor mats on either side of the bed nor was her call light within reach. On 11/29/2022 at 09:18 AM, R28 was lying in bed asleep call light within reach and bed in the lowest position but there were no floor mats on either side of the bed. On 11/29/2022 at 12:27 PM, R28 was sitting up in wheelchair at the nurses station and V6, LPN, was sitting at the nurses station. On 11/30/2022 at 08:44 AM, R28 was not in her room or anywhere around the unit, V7, Registered Nurse (RN), stated that she was told that R28 was sent to the hospital last night because she fell and that they do not know if she will be returning. V7 stated that she did not know what happened or how R28 fell . On 11/30/2022 at 10:00 AM, V11, Licensed Practical Nurse (LPN), stated that R28 was sitting up in her wheelchair across from the nurses station and that she (V11) was in another resident's room passing medications. When she (V11) exited the other resident's room, she saw R28 leaning forward like she was picking up something off of the floor and she couldn't get to her fast enough before she fell on to the floor, onto her left side. V11 continued to state that R28 complained of left arm pain so the doctor and the family was notified and V14, R28's Physician, ordered an xray of her left arm, which showed a fracture of her wrist and she was sent out to the hospital. V11 also stated that the CNA's (Certified Nursing Assistants) and the other nurse were in other rooms assisting other residents and there was no one sitting at the nurses station when R28 was in the hallway across from the nurses station. V11 continued to state that R28 was seen about 5 minutes prior to her fall. V11 stated that when R28 is up to her wheelchair she is parked in front of the nurses station because she is a high fall risk. On 12/01/2022 at 10:33 AM, V15, LPN, stated that she was in a room assisting another resident when R28 fell and that she was seen a few minutes prior to her fall but not by her. V15 also stated that they have tried everything with R28. On 11/30/22 at 12:30 PM, V14, R28's Physician, stated that R28 was very mobile and when she fell the 1st time, the facility started fall precautions. V14 stated yes that if R28 was sat out in front of the nurses station in her wheelchair, he would expect a nurse or a staff member to be there to observe her. When asked if the facility would have provided a 1 to 1 sitter or temporary sitter to sit with R28 would that have maybe prevented her from falling, V14 stated a temporary sitter would if it could be provided by the facility. V14 stated yes all safety protocols should be in place for R28. R28's Post Fall Evaluation, dated 11/29/2022, documented, Team Meeting Notes: Resident was sitting in (wheelchair) in hallway and this nurse was walking out of (R139's room) and noted resident leaning forward and to left of (wheelchair) and tried to get to resident and fell to left side of (wheelchair) and landed on left arm. (R28) states I hurt my arm. Assisted up with 2 assist to (wheelchair) . It continues, Resident wanting to go to bed, assisted to bed with this nurse assist. (V14, R28's Physician) and and informed of fall and received orders to x-ray (left) wrist. Son informed of fall and apparent injury. (Mobile X-Ray Service) here to x-ray (left) wrist and showed (fracture). Son aware and resident being sent to (local hospital emergency department). Son here to go with resident. Report given to (Registered Nurse) in (emergency room ). R28's Radiological Report, dated 11/29/2022, documented, Reason: Fall with Pain and Mild Swelling. Procedure: -Left Wrist, Complete, 3+ Views It continues, Impressions: Subacute distal radial and ulnar fractures. V18's, CNA, written statement, dated 11/29/2022 at 10:30 PM documented, I was taking (R19) to the bathroom commode the time that (R28) fell . When I was finish taking care of (R19) I went in her room and I heard (V11) talking to (R28). V17's, CNA, written statement, dated 11/29/2022 at 9:35 PM, documented, I was assisting a patient in the shower room. I didn't witness that patient falling. I didn't even know she fell until hours after. V19's, CNA, written statement, dated 11/29/2022, documented, I (V19) was with another patient on East after dinner when (R28) fell , so I didn't see anything. On 11/30/2022 at 3:55 PM, V1, Administrator stated that the facility could not provide 1 to 1 supervision for R28 and that R28's son did not want it. When asked that when R28 was placed up at the nurses station to be supervised would she expect staff be there to supervise R28, V1 stated that there was always someone at the nurses desk and it was only a matter of 1 to 2 minutes when R28 wasn't supervised. The facility's policy, Fall Management/Reduction Program, dated 09/2022, documents, Appropriate safety interventions, including potentially being placed in a Fall Reduction Program, will be implemented.

