Every finding on record at Amberwood Care Centre

Based on interview and record review the facility failed to ensure a blind resident that wanted to participate in smoking times at the facility was assisted to the activity for 1 of 3 residents (R1) reviewed for resident rights in the sample of 10. The findings include: On [DATE] at 10:49 AM, R1 was sitting in a wheelchair in her room. R1 has bilateral lower extremities amputated above the knees. R1 stated she is blind but can see some shapes. R1 stated she smokes and needs an certified nursing assistant (CNA) to take to out to smoke. R1 stated sometimes they don't have a CNA to take her. R1 stated the CNAs have told her that it isn't anyone's job to take her to smoke. R1 stated she just had her leg amputated and it just adds to her depression not being able to smoke. On [DATE] at 11:05 AM, V6 (Licensed Practical Nurse/LPN) stated the residents that smoke have to be able to take themselves downstairs to smoke. V6 stated they don't take anyone down. V6 stated the resident has to be able bodied and take themselves and then the activity aide goes outside with them. On [DATE] at 11:08 AM, V7 (CNA) stated when she works she takes R1 to the smoking times. V7 stated she doesn't know what happens on the weekends. V7 stated R1 told her that when V7 was off no one would take her to smoke. On [DATE] at 12:17 PM, V2 (Director of Nursing) stated typically residents have to be able to get themselves down for smoke times. There are some exceptions like R1. V2 stated the CNA will bring R1 down and the activity aid will bring R1 back upstairs. The Face Sheet dated [DATE] for R1 showed diagnoses including diagnoses including encounter for orthopedic aftercare following surgical amputation, chronic obstructive pulmonary disease, kidney failure, cellulitis of left lower limb, extended betas lactamase resistance, type 1 diabetes mellitus, peripheral vascular disease, hyperlipidemia, gram negative sepsis, abdominal hernia with gangrene, weakness, cognitive communication deficit, acute myocardial infarction major depressive disorder, atrial fibrillation, blind loop syndrome, shortness of breath, orthopnea, muscle weakness, history of non-pressure chronic ulcer to part of left lower leg with necrosis of muscle, visual loss both eyes, hypertension, and acquired absence of right leg above knee.The Safe Smoking Assessment Form dated [DATE] for R1 showed the resident knows the location of the designated area for smoking but cannot get to the area independently. The resident can smoke but requires supervision due to being blind.The Minimum Data Set (MDS) dated [DATE] for R1 showed no cognitive impairment.The facility's Smoking Policy (2001) showed prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preference.

Based on observation, interview, and record review the facility failed to provide assistance with activities of daily for two residents (R1 & R2) reviewed for activities of daily living in the sample of 10. The findings include:1. On 7/14/26 at 12:01 PM, some residents on the second floor in the dining room. V10 (Certified Nursing Assistant/CNA) was sitting at a table with residents with her back to the entrance of the dining room. R2 was in a wheelchair propelling himself into the dining room grabbing onto the doorway, a resident's wheelchair and a resident's walker to pull himself forward in his chair. R4 was at a table in the middle of the dining room, near where V10 was sitting. R4 watched R2 come into the room, wheel past his table, to another table in the corner that had R6's mechanical soft food on it. R4 told R2 his tray was not in the dining room. R2 shrugged his shoulders and continued to the table, took the lid off the plate, grabbed carrots and shoved them in his mouth. R4 told R2 it was not his food and R2 continued to put meat and carrots in his mouth. R4 told R2 he needed to wait and not eat someone else's food. V10 did not assist R2; she was the only employee in the room. The surveyor went to V10 and alerted her to what was happening. V10 went over to R2 and took the tray away. V10 was asked where R2's tray was, and she did not respond. V10 went out into the hall and was heard yelling down the hall asking where R2's tray was at. There were no staff in the dining room, R4 got up and took his half eaten mechanical soft diet tray over to R1 and told him he could eat it. V10 came into the dining room, asked R2 if he ate, and took R4's tray from R2. V10 left the dining room and while she was gone R4 went and retrieved his 1/2 eaten lunch tray, brought it back into the dining room and gave it to R2. V10 came back into the dining room and told R4 that he can't give R2 a tray because he doesn't know what R2's diet tray was. At 12:09 PM, V10 gave R2 a mechanical soft diet tray. All residents trays involved were mechanical soft diets.On 7/14/26 at 12:11 PM, V2 (Director of Nursing/DON) stated R2 should not be eating from other resident's trays for infection control. V2 also stated it may not be the same diet and could be a safety issue. V2 confirmed R2 needed supervision and assistance.The Face Sheet dated 7/14/25 for R2 showed diagnoses including cerebral infarction, aphasia following cerebral infarction, rhabdomyolysis, encephalopathy, insomnia, type 2 diabetes mellitus, mild protein calorie malnutrition, gastrostomy status, muscle weakness, muscle wasting and atrophy, need for assistance with personal care, dysphagia, cognitive communication deficit, anxiety disorder, major depressive disorder, unstable angina, atherosclerotic heart disease, adhesive capsulitis of left shoulder, stiffness of left shoulder, hyperlipidemia, hypertension, and cardiomyopathy.The Minimum Data Set (MDS) for R2 dated 6/17/26 showed impairment of short-term memory, and long term memory; moderate cognitive impairment. Supervision or touching assistance for eating.The Dietary Note dated 6/14/26 for R2 showed he receives tube feeding if he consumes less that 50 percent of his meal and eats a regular, mechanical soft diet with thin liquids.The Care Plan with a target date on 9/23/26 and revision date of 6/26/25 showed R2 has an activity of daily living self-care performance deficit related to confusion and stroke. Eating - supervision for meals. Bolus feed if oral intake less than 50 percent at previous meals requiring total assist.The facility's Assistance with Meals policy (2017) showed facility staff will serve resident trays and will help residents who require assistance.2. On 7/14/26 at 8:11 AM V3 (R1's sister) stated that R1 relies on the facility to help her because she is blind and a double amputee. V3 stated she has called the facility, been on the phone with R1 who is calling out for someone to help her and can hear the call light going off. V3 stated when she got to the facility 1.5 hours later R1 was wet and had not been changed.On 7/14/26 at 10:49 AM, R1 stated she was on the phone with V3, had pulled the string for her call light, and was saying, Hello, can someone help me, and no one responded but she could hear staff in the hallway. R1 stated she needs to be changed when she calls for help. R1 stated she tries not to bother staff. R1's room was located near the nurse's desk.On 7/14/26 at 11:08 AM, V7 (CNA) stated when she works, she is constantly checking on her residents and keeps busy. V7 stated she came in on her shift and saw a resident's bed all made nice and neat. V7 stated she pulled the covers back and the sheet had a large round stain of urine that was dried. V7 stated she reported it to her supervisors.On 7/14/26 at 11:28 AM, V8 (CNA) stated she has come in for her shift and resident's beds will be completely soaked. V8 stated it is usually the residents that can't advocate for themselves. V8 stated some residents are heavy wetter's but you can tell when a brief has been sopping wet for a while. V8 stated she doesn't think anything is done when it is reported to management. On 7/14/26 at 11:40 AM, V9 (CNA) stated sometimes when she comes in she will have to do a complete bed change because a residents bed is soaked.On 7/14/26 at 12:17 PM V2 (Director of Nursing/DON) stated she hasn't had complaints recently about incontinence care or beds being wet. V2 stated if urine has dried on sheets, then it means it has been over two hours since someone was checked and changed and that is a problem. V2 stated it was not the facility's standard of care.The Face Sheet dated 7/14/26 for R1 showed diagnoses including diagnoses including encounter for orthopedic aftercare following surgical amputation, chronic obstructive pulmonary disease, kidney failure, cellulitis of left lower limb, extended betas lactamase resistance, type 1 diabetes mellitus, peripheral vascular disease, hyperlipidemia, gram negative sepsis, abdominal hernia with gangrene, weakness, cognitive communication deficit, acute myocardial infarction major depressive disorder, atrial fibrillation, blind loop syndrome, shortness of breath, orthopnea, muscle weakness, history of non-pressure chronic ulcer to part of left lower leg with necrosis of muscle, visual loss both eyes, hypertension, and acquired absence of right leg above knee.The Care Plan dated 7/14/26 for R1 showed she has an activity of daily living self-care deficit related to her left and right above the knee amputation. Encourage the resident to use bell to call for assistance. R1 is totally dependent on 1 staff for peri cares, bedpan use, and adjusting clothes before and after toileting. R1 requires max/total assist of 1-2 staff with turning and repositioning in bed.The Minimum Data Set (MDS) dated [DATE] for R1 showed no cognitive impairment; dependent for toileting hygiene and personal hygiene; substantial/maximal assistance for shower, dressing, and bed mobility.The facility's Activities of Daily Living, supporting policy (2018) showed residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal, and oral hygiene.

Based on interview and record review the facility failed to ensure a resident was supervised while being toileted to prevent an injury. This applies to 1 of 3 residents (R1) reviewed for safety/supervision in the sample of 7. The findings include:R1's face sheet lists her diagnoses to include: Alzheimer's Disease and dementia. R1's unwitnessed incident report dated 2/18/26 shows, CNA (certified nursing assistant) informed writer that resident was on the floor in her bathroom. Nurse arrived observed resident sitting on buttocks with shirt on, brief down to the ankles, and with gripper socks on. The same report also shows, R1 is oriented to person only and other info shows, Resident stated to CNA I will like some privacy while using the restroom. On 2/25/26 at 1:11 PM, V6 Licensed Practical Nurse (LPN) stated, he admitted R1 when she came to the facility a day before. She was agitated about being at the facility but eventually calmed down. She would try to stand up by herself sometimes. She was a high fall risk. The night R1 fell he was doing medication pass when the CNA (V7) informed him R1 fell. He observed her on the floor in the bathroom across from the toilet on her buttocks with her back against the wall. R1 said, she didn't know how she fell and was tired. The CNA (V7) told V6 LPN she assisted R1 to the toilet and R1 asked for some privacy. R1's daughter was in the room at the time and told her it was ok she left because she was in the room with her. V7 CNA left the room. R1's daughter came out of the room and told V7 CNA she was leaving. When V7 CNA went back to the room she found her on the floor in the bathroom. V6 LPN stated, residents who are high risk for falls should not be left alone in the bathroom. On 2/25/26 at 1:39 PM, V7 CNA stated she was the CNA that cared for R1 the night she fell. It was the first time she had taken care of R1 since she was admitted . The last time she took R1 to the bathroom she asked for some privacy. The daughter was in the room and said it was ok she left. It was dinner time and the drinks came up from the kitchen. She was passing out drinks to residents when R1's daughter came to her and told her it was best she left now while her mom was in the bathroom otherwise she would want to leave with her. V7 CNA asked if she was still on the toilet and the R1's daughter told her she was. V7 CNA continued to pass drinks to a few more residents and then went to check on R1. When she got back to R1's room, R1 was already on the floor. The facility's IDPH (Illinois Department of Public Health) incident report form shows, R1 had a fall on 2/18/26 at 6:00 PM. On 2/18/26 the resident (R1) had a fall while attempting to self transfer in her bathroom. The resident pain, no injuries observed on assessment, Provider & POA (power of attorney) notified of fall & provider ordered resident to be sent to the ER (emergency room) for eval (evaluation). EMS (emergency medical system) arrived & resident sent to the ER without incident. Imaging in the ER revealed a left 4th finger fracture. Final Report: Upon staff interview & record review it was determined that the resident was in the bathroom sitting on the toilet with her daughter present in her room, resident daughter stated she would stay with resident while she was in the bathroom, resident daughter approached staff CNA down the hallway & she stated she was leaving the facility & her mother was still on the toilet in the bathroom. The daughter also indicated she did not want her mother to see her leave. Staff CNA returned to the room to observed resident sitting on her buttocks on the bathroom floor.On 2/25/26 at 2:29 PM, V10 Restorative Nurse stated, R1 was a high risk for falls. When she first came she kept trying to get up. She was pleasantly confused. She told the staff to bring her out of the room and keep an eye on her. Residents who are high risk for falls should always be supervised while toileting. R1's Morse Fall Scale dated 2/16/26 shows, she was a high risk for falling due to history of falling, impaired gait and overestimates or forgets limits. R1's Minimum Data Set, dated [DATE] shows, she is not cognitively intact and requires substantial/maximal assistance with toileting. R1's care plan shows, she has impaired cognitive function or impaired thought processes r/t (related to) Alzheimer's/Dementia, ADL (activity of daily living) self-care performance deficit r/t confusion, impaired balance and is high risk for falls r/t confusion and gait/balance problems. The facility's falls and fall risk, managing policy revised March 2018 shows, Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on observation, interview, and record review the facility failed to ensure a resident was seen by a podiatrist. This applies to 1 of 3 residents (R1) reviewed for foot care in the sample of 4.The findings include:R1's face sheet shows he was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, COPD, type 2 diabetes with diabetic peripheral angiopathy with gangrene, anxiety, and peripheral vascular disease.On 10/27/25 at 10:33 AM, R1 was in his room lying in bed. R1 said he has been at the facility for about six months and has not seen a podiatrist yet. R1 said he has told several staff, and their response is he will get put on the list to be seen. R1's left big toenail was extremely overgrown (approximately 2 inches long), curved, thickened, jagged, with yellowish discoloration. R1 has an amputee to his left 3rd toe digit and the remaining toenails are long and overgrown.On 10/27/25 at 11:12 AM, V5 (Licensed Practical Nurse-LPN) said R1 is alert and oriented, he reported to her a while go wanting to be seen by the podiatrist. V5 said months ago she called the front desk to have R1 put on the list to be seen by the podiatrist. She is not sure if R1 has been seen or not. This surveyor showed V5's toenails and she confirmed R1's toenails were overgrown and long.On 10/27/25 at 1:38 PM, V2 (Director of Nursing-DON) said the facility sends a census to the podiatrist before their bimonthly visit and they notify of new admission so they can be seen on the next visit. V2 confirmed R1 has not been seen by the podiatrist yet. The podiatrist comes every other month, and the last podiatry visit was on 9/8/25. V2 confirmed R2 should have been seen and is not sure why he was not seen. The facility's Foot Care Policy dated March 2018 states, Residents will receive appropriate care and treatment in order to maintain mobility and foot health. overall foot care will include the care and treatment of medical conditions associated with foot complications (e.g. diabetes, peripheral vascular disease, etc.) .Residents with foot disorders or medical conditions associated with foot complications will be referred to qualified professionals.