Based on interview, observation and record review, the facility failed to timely identify, treat, and provide timely repositioning for pressure ulcer treatment and prevention for 4 of 7 residents (R14, R31, R107, R108) reviewed for pressure ulcers in the sample of 48. This failure has resulted in R108 sustaining an unstageable, painful, necrotic 3.5 centimeter (cm) x 4 cm pressure ulcer to the left calf and a stage III coccyx pressure ulcer. Findings include: 1. R108's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R108's Minimum Data Set (MDS), dated [DATE], documents R108 in independent in decision making for daily tasks, requires limited assistance of 2 staff members for bed mobility, transfers, toileting and limited assistance of 1 staff member for personal hygiene. This MDS also documents R108 utilizes a wheelchair for mobility, is always incontinent of bowel and bladder, is at risk of developing a pressure ulcer and has no pressure ulcers at this time. R108's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Skin Evaluation. q (every) week. Start date 10/14/21. Pressure Reducing Mattress or Overlay. Constant Order. Start date 10/12/21. Wound Care TAR (Treatment Administration Record). Pressure Ulcer, Coccyx, Bilateral, Coccyx, Foam, q (every) 3 days, PRN (as needed), cleanse area to coccyx, apply foam dressing q 3 days and PRN. R108's Hospital Discharge Paperwork, dated 10/4/2021, documents, Other instructions: Partial weight bearing to left leg, immobilizer on at all times when up. R108's Braden Score Flow Sheet, print date of 10/20/21, documents on 10/4/21, R108's Braden Score was 15, on 10/10/21 it was 14, on 10/11/21 it was 14 and on 10/15/21 it was 13. The Braden scale for risk of pressure ulcers is 13- 14 a moderate range and 15- 18 a mild range of acquiring a pressure ulcer. R108's Nurse Wound Assessment Detail Report documents, 10/12/21. Where is skin problem? Coccyx. Origin: Acquired in facility. Wound Type: Pressure Injury . Pressure Injury Staging: Stage II. Length of measurements in cm: 1. Width of measurements in cm: 3 Depth of measurements in cm: 0.1. Describe drainage: No drainage. Describe wound: Pink, uninvolved. Comprehensive wound note: Resident has pressure injury to coccyx, measuring 1 cm x 3 cm, superficial in depth. R108's Nurse Wound Assessment Detail Report documents, 10/18/21. Where is skin problem? Coccyx. Origin: Acquired in facility. Wound Type: Pressure Injury . Pressure Injury Staging: Stage III. Length of measurements in cm: 1.1. Width of measurements in cm: 2 Describe drainage: Sero-sanguineous drainage scant. Describe wound: Slough. Comprehensive wound note: Cont (continue) foam dressing to bottom q3d (every three days) and PRN. education about off loading given to family and will work with therapy to off load as much as possible and have up in chair around meals times to allow therapy sessions and off loading. R108's Care Plan, print date of 10/20/21, documents, Skin. I am at risk for alteration in skin appearance secondary to my deficits with self-performance bed mobility. Assist me with daily repositioning as needed. Monitor my skin with daily care task assistance for any changes in skin appearance or skin integrity. Report any changes. Open area to coccyx. TX (treatment) as ordered, assist w (with)/ turning and repositioning, PT OT (Physical Therapy and Occupational Therapy) as ordered to increase ADL (activities of daily living) function. I wear a brace to my left leg only when I am up and the nurses will check my skin daily, if any changes the MD (Medical Doctor)/ POA (Power of Attorney) will be notified. On 10/19/21 at 10:28 AM, R108 was sitting in her wheelchair in her room asleep with the left leg immobilizer on and her leg extended with her heel on the floor. R108 remained in her wheelchair positioned the same way until 3:30 PM without the benefit of repositioning or incontinence care based on 15 minute or less observation intervals. At 3:30 PM, V4, Physical Therapist, assisted R108 to bed to do transfer training, therapy exercises and education with R108 and R108's daughter. On 10/20/21 at 9:45 AM, R108 was lying in bed with a soft left leg immobilizer on which started mid thigh and ended mid calf. V5, Certified Nursing Aide (CNA), and V12, CNA, performed incontinent care for R108. R108's coccyx dressing was soiled with urine and at this time a large necrotic pressure ulcer could be seen under R108's left leg immobilizer on R108's calf. V3, Assistant Director of Nurses (ADON)/ Wound Nurse, was told of the need for a new coccyx dressing. On 10/20/21 at 10:40 AM, V3 stated that R108 has a coccyx wound that is a facility acquired pressure ulcer and that the wound opened on 10/12/21 measuring 1 cm x 3 cm x 0.1 cm and that on 10/18/21 the wound measured 1.1 cm x 2 cm that it was slough with scant drainage. V3 stated that the wound is treated with cleansing the wound with normal saline and then placing a foam dressing over the wound. V3 stated, (R108) has preventative measures in place of a low air loss mattress and offloading her often. R108 is [AGE] years old sometimes she doesn't want to lay on her back. She is 104 she can do what she wants. V3 was then told of the observation of the extended period of time that R108 stayed in the same position the day before, V3 stated, I will have to do education that should not have happened. On 10/20/21 at 10:45 AM, V3 changed R108's soiled coccyx dressing and measured the wound. R108's coccyx wound measured 2 cm x 0.5 cm, the wound bed was white, the peri-wound was intact and slightly red. The old dressing had greenish brown drainage on it. At this time, a large necrotic pressure ulcer could be seen under R108's left leg immobilizer on R108's calf. On 10/20/ 21 at 10:46 AM, V3 was asked what treatment was in place for the pressure wound on R108's left calf, V3 stated, I did not know she had that. V3 unfastened the Velcro straps of the brace and then assessed, measured and treated the pressure ulcer to R108 calf. R108 would yell out in pain anytime the area was touched. The bottom of the brace had green/brown/black drainage on it. V3 stated, The wound measures 3.5 cm x 4 cm, the wound bed is necrotic, it is unstageable, the edges of the wound are inflamed, it is open at the top with slough and it is obviously painful. V3 further stated, The staff should be checking under the brace at least once a day for skin breakdown. I did her coccyx dressing Monday and that brace is new she did not have that wound or the brace on then. On 10/20/21 at 10:47 AM, V5 CNA, stated, (R108) has had that brace since she was admitted . I think it came from the hospital. V5 also stated that the brace comes off for showers and she has never seen the wound under it. On 10/20/21 at 10:50 AM, V4, Physical Therapist, stated, (R108) has always had the brace. She has a leg fracture. It always stays on. On 10/20/21 at 1:30 PM, V7, Registered Nurse (RN), stated, If someone has a brace, we look under the brace at least once a day and chart on it under the skin assessment. On 10/20/21 at 1:50 PM, V23, RN, stated, I have only taken care of (R108) two times this Monday and Tuesday. I did not look under her brace. I did not know that she had a large pressure wound under it. If someone does have a brace, we will chart on it under the skin assessment tab. On 10/20/21 at 1:55 PM, V12, CNA, stated, (R108) has always had the brace, and I have never taken it off. I didn't know she had a wound under it. On 10/20/21 at 2:15 PM, V3 stated, The nurses should have been charting on looking at the brace. Under the skin assessment tab, it will have an area for braces, but for that to be there (show up), there needs to be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound doctor will see her tomorrow by teleconference. On 10/20/21 at 2:30 PM, V3 stated, I misspoke she did have the leg brace on. I talked with her daughter because she was in there when I did it (the coccyx dressing) Monday and (R108) had sweat pants on. When I did her dressing to the coccyx, she had sweat pants on and I did not see her whole leg. She was admitted with the brace. On 10/21/21 at 1:06 PM, V3 stated, The wound doctor did see (R108) today and she said she expects the wound to get much worse considering her advanced age. She requested that we notify the orthopedic doctor which we have done and maybe we can get a different brace for her since this one is causing pressure. We have not heard back from the orthopedic doctor. On 10/21/21 at 1:26 PM, V2, Director of Nurses (DON), stated, The nurses were doing skin assessments but it doesn't show anything other than they did it. They were not documenting specifically on the brace. On 10/21/21 at 2:50 PM, V25, Wound Doctor, stated, I did see (R108's) wound on her calf by teleconference today. It was hard to get a good look at it, but it is obviously it is a pressure wound caused by the leg brace. Which I see too many of those. It is necrotic and unstageable due to the necrotic area. I recommended that they contact ortho (orthopedic doctor) to see if she needs the brace still and if she does, is there a different brace she could use. That wound will not heal with the brace that she has because it is causing pressure. I cannot say what the outcome will be or how long she has had that wound. I do know that it is very sad, she is [AGE] years old and to get a wound like that it is just sad. V25 further stated, The nurses should have been checking under that brace at least once a day for wounds at least. 2. R107's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R107's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Skin Care Protocol. Start Date 10/17/21. Wound Care TAR. Abrasion, Heel, Right, Heel, Foam, q3days, PRN, Cleanse right heel, apply foam dressing q3days and PRN. R107's Nurse Wound Assessment Detail Report, print date of 10/20/21, documents R107 did have bilateral heel wounds that were documented as healed on 10/5/21. R107's Braden Score Flow Sheet, print date of 10/20/21, documents on 10/7/21 it was 16. The Braden scale for risk of pressure ulcers is 15- 18 a mild range of acquiring a pressure ulcer. R107's MDS, dated [DATE], documents R107 is cognitively intact and is at risk for pressure ulcers. R107's Care Plan, print date of 10/20/21, documents, Skin. I am at risk for impaired skin, interventions are to off load my heels as much as possible and notify my nurse of any changes to my skin integrity. On 10/18/21 at 11:00 AM, R107 stated, I have a sore on my right heel. I got it here. They weren't checking my heels. It started as a blister then the skin got really hard. They had the wound doctor come in and he pulled it off. That really hurt. I put oil and a bandage on it but the nurses don't do anything with it. I asked over the weekend multiple times for a nurse to look at it because it hurts. I bought shoes this weekend because walking with socks was really hurting. The nurses never came and looked at it. On 10/20/21 at 2:10 PM, R107's feet were assessed by V3, ADON. R107's right upper heel area measured 1 cm x 0.8 cm. R107's flinched and stated the right heel hurt upon assessment. R107's left heel was assessed to be a large callous area. On 10/20/21 at 2:15 PM, V3 stated, The right heel is mushy and has drainage. I would stage it as a deep tissue injury. I wish someone would have let me know about it. I will have to figure out who she told. The left heel is just a callous area. She was admitted with them and we healed them up a couple of weeks ago. 3. R14's MDS dated [DATE], documents that R14 is cognitively intact and requires extensive assist from two staff members for bed mobility, requires extensive assistance from one staff member for toileting and personal hygiene, and is totally dependent on two staff members for transfers. R14 has a functional limitation to one side and is always incontinent of bowel and bladder. R14's Care Plan, dated 10/19/21, documents R14 is a total assist for bathing and bed mobility, an extensive assist for dressing and transferring by use of mechanical lift. It continues with R14 is incontinent of both bowel and bladder. It continues with R14 sits in a geriatric reclining chair, turn and reposition routinely. It continues with R14 has an unstageable wound to the right hip. It continues with R14 is at risk for skin breakdown. Assist with repositioning frequently. Interventions: Turn and reposition as needed, provide incontinent care as needed, keep skin dry, wheelchair cushion, low air loss mattress, treatments as ordered. On 10/18/21 at 