Based on observation, interview, and record review the facility failed to ensure the facility was at a comfortable temperature and failed to accurately assess and monitor ambient room temperatures during an outage of the air conditioning system. This applies to all residents residing in the facility. The findings include: The facility provided a resident roster dated 6/23/25 showing 121 residents were residing in the facility. R2's face sheet showed he was admitted to the facility 11/2/23 with diagnoses to include dysarthria, hemiplegia and hemiparesis, muscle weakness, depression, congestive heart failure, and atherosclerotic heart disease. R7's face sheet showed he was admitted to the facility 9/5/23 with diagnoses to include Multiple sclerosis, venous insufficiency, muscle spasm, hyperlipidemia, muscle weakness, hypertension, and activated protein c resistance. R8's face sheet showed he was admitted to the facility 9/7/23 with diagnoses to include Chronic Obstructive Pulmonary Disease, cognitive communication deficit, anxiety disorder, depression, radiculopathy, polyneuropathy, Type 2 Diabetes, spinal stenosis, and low back pain. R8's facility assessment dated [DATE] showed he has no cognitive impairment. R9's face sheet showed he was admitted to the facility 6/24/22 with diagnoses to include spinal stenosis, atrial fibrillation, emphysema, chronic kidney disease, anxiety disorder, and hyperlipidemia. R9's facility assessment dated [DATE] showed she has no cognitive impairment. R10's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include anxiety disorder, paroxysmal atrial fibrillation, congestive heart failure, muscle weakness, acute kidney failure, presence of prosthetic heart valve, hypertension, anemia in chronic kidney disease, and seizures. R10's facility assessment dated [DATE] showed he has moderate cognitive impairment. On 6/24/25 at 12:46 PM, R7 was lying in bed. R7 said he was doing good except the heat issue which has been going on since Friday (6/20/25). R7 said the facility is working on the issue but it is taking forever. R7 said,They have a maintenance guy working on it. It affects my MS (multiple sclerosis). I spent Friday, Saturday, Sunday, and Monday in bed to not take any chances. I get really weak with heat due to my MS (Multiple Sclerosis). At first they were checking temperatures, it was 86 degrees in here and that is way too hot for me. They had the air conditioning working at one point but then it broke down completely. On 6/24/25 at 12:32 PM, R8 said, They have to fix this air conditioning. Its been really hot . On 6/24/24 at 3:01 PM, V5 CNA (Certified Nursing Assistant) said, . I didn't work this past weekend but I worked yesterday (6/23/25). It was drastically hot. I was sweating . A lot of them stayed in their rooms with the fans on . On 6/25/25 at 1043, R10 said, The staff have been encouraging water but they haven't offered a room change. I would have moved rooms if there was one cooler available. This heat made me sleep more because I have been trying to ignore it. I guess it is not too bad right now but it sure could be cooler. I wasn't offered a fan. A fan would probably help. On 6/25/25 at 10:50 AM, R2 said, . I'm just trying to stay cool. Our room was hot last night. Today (6/25/25) and yesterday (6/24/25) for sure were hot in here. Its hotter in here today than it was yesterday. My eyes are watering and my nose is stopped up . The facility's temperature log dated 6/21/25 at 2:50 PM showed 24 of 26 temperatures recorded throughout areas of the facility were out of range. The out of range temperatures were between 80.1 degrees through 83.5 degrees Fahrenheit. The facility's temperature log dated 6/21/25 at 3:29 PM showed 17 of 23 temperatures recorded were out of range. The out of range temperatures were between 80.2 degrees and 86.9 degrees. The facility's temperature log dated 6/21/25 at 4:21 PM showed 11 of 28 temperatures recorded throughout areas of the facility including resident rooms and common areas were out of range. The out of range temperatures were between 80.1 degrees and 85.5 degrees. The facility's temperature log dated 6/21/25 at 5:19 PM showed 14 of 29 temperatures recorded throughout areas of the facility including hallways and resident rooms were out of range. The out of range temperatures were between 80.4 degrees and 86.2 degrees. The facility's temperature log dated 6/21/25 at 10:30 PM showed 20 of 21 temperatures recorded throughout areas of the facility were out of range. The out of range temperatures were between 80.1 degrees and 84.5 degrees. The facility's temperature log dated 6/22/25 and titled 3rd shift showed 28 of 44 temperatures recorded throughout areas of the facility were out of range. The out of range temperatures were between 80.4 degrees to 86.2 degrees. The facility's temperature log dated 6/22/25 at 7:00 AM showed 20 of 26 temperatures recorded throughout areas of the facility including hallways and resident rooms were out of range. The out of range temperatures were between 80.1 degrees and 88.6 degrees. The facility's temperature log dated 6/22/25 at 9:00 AM showed 30 of 62 temperatures recorded throughout areas of the facility remained out of range. The out of range temperatures were between 80.1 degrees and 86.4 degrees. The facility's undated and untimed temperature log showed 13 of 28 temperatures recorded throughout the facility were out of range. The out of range temperatures were between 80.6 degrees and 85.3 degrees. The facility's temperature log dated 6/22/25 at 12:02 PM showed 19 of 46 temperatures recorded throughout areas of the facility including resident rooms were out of range. The out of range temperatures were between 80.3 degrees and 84.8 degrees. The facility's temperature log dated 6/22/25 at 12:44 PM showed 3 of 22 temperatures recorded throughout the facility were out of range. This log sheet showed a notation that R7's room had no air at all. The out of range temperatures were between 80.0 degrees through 91.0 degrees. The facility's temperature log dated 6/22/25 between 3:30 and 4:00 PM showed 26 of 41 temperatures recorded throughout areas of the facility were out of range. The out of range temperatures were between 80.3 degrees and 85.4 degrees. The facility's temperature log dated 6/22/25 at 5:00 PM showed 17 of 37 temperatures recorded throughout areas of the facility including resident rooms remained out of range. The out of range temperatures were between 81.0 degrees and 85.8 degrees. The facility's temperature log dated 6/22/25 and titled 2nd shift showed 23 of 35 temperatures recorded throughout areas of the facility were out of range. The out of range temperatures were between 80.2 degrees and 86.5 degrees. The facility's temperature log dated 6/22/25 at 10:00 PM showed 31 of 37 temperatures recorded were out of range. The out of range temperatures were between 80.2 degrees and 88.0 degrees. The facility's temperature log dated 6/22/25 at 11:30 PM showed 28 of 43 temperatures recorded throughout areas of the facility were out of range. The out of range temperatures were between 80.1 degrees and 86.5 degrees. The facility's temperature log dated 6/23/25 at 3:30 AM showed 17 of 46 temperatures recorded were out of range. The out of range temperatures were between 80.2 degrees and 85.8 degrees. The last temperature log kept by the facility was dated 6/23/25 at 9:30 AM and showed 23 temperatures were recorded and all within range. No logs were presented for 6/24/25 and 6/25/25. On 6/25/25 at 2:28 PM, V1 Administrator and this surveyor entered R7's room and used a thermometer that is capable to checking ambient room air temperatures. R7's room was 81 degrees. On 6/25/25 at 10:54 AM, V10 (Maintenance Director) said, Right now we have a technician from [a local heating and air repair company] working on cleaning the compressors. The outage was reported to me on Saturday (6/21/25) around 1:40 PM by the nurse who was on call . I called and verified the problem. They confirmed it was hotter in some areas of the building than others. I told them to check the rest of the units on 2nd floor. At that moment I called [a local heating and air conditioning repair company] and opened a ticket telling them we had no air conditioning and that it was an emergency because we are a healthcare place. I notified the Administrator and Director of Nursing that the air conditioning was not working. Around 3:30 PM, I called [the heating and air conditioning repair company] again since I hadn't heard anything from them and reiterated this was a very emergency and we had 127 residents in the building with no air conditioning. Give or take 10-20 minutes later I received a call from the technician saying he was already on his way over here. We got the air conditioning up and running on Saturday (6/21/25). Our air conditioning system has 2 chillers, a stage 1 and a stage 2. He was able to put stage 1 back up and running. The technician here now came back Sunday (6/22/25) in the early morning to work on stage 2 . Monitoring was put in place of temperatures. We were doing all surface temperatures. V10 showed the thermometer to the surveyor. V10 said, This is the only thermometer we use. I did the first monitoring of temperatures and we were doing the temps almost every hour of different areas of the facility. We were also taking temperatures in the hallways and in the rooms to make sure what temperature both hallways and rooms were. I turned all those log sheets into the administrator as well. We are still monitoring temperatures at this time. I haven't done any since yesterday (6/24/25).We can not be any higher than 80 degrees so the temperatures that we are normally at are around 74-76 degrees. This is for hallway temperature and room temperature as well. The technician yesterday put the replacement parts in. Today he arrived around 7:00 AM and he is cleaning the condenser on the roof. He did have to shut the system down to clean the compressor. On 6/25/25 at 11:00 AM, V10 used the thermometer and checked the temperature in the hallway. The temperature of the hallway was 81.5 degrees. On 6/24/25 at :44 PM V1 (Administrator) said, The air conditioning issues started on Saturday (6/21/25). We got the people out and they got it back up and going but it had a hard time keeping up. We ordered portable units in to supplement, they were here Saturday (6/21/25) and Sunday (6/22/25). Sunday there were temporary parts put in. We got more portable units yesterday. Today they were back in and put the permanent parts in. Everything is up and running at this time . We were rounding with extra water passes. monitoring residents, and monitoring temperatures. There were some rooms that were in the low to mid 80 degrees. We offered room moves . On 6/25/25 at 12:30 PM, V1 said she has obtained thermometers that read ambient air temperatures and would be checking temperatures throughout the facility. V1 said she was not aware that surface temperatures were not sufficient for monitoring room temperatures. The facility's policy and procedure effective 4/1/24 showed, Summer Temperature Monitoring Guidelines, Purpose: to provide a safe and comfortable environment for residents. To determine if the Extreme Hot weather Guidelines need to be implemented. Person Responsible: Facility Administrator. Guidelines: Routine temperature and humidity monitoring of the facility will occur at minimum of two times per day during daylight hours. For example, 10:00 AM and 4:00 PM. These temperatures/humidity's are to be taken in the warmest areas of facility identified through base-line monitoring. Should the combined value fall in the shaded area of the chart the Hot Weather Policy must be implemented . Should it be determined that the high temperatures procedures do not sufficiently maintain resident safety for an extended period of time determined by facility Administrator in concert with the [NAME] President of Clinical Operations. The facility will consult with Public Health regarding next steps to ensure resident well being . The facility's policy and procedure with revision date of 4/15/24 showed, Extreme Hot Weather Guidance . Purpose: Provide guidance to facility in times of unseasonably hot weather and/or cooling system malfunction. Responsible Party: Facility staff . Should the temperature index for relative humidity and temperature in this facility rise above 80 degrees, the facility shall implement the appropriate high temperature procedures. Should a specific area of the facility rise above 80 degrees, it may be necessary to relocate residents to a cooler section of the facility .