10:02 AM, R14 was sitting in the dining room in her geriatric reclining chair. R14 stated, I have a sore on my butt. I think it's on my right side. On 10/19/21 at 9:30 AM, R14 was sitting in her geriatric reclining chair, leaning to her left side and eating breakfast. On 10/19/21 at 10:00 AM, R14 continued to sit in her geriatric reclining chair in the dining room. She was now facing the TV and continued to lean to her left side. On 10/19/21 at 11:00 AM, R14 was sitting in the dining room by herself in the same position and continued to lean to her left side. On 10/19/21 at 11:50 AM, R14 remained sitting in dining room in her geriatric reclining chair leaning to the left. R14 was asked if she had been there since breakfast, R14 stated Well, I was over by the TV and now I'm by the table. R14 was asked if anyone has changed her or checked on her R14 stated, No, no one has done anything yet. On 10/19/21 at 12:00 PM, R14 remained in her geriatric reclining chair at the dining room table and staff served her lunch. On 10/19/21 at 12:45 PM, V13, CNA, pushed R14 out of the dining room and left her in the hallway. At this time, V13 stated, They are helping someone else get into bed now and will get with R14 shortly. On 10/19/21 at 12:55 PM, R14 was placed in her room and transferred to her bed. Perineal care was provided. R14's incontinent brief was soiled with both urine and stool. R14's dressing dated 10/18/21 on R14 right hip had moved and was not over the open area. V14, CNA, stated, The nurse will have to come and change that dressing then continued with the perineal care. R14 was pulled up in bed. R14 was positioned that R14 remained on R14 left side. The wound management log documents on 10/19/21 R14's pressure ulcer to her right hip as a stage 4 wound measuring 0.5 X 0.5 X 1.8 cm. The previous measurement (unsure of date) documents a measurement of 0.4 X 0.7 X 1.3 cm. On 10/20/21, at 2:00 PM, V19, Licensed Practical Nurse (LPN), stated We try and put (R14) back to bed to rest after every meal and get R14 up for the next meal. 4. R31's MDS dated [DATE], documents that R31 is cognitively intact and requires extensive assistance from one staff member for toileting, bathing, and dressing. R31 is incontinent of bowel and bladder. R31's Care Plan, dated 9/26/21, documents R31 requires extensive assist with most ADL's. It continues with R31 is incontinent of urine and bowel. It continues with R31 has skin breakdown that includes a pressure ulcer (PU). It continues with R31 is incontinent and requires assistance with turning and repositioning. Intervention: provide perineal and skin care as needed and after episodes of incontinence. On 10/18/21 at 9:30 AM, R31 was sitting in her wheelchair requesting to get into bed. R31 stated, I have been up since before breakfast. V13, CNA, transferred R31 from her wheelchair to her bed and left R31 on her back with Head of Bed (HOB) elevated in bed. On 10/18/21 at 11:00 AM, R31 remained in bed on her back with HOB elevated. R31 stated, I should be getting lunch soon. On 10/18/21 at 12:35 PM, R31 remained in bed on her back with HOB elevated. R31 stated, I told them I was wet and needed changed and was told I would have to wait until after lunch was over. On 10/18/21, at 1:15 PM, R31 was sitting upright on her back in bed and had not been cleaned up from her previous incontinent episode. V18, R31's son, stated, They are so short staffed here. She (R31) does not get the same care on the weekends as she normally gets during the week. On 10/18/21 at 2:00 PM, R31 stated, They finally came in around 1:30 (PM) and changed me and was done by 1:45 (PM). R31 was is in bed resting on her back with HOB elevated. On 10/19/21 at 9:15 AM, R31 was s resting in bed on her back, HOB elevated and without complaints at this time. On 10/19/21 at 12:30 PM, R31 remains wasn bed on her back with HOB elevated. On 10/20/21 at 8:50 AM, R31 was sitting up in her wheelchair at the side of her bed and was finishing her breakfast. On 10/20/21 at 12:10 PM, R31 was resting in bed, just finished lunch, turned to her left side. Stated They just rolled me over to my side. On 10/20/21, at 2:00 PM, V19, LPN, stated The aides are supposed to turn and reposition each resident every two hours. If I'm doing care on a resident, I will turn and reposition them at that time because I'm not sure when they were done last. On 10/21/21, at 2:15 PM, V3, ADON, stated The pressure ulcer situation is a case by case issue. Each one has specific reasons why they're not getting any better. On 10/21/21, at 2:20 PM, V3, ADON, stated I'm constantly on the floor, and I honestly can't say the staff are turning the residents every two hours. The facility's Skin Integrity, Assessment and Prevention of Wounds / Other Skin Conditions policy and procedure, dated 5/2019, documents, II> Prevention. A. Residents at risk should have a visual skin inspection daily, paying particular attentions to bony prominences and pressure caused by ill - fitting shoes or medical devices such as splints, braces, cast, compressions stocking, oxygen cannulas, pommel cushions, etc (et cetera). CNAs will report report any abnormal finding to a nurse. The policy continues, 3. Activity and Mobility. For limited mobility, implement the following. a. For bed bound residents, individualized turning schedule with a minimum of turn every 2 hours. b. For chair bound residents, individualized repositioning schedule. Develop plan of care for scheduled rest periods in bed. The policy continues, 7. Medical Devices. Pressure injuries may develop at sites from positioning or use of medical devices. Examples: Ear lobes. Side of head from oxygen cannulas/masks. Nares, urinary meatus, and extremities caused by tubes, casts, orthotic devices (braces, splints, boots), cervical collars, pommel cushions or other medical devices. Ill-fitting shoes may cause blisters or pressure on the feet. Note: Orthotic devices such as boots, braces and splints require diligent checking to ensure proper fit and positioning. Consider also consultation and evaluation from Rehab (rehabilition) when using these devices. Careful observation and appropriate interventions relative to all medical devices is important and should be care planned and communicated to all caregivers.

Based on interview and record review the facility failed to provide assistance to prevent a fall for 1 of 7 residents (R2), reviewed for falls in the sample of 9. This failure resulted in R2's fall sustaining a right distal femur (leg) fracture. Findings include: R2's Minimum Data Set (MDS), dated [DATE], documents R2 had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. The MDS further documents R2 requiring extensive assistance of two persons physical assist with bed mobility and transfers. R2's Fall Risk Assessment, dated 7/26/19, documents R2 scoring a 50, indicating high risk for falls. On 8/11/19 at 11:44 AM, R2 stated she was initially admitted to the facility to get therapy. R2 stated on the date she fell (7/26/19), she needed to sit up on the side of the bed to get ready for her appointment with the wound center, and was in need of staff assistance. R2 stated the Certified Nursing Assistant (CNA) (V3) had removed the bumpers from the sides of the bed. V3 had a hold of her (R2's) left hand. V3 let go of her (R2's) hand and walked towards the foot of the bed and R2 slid right off the bed. R2 stated the pain comes and goes, and it's painful with any movement. R2 further stated she had informed the facility multiple times about the bed being so slick. On 8/9/19 at 10:42 AM, V4, Nurse Practitioner (NP), stated she was at the facility on 7/26/19 when R2 sustained a fracture to her right leg. V4 stated R2 told her she landed on her knee when she fell out of bed. V4 further stated the best standard of practice is to not move a resident with a suspected fracture, but the staff had already put R2 back to bed when she went to assess R2 after her fall. V4 also stated she sent R2 to the ER (emergency room ) for evaluation and treatment of [REDACTED]. On 8/9/19 at 10:04 AM, V3, CNA, stated she has only been employed with the facility since 6/2019 as a CN[NAME] V3 stated she answered R2's call light and noted R2 was on a low air loss bed that was slick, and that R2 could pretty much do it (sit up) herself, while in bed. V3 further stated that R2 complained of pain in her right knee and was very uncomfortable. V3 stated the bed was slick, and V3 couldn't stop R2 from falling. On 8/9/19 at 2:12 PM, V10, CNA, stated he assisted V3, CNA, with putting R2 back to bed after she fell . V10 further stated R2 didn't want anyone to touch her, R2 expressed pain in her knee, and we were holding it the whole time. On 8/9/19 at 8:47 AM, V2, Director of Nursing (DON), stated she assessed R2 on 7/26/19 when R2 fell out of her bed. V2 stated the CNAs (V3 and V10) assisted R2 back to bed with a full mechanical lift. V2 further stated she then requested the NP to come and assess R2 at bedside. On 8/11/19 at 10:12 AM, V2 stated, Yes, two people for bed mobility was the case because (R2) is a large lady and the MDS did say extensive assist with bed and transfers, and V2 was aware V3, CNA, had assisted R2 without any assistance from additional staff. R2's Hospital records, dated 7/26/19, document, (R2) presented to the emergency room via EMS (Emergency Medical Services) after falling out of her bed and has had right leg pain, radiographs were obtained that demonstrated a right femur (leg) fracture. The records further document, (R2) was admitted under the care of the geriatric trauma team. Post Fall Evaluation Findings for R2, authored by V2, DON, documents the CNA (V3) was assisting and setting up (R2) on side of bed prior to going out for appointment. (R2) lost her balance and started to slip off the bed (has an air mattress). (R2) landed on her right knee. The findings further document R2 was lifted back to bed using a full mechanical lift and results of the portable x-ray revealed a possible right femur fracture and orders were received to send R2 to the ER for evaluation and treatment. R2's X-ray report, dated 7/26/19, documents, A total right knee replacement is noted. A complete fracture through the distal femur (leg) is identified with lateral displacement of the distal fracture fragment. The facility's policy entitled USING A TOTAL BODY LIFT TO LIFT FALLEN RESIDENT OFF FLOOR, documents, 1. Once resident has been assessed by nurse and is approved to be moved, resident can be moved to a supporting surface. The policy did not address transferring a resident if suspected of a fracture.