Based on observation, interview, and record review the facility failed to ensure foods were dated, expired foods were discarded, and kitchen temperature logs were complete. This applies to all residents residing in the facility. The findings include: The facility census report dated 6/30/25 showed 123 residents resided in the facility. On 7/1/25 at 9:29 AM, the reach-in refrigerator had multiple food items missing dates. The items included five plated lettuce salads, half a brick of open butter, open cheese slices, a plastic container of fruit cocktail, an open bag of shredded cheese, an opened and browning bag of shredded lettuce. The same refrigerator had a plastic container of puree bread dated 6/23 and a cut up watermelon dated 6/25. A stainless-steel pan held an undated turkey breast in the same refrigerator. At 9:39 AM, V5 (Dietary Aide) stated any undated food needs to be tossed out. No date means it must go in the garbage. The dates tell us when it is too old to serve and when the food has gone bad. On 7/1/25 at 9:45 AM, the walk-in refrigerator had approximately 28 individual size cups of pudding which were all undated. The same refrigerator had a tub of cottage cheese that showed best by 6/28/25. The refrigerator had a tub of sour cream with an expiration date of 4/21/25. On 7/1/25 the five temperature logs for all the refrigerators and freezers were reviewed by this surveyor. Each log was posted on the unit doors and reflected the month of June 2025. Multiple days were missing on every log. Dietary staff were questioned for the location of the current day's temperatures and were unable to locate any of them. On 7/1/25 the food temperature logs were reviewed with V4 (Dietary Manager) present. Multiple food temperatures were missing from the logs, including multiple days at a time for the evening meals. On 7/1/25 at 9:50 AM, V4 (Dietary Manager) stated the July 2025 refrigerator and freezer logs have not been put out yet. They have not even been started. They should be done every day and somebody didn't do it right. The storage units (refrigerators and freezers) need temperature checks at least two times each day. It ensures the units are working correctly and keeps resident food safe. Bad storage temperatures can spoil food and make residents sick. V4 was questioned about the multiple missing temperatures on the June logs and said there is no way to know if the units were working right if the temperatures aren't on the logs. V4 said every food needs a date to show when it comes in and when it was opened. Old food is dangerous to eat. Any food that is expired or not dated should be thrown out. All the kitchen staff are responsible for dating food and checking the dates. V4 said the cooks are responsible for taking and documenting final cooking temperatures. It should be done every meal to be sure the food is hot and cooked to the proper temperature. No temperatures mean someone is forgetting to do it and that is a problem. On 7/1/25 at 10:58 AM, R2 and R4 were interviewed together. Both residents stated the food is up and down. Some days it is cold and just recently they got served burnt chicken. Both stated it was so tough and overcooked it was hard to chew. On 7/1/25 at 11:14 AM, R3 said the food is terrible and the kitchen messes up a lot. V3 stated she eats outside food a lot because it is so bad. On 7/1/25 at 11:20 AM, R1 stated the food is not edible and gets delivered cold most of the time. At 11:52 AM, R1 was seated in her room with her lunch tray and said this turkey burger and fries are cold today too. On 7/1/25 at 11:50 AM, R7 was eating his lunch in his bed and said this food is super cold. On 7/1/25 at 12:07 PM, R5 and R6 were interviewed together. Both residents said it is cold or else overcooked many times. R6 had an untouched lunch tray next to him and said this arrived ice cold today. On 7/1/25 at 12:13 PM, V7 (Certified Nurse Aide) said residents complain about the food all the time. They don't like it and many of them leave their food uneaten. On 7/1/25 at 12:15 PM, V8 (Certified Nurse Aide) said the kitchen makes a lot of errors and we must take time away from our duties to correct them. Residents say the food is bad and cold a lot. The facility's June 2025 food temperature logs were reviewed and showed missing temperature documentation for every day except June 17 and June 24. The facility's undated Food Temperatures Correct Use of the Thermometer policy states: Food temperatures are taken and recorded on the temperature monitoring log which indicates the correct temperature for each item .Corrective action is taken for foods not meeting the temperature standard. The facility's undated Storage of Food and Supplies policy states: 4. Prepared foods stored in the refrigerator until service will be covered, labeled, and dated with an expiration date. 6. All foods will be covered, labeled, and dated.