Based on observation, interview and record review, the facility failed to ensure 4 residents, R2, R3, R5 and R6 of 6 sampled residents, receive necessary care and services to promote healing and prevent new pressure sores from developing. Findings include: 1. R2's most current Care Plan identifies R2 as being at risk for the development of pressure sores; being dependent on staff for turning and positioning; and being incontinent of bowel and bladder. R2's November 2010 Physician order [REDACTED]. R2 was observed on 11-10-10 at 11:10AM to be brought in a wheel chair directly from activity to the hallway by her room. R2 was taken at 11:12AM to the TV area by the Dining Room. R2 then went to the Dining Room for her meal. R2 did not receive a Mighty Shake at her meal until the Surveyor informed E2, Director of Nursing. E2 stated he would see to it that she got her shake/supplement. R2 remained in her wheel chair until 1:35PM. At 1:35PM, E6 and E7, Certified Nurse Aides, CNA's put R2 to bed using a mechanical sling lift. R2 had no cushion in her wheel chair seat. She had a folded bed pad instead. R2 had 2 bed pads on her pressure relieving mattress on her bed. Her incontinent brief was saturated with urine and her buttocks were deep creased and red. R2 did not have a treatment/dressing on her coccyx. Interview with E5, Activity Aide, at 1:05PM reflected R2 was in church activity that started at 10:05AM and remained in the activity in her wheel chair. Facility Cumulative Ulcer Tracking Form of 11-6-10 identified R2 as having a stage 3 pressure sore on her coccyx measuring .5 cm x .5 cm x 1 cm depth. 2. R5's admission form shows she was admitted to the facility on [DATE] with a reddened coccyx. R5's Interim Care Plan does not address pressure sores or pressure sore prevention. On 11-10-10, R5 was observed at 10:40AM to have a white denuded slit on her coccyx. E8, Licensed Practical Nurse (LPN) was informed and stated she will have R5 cleansed and will look. At 10:45AM, E8 stated the coccyx was open and measured 1 cm. At 12:25PM, R5 was stating her coccyx was sore. She was in bed lying on 2 bed pads. R5 received an order on 11-10-10 at 12:45PM for Allevyn placed to coccyx area until healed and to change every 3 days. 3. The Minimum Data Set ((MDS) dated [DATE] identifies R1 to require extensive assist of one staff for bathing/hygiene, has a current stage II pressure sore on his coccyx. The physician's orders [REDACTED]. The current care plan identifies R1 to have an ulcer on his heel, 2 necrotic areas on his toes "as well as areas to my buttocks". The care plan indicates R1 requires staff assist to turn/reposition and states staff are to turn at least every two hours. R1's treatment sheet indicates that staff are to keep R1 off his buttocks "at all times." On 11/10/10 at 9:51am, R1 rolled over to his right side and was found to be incontinent of bowel and bladder. He had no boot on his left lower extremity and was noted to have three thick incontinent pads under him. R1's coccyx dressing was waded up in a bunch and the lower seal was broken. The dressing had bowel movement inside the wound area and some was noted to be dried on his skin. R1 stated "there's something wrong with my bottom that I have trouble with" and stated it hurt. E3 Certified Nurses Aide (CNA) wiped R1's coccyx area with a dry wash clothe then dampened some wash clothes but didn't put any cleansing agent on them. E3 wiped R1 several times acrossed his abraised buttocks as he was complaining of pain. E3, CNA, was asked whether the clothe had soap or a cleansing solution on it and replied no, stating she didn't use soap/cleanser because R1 had open areas and it stung when she did. R1 was observed through a pressure ulcer dressing change and then was left on his back through lunch until the observation ended at 1pm which was over the 2 hours identified in his careplan. 4. The MDS dated [DATE] identifies R6 as requiring staff for mobility, bathing and hygiene. According to the Admission assessment dated [DATE], R6 have a stage II pressure ulcer on his coccyx along with both heels being identified to have scabbed areas present on admission. The Treatment sheet for November 2010 indicates staff are to put [MEDICATION NAME] to bilateral heels every shift. The weekly pressure ulcer documentation indicates R6's coccyx wounds was healed on 11/6/10. There is no weekly documentation of the heels per interview with the Director of Nursing, E2 on 11/10/10. The nurses notes for 11/8/10 and 11/9/10 have no pressure ulcers identified for R6. On 11/10/10 at 10:20am, R6 was in bed on his back. Both feet were pushing against the foot board of the bed and he had no protective covering on either foot. R6 had an abraised area across his left buttocks along with a small stage II coccyx pressure sore the facility was unaware of. In addition, he was noted to still have black scabby areas on his heels. E3, CNA, removed R6's paper incontinent brief which was wet with urine and placed a new one on him after wiping him with a wash clothe that had no cleansing agent on it. R6 repeatedly said "Ow" as E3 wiped his reddened coccyx area. R6 was also noted to have 2 thick cloth incontinent pads under him. R6 was then dressed and transferred to his chair where he remained until the observation ended at 1pm. The facility did not reposition him timely according to his need. On 11/10/10, during the daily meeting with the facility, E2, DON stated there was no weekly documentation on R6's feet and that all the other areas were thought to be "healed." On 10/10/10, the physician was notified and the Allevyn was restarted on the coccyx/buttocks area.