Based on interview and record review, the facility failed to report an injury of unknown origin for 1 of 3 residents (R1) reviewed for accidents in the sample of 3. The findings include: On 5/14/25 at 10:38 AM, V2, Director of Nursing (DON), said R1 did not fall on 4/30/25, the last time he fell prior to 4/30/25 was on 4/23/25. V2 agreed that her report to IDPH dated 5/1/25 could be misleading since it shows the date of incident is 4/30/25 at 6:00 PM, then describes R1 being found on the floor. V2 said they attributed R1's rib fractures (discovered on 4/30/25) to his fall from 4/23/25. V2 said she did not do an additional report on R1's rib fractures as an injury of unknown origin. On 5/14/25 at 11:09 AM, V3, Licensed Practical Nurse (LPN), said R1 fell on (Wednesday) 4/23/25. R1 was found at the end of his roommate's bed on the floor on his bottom, he was not in a weird position, and no objects were present that he would have fallen onto. V3 said R1's roommate said R1 was walking to the bathroom and fell to the floor onto his butt. V3 said she assessed R1, checked his range of motion and vital signs. V3 said R1 had no pain, bruising, or complaints. V3 said two CNAs (certified nursing assistants) used a gait belt and assisted R1 to a standing position and walked him to the bathroom. R1 did not have any complaints while walking and was not guarding. V3 said she took care of R1 again the following Monday (4/28/25) and noted nothing out of the ordinary. R1 did not complain of anything, he was quiet and did not complain of pain. V3 said V4, LPN, was R1's nurse on 4/30/25 from 7:00 AM until 7:00 PM and R1 complained of pain in his side. V3 said R1 did not have a new injury or accident between 4/23/25 and 4/30/25. On 5/14/25 at 11:46 AM, V4 said the CNA, V5, reported that R1 was guarding his right side and saying ow when she was toileting him on 4/30/25. V4 said she did a body check and R1 complained of pain with movement, especially bending to the side. R1 was grimacing and saying ouch. V4 said she informed V2, and the nurse practitioner (NP) and an X-ray was ordered. V4 said she is one of R1's primary nurses and R1 had no complaints of pain prior to 4/30/25, and his pain was noticeable that day with grimacing. V4 said nothing happened to him on 4/30/25; she looked at his record and saw his last fall was on 4/23/25. R1 had no other accidents, incidents, or injuries and there was no bruising or deformity noted on his skin check. V4 said it does not seem like R1's rib fractures happened when he fell on [DATE] because he did not have pain until 4/30/25, and that is what made her so concerned about his pain. V4 said she has no idea what could have triggered R1's rib pain on 4/30/25. On 5/14/25 at 12:48 PM, V5, said R1 is on her permanent assignment. V5 said on 4/30/25 when she returned from being off work for four or five days, R1 started complaining of pain and was grabbing his right side every time she moved him. V5 said R1 didn't know what was wrong and she notified V4 right away. V5 said no one had reported any injuries or falls or that R1 was having pain when she started her shift on 4/30/25; nothing was reported of which she knows. V5 said R1 was not having any pain the previous time she had cared for him. On 5/14/25 at 2:41 PM, V7, LPN, said she came in to work (night shift) and got report from (evening shift) V3, on 4/30/25. V7 said she works almost every night on R1's floor. V7 said she was told V4 discovered R1 started having right sided pain that day. V7 said R1 did not have any pain the night before when she cared for him. V7 said it was completely new, nothing happened to R1 the night before (4/29/25) when she cared for him. V7 said he was himself; he had no injuries and no falls. V7 said R1's pain was, a total shock to her. On 5/14/25 at 1:15 PM, V6, Physician, said it seems odd that R1 fell on [DATE] and began having pain on 4/30/25. V6 said she would think R1 would have had pain immediately after falling on 4/23/25 if he sustained rib fractures as rib fractures can be very painful. V6 said it's difficult to attribute R1's rib fractures found on 4/30/25 with his fall on 4/23/25. V6 said it's hard to believe R1's fall on 4/23/25 could have caused his rib fractures identified on 4/30/25 since he had no pain immediately. V6 said she saw R1 on 5/1/25 and R1 was splinting his ribs, grimacing in pain with movement, and there was even a little tear coming from his eye. V6 said she prescribed him stronger medications to help with his pain. R1's Progress Notes show documentation on 4/23/25 at 9:43 PM that R1 was found on the floor in his room with no injury noted. The very next progress note documented was on 4/30/25 at 10:30 AM which shows R1 complained of pain to his right rib area and was noted to be holding his side and grimacing. R1's Admission Record dated 5/14/25 shows R1's diagnoses include, but are not limited to cognitive communication deficit, dementia, and metabolic encephalopathy. R1's Minimum Data Set, dated dated dated [DATE] shows R1 has severe cognitive impairment. R1's Medication Administration Record for 4/1/25 to 4/30/25 shows R1 had a pain rating of 0 for the entire month until 4/30/25 when he had a pain rating of 5. R1's Radiology Results obtained 4/30/25 at 2:08 PM and resulted on 5/1/25 at 12:06 AM show R1 has acute minimally displaced right lateral fractures of his 10th and 11th ribs. The facility's Incidents by Incident Type log for the period of 3/1/25 to 5/14/25 show R1 fell on [DATE] and no other incidents were listed for R1 between his fall on 4/23/25 and 4/30/25. The facility was unable to provide a report regarding R1's injury of unknown origin discovered on 4/30/25. The facility's Abuse and Prevention Program shows the facility will file accurate and timely investigative reports. An injury should be classified as an injury of unknown source when the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury. The Department of Public Health will be notified of an injury of unknown source.

Based on interview and record review, the facility failed to investigate an injury of unknown origin for 1 of 3 residents (R1) reviewed for accidents in the sample of 3. The findings include: On 5/14/25 at 10:38 AM, V2, Director of Nursing (DON), said R1 did not fall on 4/30/25, the last time he fell prior to 4/30/25 was on 4/23/25. V2 said they attributed R1's rib fractures (discovered on 4/30/25) to his fall from 4/23/25. V2 said she doesn't have a full investigation regarding R1's rib fractures, she just has scratch paper about speaking to staff about possible incidents. On 5/14/25 at 11:09 AM, V3, Licensed Practical Nurse (LPN), said R1 fell on (Wednesday) 4/23/25. R1 was found at the end of his roommate's bed on the floor on his bottom, he was not in a weird position, and no objects were present that he would have fallen onto. V3 said R1's roommate said R1 was walking to the bathroom and fell to the floor onto his butt. V3 said she assessed R1, checked his range of motion and vital signs. V3 said R1 had no pain, bruising, or complaints. V3 said two CNAs (certified nursing assistants) used a gait belt and assisted R1 to a standing position and walked him to the bathroom. R1 did not have any complaints while walking and was not guarding. V3 said she took care of R1 again the following Monday (4/28/25) and noted nothing out of the ordinary. R1 did not complain of anything, he was quiet and did not complain of pain. V3 said V4, LPN, was R1's nurse on 4/30/25 from 7:00 AM until 7:00 PM and R1 complained of pain in his side. V3 said R1 did not have a new injury or accident between 4/23/25 and 4/30/25. On 5/14/25 at 11:46 AM, V4 said the CNA, V5, reported that R1 was guarding his right side and saying ow when she was toileting him on 4/30/25. V4 said she did a body check and R1 complained of pain with movement, especially bending to the side. R1 was grimacing and saying ouch. V4 said she informed V2, and the nurse practitioner (NP) and an X-ray was ordered. V4 said she is one of R1's primary nurses and R1 had no complaints of pain prior to 4/30/25, and his pain was noticeable that day with grimacing. V4 said nothing happened to him on 4/30/25; she looked at his record and saw his last fall was on 4/23/25. R1 had no other accidents, incidents, or injuries and there was no bruising or deformity noted on his skin check. V4 said it does not seem like R1's rib fractures happened when he fell on [DATE] because he did not have pain until 4/30/25, and that is what made her so concerned about his pain. V4 said she has no idea what could have triggered R1's rib pain on 4/30/25. On 5/14/25 at 12:48 PM, V5, said R1 is on her permanent assignment. V5 said on 4/30/25 when she returned from being off work for four or five days, R1 started complaining of pain and was grabbing his right side every time she moved him. V5 said R1 didn't know what was wrong and she notified V4 right away. V5 said no one had reported any injuries or falls or that R1 was having pain when she started her shift on 4/30/25; nothing was reported of which she knows. V5 said R1 was not having any pain the previous time she had cared for him. On 5/14/25 at 2:41 PM, V7, LPN, said she came in to work (night shift) and got report from (evening shift) V3, on 4/30/25. V7 said she works almost every night on R1's floor. V7 said she was told V4 discovered R1 started having right sided pain that day. V7 said R1 did not have any pain the night before when she cared for him. V7 said it was completely new, nothing happened to R1 the night before (4/29/25) when she cared for him. V7 said he was himself; he had no injuries and no falls. V7 said R1's pain was, a total shock to her. On 5/14/25 at 1:15 PM, V6, Physician, said it seems odd that R1 fell on [DATE] and began having pain on 4/30/25. V6 said she would think R1 would have had pain immediately after falling on 4/23/25 if he sustained rib fractures as rib fractures can be very painful. V6 said it's difficult to attribute R1's rib fractures found on 4/30/25 with his fall on 4/23/25. V6 said it's hard to believe R1's fall on 4/23/25 could have caused his rib fractures identified on 4/30/25 since he had no pain immediately. V6 said she saw R1 on 5/1/25 and R1 was splinting his ribs, grimacing in pain with movement, and there was even a little tear coming from his eye. V6 said she prescribed him stronger medications to help with his pain. V6 said at the point on 4/30/25 when R1 started having rib pain, the facility should have looked deeper into the cause of R1's pain. R1's Progress Notes show documentation on 4/23/25 at 9:43 PM that R1 was found on the floor in his room with no injury noted. The very next progress note documented was on 4/30/25 at 10:30 AM which shows R1 complained of pain to his right rib area and was noted to be holding his side and grimacing. R1's Admission Record dated 5/14/25 shows R1's diagnoses include, but are not limited to cognitive communication deficit, dementia, and metabolic encephalopathy. R1's Minimum Data Set, dated dated dated [DATE] shows R1 has severe cognitive impairment. R1's Medication Administration Record for 4/1/25 to 4/30/25 shows R1 had a pain rating of 0 for the entire month until 4/30/25 when he had a pain rating of 5. R1's Radiology Results obtained 4/30/25 at 2:08 PM and resulted on 5/1/25 at 12:06 AM show R1 has acute minimally displaced right lateral fractures of his 10th and 11th ribs. The facility's Incidents by Incident Type log for the period of 3/1/25 to 5/14/25 show R1 fell on [DATE] and no other incidents were listed for R1 between his fall on 4/23/25 and 4/30/25. The facility was unable to provide an investigation regarding R1's injury of unknown origin discovered on 4/30/25. The facility's Abuse and Prevention Program shows an injury should be classified as an injury of unknown source when the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury. Time frames for reporting and investigating abuse will be followed. The appointed investigator will attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Written statements will be reviewed along with any pertinent medical record or other documents. The final investigation report shall contain facts determined during the process of the investigation, review of medical record and interview of witnesses, and conclusion of the investigation based on known facts.