Based on observations, interviews and record review, the facility failed to ensure that two (R1 & R3) of four residents on the sample with pressure ulcers, maintained acceptable parameters of nutritional status including body weight, protein/[MEDICATION NAME] levels and failed to ensure that they received the appropriate therapeutic diet including supplements ordered to promote wound healing. The facility failed to have a system in place to monitor weekly weights, meal/supplement intakes and failed to provide needed assistance. This failure resulted in R3 having a 10.6% weight loss from 8/17/10 to 8/31/10. Findings include: 1. The Admission sheet identifies R3 as being admitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. diff history and [MEDICAL CONDITION]. According to the admission orders [REDACTED]. The Interim care plan identifies "puree" as the mechanical altered diet and honey thick liquids. Under the "EATING" section of the care plan, it indicates that R3 required assist or feeding. There is no further information regarding R3's eating/swallowing abilities according to the Interim care plan. The Registered Dietician (RD) nutritional assessment dated [DATE] identifies that R3 was on a puree diet, no concentrated sweets and honey thick liquids and also reflects redness to the groin area. According to the RD's assessment, R3's admission weight was 217 pounds. The assessment indicates he received [MEDICATION NAME] and had impaired chewing and diarrhea. Decreased appetite is marked "no" as is feeds self as he requires feeding. The RD circles [MEDICAL CONDITION] bilateral lower extremities 2+ and upper body 1+. Review of the nurses notes on admission indicates R3 had "generalized [MEDICAL CONDITION] 1+ to upper part of body 2+ to lower part of body." The note also identifies scrotal/penis [MEDICAL CONDITION]. On 8/17/10 at 1800 (6pm), the nurses notes state "having difficulties c (with) chewing - dental mech soft diet - dietary notified to change diet tomorrow to pureed - will cont (continue) to monitor." However, there is no evidence that the facility further assessed this concern. On 8/18/10 at 8:30pm, the nurses notes state R3 is "unable to feed himself. Fed resident et (and) he ate 100% of meals. Aspiration precautions maintained." The nurses notes indicate the body [MEDICAL CONDITION] is basically the same but there is no indication that consistent monitoring was being done. On 8/19/10 at 1400, the nurses notes indicate R3's weight is 207, 10 pounds less than his admission weight 2 days prior. No evidence of further assessment and/or monitoring to determine if the weight loss was fluid or actual weight although the note continues to state R3 remains [MEDICAL CONDITION] and his appetite is poor-"chokes easily-will continue to monitor." On 8/19/10, the nurses notes indicate he was fed by staff and ate 75% of his meal. The next entry is on 8/20/10 at 1pm and indicates R3 has "loose stools." At 2:45pm, the nurses notes indicate he has noted blisters (2) on his anterior right leg. The nurses notes have no further information regarding the [MEDICAL CONDITION] and/or poor appetite but does indicate on 8/23/10 that he continues to have loose stools. On 8/23/10, R3 was seen by the physician and stool specimens were collected. The physician's note dated 8/23/10 indicates that nursing complained of R3 having diarrhea but his stools were non-bloody and he had a history of [REDACTED]. There was no reference to R3's ability to eat, choking episodes and/or food intake or his appetite. Lab results dated 8/24/10 show low [MEDICATION NAME] 1.6 (normal 3.3-4.5) and Protein 5.5 (normal 6.4 - 8.0). There is no indication the facility notified the Registered Dietician of the low labs and/or of the skin issues on his coccyx. On 8/25/10, an order for [REDACTED]. From 8/25/10 until 8/29/10 at 9pm there is no evidence the facility was monitoring R3's [MEDICAL CONDITION] and/or appetite/food intake. On 8/30/10, at 1215pm, R3 is identified with several open areas on his coccyx and buttocks. Again, no evidence is present in the nurses notes that R3's food intake/appetite was being monitored. On 8/31/10, the nurses notes indicate that R3 was sent to the emergency room for lethargy. The transfer sheet from the hospital dated 8/31/10 identifies the chief complaint/reason for visit as "altered LOC (level of Consciousness) Not eating or taking meds". There is no indication from the facility's documentation regarding R3 "not eating." According to the hospital records, R3's admitting weight recorded on 8/31/10 was 88.2 kg or 194 pounds, a weight loss of 25 pounds in less than two weeks. On 9/9/10, R3's sons, Z2 and Z1, stated R3 got pureed diet the entire time he was in the facility. Z2 and Z3 both stated R3 needed assistance to eat but staff would be feeding numerous people at the same time adding that they would give him a bite of food and then move on to other residents. Neither son had been notified of weight loss but both stated they could tell by looking at him and both were aware that he had a poor appetite. On 9/9/10, E2 was asked to clarify R3's diet order since the POS said mechanical soft and the Registered Dietician's said pureed. E2 stated that R3 was seen by the speech therapist 8/19/10 and the diet was to be mechanical soft with honey thick liquids. E2 checked with the dietary department and confirmed that R3 received a pureed diet the entire time he was in the building. E2 also stated that some of the weight loss could be [MEDICAL CONDITION] and added that he had changes in his [MEDICATION NAME] ordered. However, nurses notes do not reflect consistent monitoring for [MEDICAL CONDITION] in an effort to determine if the weight loss was fluid and/or actual weight. There is no documentation regarding his food intake. E2 was also unable to provide intake sheets for meals and stated that the facility does not currently record intake. E2 also acknowledged that weekly weights