Based on interview and record review the facility failed to ensure pain and anxiety medications were documented on the Medication Administration Record for 1 of 3 residents (R1) reviewed for medications. The findings include: R1's face sheet showed he was admitted to the facility 2/14/23 with diagnoses to include Type 2 Diabetes Mellitus without complications, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Depression, hyperlipidemia, chronic kidney disease, anxiety disorder, dysphagia, anemia, atherosclerotic heart disease, abdominal aortic aneurysm, and peripheral vascular disease. R1's facility assessment dated [DATE] showed he has severe cognitive impairment. R1's January 2025 Physician Order Sheet showed, Ativan 0.5 mg give 0.25 tablet by mouth every 12 hours as needed for anxiety .Norco 5-325 mg Give 1 tablet by mouth every 8 hours as needed for pain . Tylenol Extra Strength Oral Tablet 500 mg . Give 2 tablets by mouth every 6 hours as needed for pain . R1's January 2025 eMAR (electronic Medication Administration Record) showed no documentation of administration of Ativan, Tylenol, or Norco. R1's Narcotic Count Sheet for Lorazepam (Ativan) 0.25 mg tablets showed doses signed out 1/3/25 at 8:00 PM and 1/5/25 at 4:30 PM. R1's Narcotic Count Sheet for Norco 5-325 mg showed doses signed out 1/2/25 and 1/3/25. On 1/10/25 at 9:35 AM, V3 (Licensed Practical Nurse-LPN) said she gave R1 a dose of Ativan on 1/3/25 due to his behaviors of yelling out, being restless, and anxious. V3 said controlled medications should be documented when administered on the eMAR and on the narcotic sign out sheet. On 1/10/25 at 11:24 AM, V6 (LPN) said she gave a dose of Ativan to R1 on 1/5/25 when he was anxious while not feeling well. On 1/10/25 at 10:20 AM, V2 (Director of Nursing-DON) said the nurses are expected to be signing controlled medications out on the eMAR (electronic Medication Administration Record) and on the narcotic sign out sheet. V2 said it is important for the nurses to sign the medication out on the eMAR so other nurses can easily see when the resident last received each medication. The facility's policy and procedure with revision date of April 2007 showed, Documentation of Medication Administration; Policy: The facility shall maintain a medication administration record to document all medications administered. Procedure: A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR). 2. Administration must be documented immediately after it is given .

Based on observation, interview and record review the facility failed to provide a clean, comfortable, homelike environment to 4 of 25 residents (R92, R28, R19, R84) reviewed for clean, comfortable, homelike environment in the sample of 25. The findings include: 1. On 9/9/24 at 8:31 AM, R92 was seated in a wheelchair in his room. Multiple areas of chipped paint were noted on the walls of R92's room. Large, grease-like stains were noted across the walls of R92's room. Large black scuff marks were noted on the wall behind R92's bed. A urinal, half-filled with urine, sat on the floor, by R92's bed. A strong odor of urine was noted in R92's bathroom. R92 stated, My bathroom stinks. My room is dirty looking. I don't live like this. I am a clean person. I have to empty that (urinal). They don't. 2. On 9/9/24 at 10:00 AM, V7 (Power of Attorney (POA) for R28) was in the facility, visiting R28. V7 stated, This place is filthy. The walls are chipped and dirty. V7 pointed to the wall by R28's bathroom. The wall had multiple scuff marks with missing, chipped paint. On 9/9/28 at 11:38 AM, V7 was seated in the first-floor dining room of the facility with R28. V7 pointed to ceiling tiles in the dining room. Two ceiling tiles, located on the northwest part of the dining room ceiling, were covered with a black-like substance. V7 stated, That's mold. On 9/10/24 at 11:30 AM, V5 Maintenance Director stated the facility recently hired a painter due to complaints about the chipped, scuffed walls located throughout the facility. V5 stated he was unsure when the last time the interior of the facility was painted. V5 stated, I took down two moldy ceiling tiles in the first-floor dining room this morning. I need to get better about monitor the ceiling tiles for mold. The facility's Quality of Life-Homelike Environment policy dated 5/2017 showed, The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: Clean, sanitary and orderly environment . 35174 3. On 9/10/24 at 10:15 AM, during the Resident Council Meeting, R19 and R84 stated they had problems with water dripping out of their air/heating units. R19 stated the thermostat in her room cover has been off for a long time. R19 stated the wires and innards are just sticking out. R19 stated the heat/air unit took a long time to change the temperature in the room. R19 and R84 stated the air conditioner/heater units would have water pool under them when they were running. R19 and R84 stated this has happened multiple times. R19 stated a pink basin was placed under the unit to catch the water and needed to be dumped once in a while. R84 stated housekeeping has had to place towels under the unit to collect the water. R84 stated she first time she knew about it was when she stepped in water walking around the end of the bed on the way to the bathroom. On 9/10/24 at 10:35 AM, R19's thermostat did not have a cover on it which had the internal wiring and controls exposed. The cover was not seen in R19's room. R19's air unit was running. The bottom edge of the unit felt damp with a few droples of water on it. On 9/10/24 at 10:45 AM, V5 Maintenance Director translated the interview with V13 Housekeeper. V13 stated R19 and R84's air/heating units have had problems with dripping water when they are running. V13 stated sometimes when they are running we have needed to leave towels and mop up the water when it happens. When it gets hotter out it is worse. On 9/11/24 at 10:30 AM, V5 stated the units in R19 and R84's rooms have had issues with lots of condensation when the air units are running. We need to make sure the drain tubes on the units are clear to drain the water outside which should stop the water dripping on the floor. The water should not be on the floor. We have used towels in R84's room. In R19's room we were using a basin to collect the water dripping from the unit. When it is hotter outside the units work longer which causes more condensation to occur. With the cooler weather it has not been an issue.