on admission were not done on R3 as he only had weights from 8/17/10 and 8/19/10. E2 was also unable to provide any documentation indicating that the RD had been notified of the pressure ulcers and/or the low [MEDICATION NAME]/protein. E2 also said the nurses usually monitor intake. On 9/10/10 at 10:30am, E3, Registered Nurse stated that R3 had [MEDICAL CONDITION] upper and lower body and added that his [MEDICAL CONDITION] appeared to increase all over. E3 stated she documented it in the nurses notes. However, other than vague references to the body [MEDICAL CONDITION] in the first days following his admission, there is no notes reflected the [MEDICAL CONDITION]. E3 also stated that in the week before she sent R3 to the hospital, he "ate good" and on a good day, could feed himself. However, at 10:38am, E10 Certified nurses Aide stated that R3 was totally fed and had a poor appetite stating he maybe ate 25-50%. E10 confirmed that R3's family members were in the facility to visit often. There is no evidence the facility provided the correct diet, monitored his weights following his admission, monitored his intake and took measures to address his dietary needs when he ate poorly and developed pressure sores. On 9/9/10 at 11:32am, E13 Registered Dietician indicated she is only in the building two days per week and that communication is poor at times. E13 stated that she only knows when residents develop pressure ulcers when the MDS reflects them and that she checks the labs when she visits. E13 stated the facility does not have a system currently in place to ensure recommendations are carried through, evaluations are done timely on residents that develop pressure ulcers and those who have poor appetites. E13 stated she is not provided a list of resident with needs but does routine visits. She confirmed the facility does not track meal/supplement intakes and that she often has to ask staff how residents eat and it they take the supplements or not. E13 was familiar with R3 but not aware that he had any weight loss during his stay. 2. MDS dated [DATE] identifies R1 as being a [AGE] year old male readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicates R1 requires extensive assist of staff for most activities of daily living and requires supervision and set up for eating. The POS indicates R1 is currently being treated for [REDACTED]. The POS identifies R1's diet as No added salt, no concentrated sweets. The RD assessment indicates his average meal intake is 75-100%. According to R1's care plan , R1's goal is to maintain good skin integrity and hydration along with his weight. The care plan indicates R1's weight is monitored weekly and as needed and substitutes are offered when needed if he is not eating well. Interventions also indicate R1 is to be encouraged to feed himself and help if needed. Staff are to provide a can of ensure if R1 eats less than 50% of his meal. Review of laboratory values dated 5/25/10, R1 has low Albumen at 2.8 (normal 3.3-4.5). There is nothing in the care plan regarding nutritional support to aid wound healing. Review of the RD's assessment dated [DATE] shows a recommendation made [MEDICATION NAME] twice daily to "promote wound healing of dec (decubitus ulcer)". There is no indication the facility followed thru with this recommendation. R1's weight was 277 at the time. The next RD review dated 8/2/10 includes another recommendation [MEDICATION NAME] twice daily and includes a note stating "dietary notified." R1's weight was recorded in the assessment as 261, down 16 pounds or 5.8 % in 4 months. E13, RD was present at the time and stated she did not know if the original recommendation for the nutritional supplement was acted on in April and in August, she notified the dietary department herself to be sure he got it. E13 acknowledged R1's low [MEDICATION NAME] and stated R1 has recently lost a substantial amount of weight and she had requested a reweigh. E13 also said that the supplements would come on his meal tray at lunch and dinner. E13 was asked about who processes the dietary recommendations and stated she didn't know for sure but that she either notifies the dietary department herself or the nurses do. A reweigh on 9/9/10 was done and R1 weighed 252 pounds, an additional loss of approximately 4% within a months time. On 9/7/10 at 11:45am, R1 was laying in bed in a hospital gown. E4, Certified Nurses Aide, entered the room stating she needed to get him up soon as she have only time to feed him cornflakes and orange juice for breakfast. On 9/10/10 at 10:30am, E2 confirmed that R1'[MEDICATION NAME] twice daily was not implemented until August and that the facility does not currently have a system in place that monitors intake of meals or supplements. This was confirmed by review of the intake sheets from the dining room which had no intakes records for the majority of the people and all of them reviewed for the past 1 1/2 months were blank for R1. At 11:32 am on 9/9/10, R1's lunch tray was noted to have [MEDICATION NAME] on it. E13 checked and said that the facility was "out [MEDICATION NAME]" that day as the order didn't come in the previous day. E13 stated she would see that he got [MEDICATION NAME] in it's place. At 11:45am, R1 was in bed with his meal tray in front of him. He had a cup of [MEDICATION NAME] on his tray. He had no staff in with him at all for supervision and set up assistance was incomplete as his bread was still in the package and his butter hadn't been opened. Interview with E4, CNA on 9/10/10 indicates that R1 "will eat 75-100% if he likes" the food. There is no indication that substitutes are offered for food uneaten. The facility's policy on feeding residents indicate that all residents will be assisted with their meals when needed to ensure proper food intake. On 9/10/10, during the daily meeting, E2 stated that usually R1 eats in the assisted dining room but that dining room was recently closed to allow repairs.