Based on interview and record review the facility failed to provide the necessary care and services for a resident that required a sleep study for 1 of 25 residents (R28) reviewed for necessary care and services in the sample of 25. The findings include: R28's Admission Record dated 9/29/23 showed R28 was admitted to the facility with diagnoses of insomnia, dysarthia (difficulty speaking), dysphagia, and CVA (cerebrovascular accident) with right arm/leg hemiplegia (weakness). R28's current care plan showed R28 was dependent on staff for toileting, repositioning, mobility, and transfers. On 9/9/24 at 10:00 AM, V7 (Power of Attorney (POA) for R28) was in the facility, visiting R28. V7 stated, He (R28) was supposed to have a sleep test done months ago but it was never done. They said it was because they didn't have a way to transport him (to the test) after 5 PM. I can't take him myself. He's dead weight. I can't lift him in and out of the car. I also live an hour away. R28's Nurse Practitioner (NP) note dated 12/4/23 showed, Sleep medicine study if ok with PCP (primary care physician) . A physician order for R28, dated 12/5/23, showed, Sleep study, r/o OSA (rule out obstructive sleep apnea). R28's nurses notes and appointment notes dated 12/6/23-3/16/24 were reviewed and showed a sleep study was never completed on R28. R28's nurses note dated 3/16/24 showed, Resident states he is not sleeping well at night. Resident states that current sleep regimen is not working. He was found with his head down on the table sleeping in the dining room. R28's nurses notes and appointment notes dated 3/17/24-5/2/24 were reviewed and showed a sleep study was never completed on R28. R28's nurses note dated 5/2/24 showed, Resident had an appointment today and needs to call to schedule for a sleep study . R28's appointment note dated 6/17/24 showed R28's outpatient sleep study, that had been scheduled for 6/17/24, was canceled by the facility due to the POA (V7) not being able to provide care to R28 during his sleep study testing. R28's notes dated 6/18/24-8/2/24 were reviewed and showed R28 a sleep study was never completed on R28. A physician order for R28, dated 8/2/24, showed V3 Assistant Director of Nursing (ADON), canceled R28's order for a sleep study. On 9/10/24 at 9:20 AM, V3 ADON stated R28's sleep study, ordered in December 2023, was ordered because R28 was having trouble sleeping. When V3 was asked why she canceled R28's sleep study order in August 2024, V3 stated, I am not sure. I might have been going through resident's charts and cleaning up old orders. V3 stated she canceled R28's order for a sleep study without contacting R28's physician. V3 stated, I know we attempted to schedule his study but there was some issue he couldn't go. No family to go with. He still needs the study. We could check to see if it could be done in-house or maybe a staff member could go with him. On 9/10/24 at 9:35 AM, V2 Director of Nursing (DON) stated any outpatient testing or studies ordered on residents should be scheduled as soon as possible. V2 stated, We have had residents go out (out of the facility) for a sleep study before. We have also had residents that have had sleep studies done in-house (in the facility). V2 stated, If family can't go to the test with the resident, I would see if the test could be done here (in the facility) or see if a staff member could go with the resident. The facility's Lab and Diagnostic Test Results-Clinical Protocol policy dated 9/2012 showed, The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. The staff will process test requisitions and arrange for test .

Based on observation, interview and record review the facility failed to identify a resident's pressure injury prior to the injury becoming a Stage 2. The facility also failed to implement pressure injury prevention interventions and pressure relieving interventions. These failures apply to 2 of 6 residents (R28, R120) reviewed for pressure injuries in the sample of 25. The findings include: 1. R28's Admission Record dated 9/29/23 showed R28 was admitted to the facility with diagnoses of dysarthia (difficulty speaking), dysphagia, diabetes mellitus, and CVA (cerebrovascular accident) with right arm/leg hemiplegia (weakness). R28's care plan dated 9/21/24 showed R28 was dependent on staff for toileting, repositioning, mobility, and transfers. The plan showed, Check all of body for breaks in skin and treat promptly as ordered by doctor. R28's Monthly Summary report dated 8/10/24 showed R28 had no pressure injuries or impairments to his skin. R28's nurse notes dated 8/11/24-9/8/24 showed no documentation of R28 having any pressure injuries or wounds. On 9/9/24 at 10:00 AM, V7 (Power of Attorney (POA) for R28) was in the facility, visiting R28. R28 was seated in a wheelchair. R28 appeared sleepy. When R28 was asked if he had any pain, R28 stated, My butt. R28 was unable to state when the pain to his buttocks started. V7 stated, I don't think he has any wounds to his butt. No one has reported that to me, but they get him up in the morning and don't lay him down again until after lunch. Some days, he is up in his wheelchair for hours. On 9/9/24 at 10:50 AM, R28 remained seated in a wheelchair. On 9/9/24 at 11:30 AM, R28 remained seated in a wheelchair. On 9/9/24 at 1:11 PM, V6 and V8 Certified Nursing Assistants (CNA) wheeled R28 into his room to provide cares to R28. V6 CNA was asked when she last toileted or provided incontinence care to R28, V6 stated, When I got him up this morning, around 8 AM. V6 and V8 transferred R28 via mechanical lift from his wheelchair to bed. V6 and V8 repositioned R28 in bed and removed R28's incontinence brief. R28's incontinence brief was saturated with urine. Multiple, large, creases were noted to the skin of R28's buttocks. A large, reddened area was noted to R28's sacral area with a quarter-sized, fluid-filled blister noted to R28's right inner sacral area. V6 CNA stated, His bottom is a little red, but he's had that. R28's Wound Assessment Report dated 9/10/24 showed R28 had a new, facility-acquired Stage 2 pressure injury to his sacrum, measuring 4.0 centimeters (cm) x 8.0 cm x unknown. On 9/10/24 at 10:15 AM, V9 Wound Nurse stated R28 is wheelchair bound and dependent on staff for most cares due to his CVA. V9 stated R28 is unable to reposition himself and is incontinent of bowel and bladder. V9 stated she initially assessed R28's sacral wound, on 9/9/24, as a MASD (moisture associated skin damage) that was caused by R28 most likely being wet with urine for periods of time. He is someone who need to be kept clean and dry. He needs to be repositioned every two hours. V9 stated that when she reassessed R28's sacral area on 9/10/24, she staged R28's sacral injury as a Stage 2 pressure injury due to her finding an opened blister to R28's sacrum. The facility's Prevention of Pressure Ulcers/Injuries policy dated 7/2017 showed, The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors . Inspect the skin on a daily basis when performing or assisting with personal care or ADLs (activities of daily living) . Keep the skin clean and free of exposure to urine and fecal manner . At least every two hours, reposition residents who are reclining and dependent on staff for repositioning . 33760 2. On 9/9/24 the facility provided the Pressure Report List. The document show, R120 with an admitted [DATE], has pressure injuries present on admission: stage 4 pressure injury to right hip and stage 3 pressure injury to sacral area. R120's Braden Scale dated 9/9/24 show R120 was a high risk for pressure injuries. R120's careplan date initiated 6/12/24 show Apply pressure reduction or low air loss therapy pressure relieving cushion when up in wheelchair. On 9/9/24 at 9:10 AM, R120 was in bed, a regular mattress was noted in her bed. R120 had a regular foam cushion to her wheelchair. On 9/10/24 at 8AM, (V9) Wound Nurse assessed and provided wound treatment to R120's pressure injuries to right hip stage 4 measuring 1.0 centimeters x1.0 cm x 0.30 cm and sacral area.sacral area stage 3- 2.5cm x.0.5cm x0.10cm V9 said R120's pressure injuries were in advanced stages of stage 3 and stage 4. V9 confirmed that R120 just have a regular mattress. This regular mattress is not indicated for stage 3 or 4. V9 said the facility will order a lo air loss mattress today. V9 said R120 prefers to stay in bed most of the time but will also get a better relieving cushion to R120's wheelchair On 9/10/24 at 1:25 PM, V2 (Director of Nursing) said the facility regular mattress is a pressure relieving mattress indicated only for up to stage 2, not appropriate for R120 who has stage 3 and stage 4 pressure injuries. The facility policy on Prevention of Pressure Ulcers/Injuries dated 2017 show, Support Surfaces and pressure redistribution, Select appropriate support surfaces based on residents mobility, continence, skin moisture and perfusion body size, weight and overall risk factors.

Based on observation, interview and record review the facility failed to provide treatment and services to residents with limited range of motion to to 2 of 10 residents (R120, R34) reviewed for limited range of motion in the sample of 25. The findings include: 1.R120's diagnoses include stroke and transient ischemic attack (TIA) with right sided limitations. R120's admitted [DATE]. On 9/9/24 on 9:10 AM, R120 was in bed. R120 was alert and smiling but aphasic (inability to express herself/communicate) R120's right hand was contracted closed fist and whole right hand curled inward. R120's latest Restorative assessment dated [DATE] show R120 has limitations to extremities including R120's upper extremities. On 9/10/24 at 8:25 AM- (V4) previous Restorative Nurse said R120 was admitted from home due to stroke (admitted [DATE]), with right hand contractures. R120 was assessed at that time due to limited range of motion to her right hand but R120 was not on any Restorative Program (range of motion-ROM). R120 also has no device to her contracted right hand. ROM should have been implemented to prevent further decline. V4 said she will have therapy assessed R120 today. On 9/10/24 at 11 AM, V4 said R120 was just now placed on passive ROM to right hand and AROM to left hand. On 9/10/24 V4 and V12 (present Restorative Nurse) presented this surveyor an Occupational Therapy note dated 9/10/24 (today) documenting, R120 will now have right hand splint. The facility policy entitled Restorative Nursing Services dated 7/2017 show, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. 45540 2. R34's Restorative: ROM (range of motion): AROM (active range of motion) to all extremities/all joints x10 reps twice daily do PROM (passive range of motion) if unable to preform AROM. Look Back 30 days. On 8/18/2024, 8/22/2024, 9/1/2024, 9/8/2024 R34 only received AROM one time on those days. On 9/10/2024 at 9:46AM, V4 Registered Nurse Previous Restorative Nurse stated [R34] is part of restorative services. V4 said [R34] should be seen twice a day for restorative AROM or PROM. V4 said the restorative services provided should be documented in the computer twice a day. V4 said if a resident is unavailable staff should follow up with the resident another time to make sure the resident receive services twice a day. The facility's Restorative Nursing Services policy revised July 2017 states residents will receive restorative nursing care as needed to help promote optimal safety and independence.

Based on observation, interview, and record review the facility failed to ensure a resident did not attempt to exit the facility out a fire exit door, and failed to transfer a resident with a gait belt which applies to 2 of 25 residents (R39, R104) reviewed for safety in a sample of 25. The findings include: 1. R39's Facility assessment dated [DATE] showed R39 to be a [AGE] year old male male with moderate cognitive deficits. This Assessment showed R39 was admitted to the facility with diagnoses which include: cognitive communication deficit, hemiplegia an hemiparesis following a cerebral infarction, and history of traumatic brain injury. On 9/9/24 at 12:10 PM, R39 was attempting to go out the South East fire exit door in his wheelchair at the end of the hallway. The exit door is adjacent to R39's room. R39 pushed the release bar to open the door. The door alarm was not going off when the door was opened. There was no staff in the hallway at the time R39 opened the door. R39 was in his wheelchair having difficulty exiting the door. V14 Human Resources Manager was alerted by this writer to check on R39 as he attempted to exit the doorway. V14 was able to stop R39 from exiting the door. V14 redirected R39 into his room. V14 stated the alarm should have gone off for the door being opened. At the top of the metal doorway the door sensor was hanging down and a wire was sticking out approximately 6 inches. On 9/9/24 at 12:20 PM, V5 Maintenance director arrived at the doorway. V5 opened the door, and the alarm did not go off. V5 pointed to a yellow light on the ceiling. V5 stated that light should flash, and it should have an alarm go off. V5 stated he did not know what happened to the alarm sensor. V5 stated the alarm had been working during morning rounds this morning. V5 stated the sensor may have been damaged and wire looked like it had been hit or pulled by something. V5 stated they had brought in some of the personal protective equipment (PPE) boxes this morning from the storage container (pointed to container in the parking area), and it could have been hit by one of the bigger boxes. V5 stated the alarms should be working all the time. On 9/9/24 at 12:45 PM, V15 (R39 Family) was interviewed with R39 present. V15 stated R39 used to garden a lot, and they have tomato plants we check on. V15 asked R39 if he was trying to go see the tomato plants. R39 nodded yes to the question. On 9/10/23 at 11:35 AM, V2 Director of Nursing stated R39 has had no previous exit seeking behaviors. V2 stated the door alarm should have activated when R39 attempted to go out the door. The facility Door Alarm Policy dated 12/2023 showed .the door alarm system needs to be maintained in proper repair and equipment is functioning appropriately 33760 2. On 09/9/24 at 9:25 AM, V11 (Ccertifide Nursing Assistant-CNA) was in R104's room to transfer R104 from the bed to the wheelchair. R104 scooted himself at the edge of the bed and tried to boost himself up by putting both of his hands in the wheelchair arms in front of him. R104 tried to stand up but then sits back down unable to pull himself up. R104 tried again but still unable to pull himself to standing position, then said to V11, I think I need help V11 (CNA) applied a gait belt around R104 waist, then pulled R104 up by pulling the back of R104's pants then placed R104 in his wheelchair. V11 did not use the gaitbelt that was already in R104's waist to transfer R104 to his wheelchair. R104's careplan dated 6/8/24 show, (R104) has terminal diagnosis of Multiple Sclerosis-hospice services . R104 has intention tremor, nystagmus, other tremors, poor coordination, ataxia, (poor muscle control that causes clumsy movements) history of falls. On 9/10/24 at 1:25 PM, V2 (Director of Nursing) said staff should use gait belt for safe transfers for both staff and the resident. The facility policy entitled Safe Lifting and Movement of Residents dated 7/17 show, In order to protect the safety and well being of staff and residents and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. 4. Staff responsible for direct resident care will be trained in the use of .(gait/transfer belts.)

Based on observation, interview, and record review the facility failed to maintain resident catheters below the level of the bladder and keep the drainage bag off the floor. This applies to 3 of 8 (R66, R90, R39) residents reviewed for catheters in the sample of 25. The findings include: 1. On 9/9/2024 at 11:09AM, R66's urinary catheter drainage bag was observed hanging on the resident's walker level with the resident's bladder. Urine was observed sitting in the catheter tubing with sediment present in the tubing. On 9/10/2024 at 11:53AM, V2 Director of Nursing (DON) said catheter bags should be kept below the level of the resident's bladder to prevent infections. R66's Order Summary Report dated 9/9/2024 shows an order for Foley Catheter, change monthly and PRN (as needed). 33760 2. On 9/9/24 at 11:00 AM, R90 was sitting in his reclined wheelchair in his room. R90's urinary catheter drainage bag was tucked to R90's right side hip level above the level of the bladder. At 12: 15 pm- R90 was still in his room watching TV, catheter bag remained in the same position, tucked on his right side hip level above the level of the bladder, urine was noted backflowing in the tube. V10 (Registered Nurse) who was with this surveyor said the catheter bag needs to be lowered, below the level of the bladder to prevent from urine backing flow to prevent infection. R90's latest careplan show, The resident has a Foley Catheter 16fr 10cc Balloon: Neurogenic bladder, has history of Urinary Tract Infections (UTI's.) 35541 3. R39's Admission Record dated 5/31/24 showed R39 was admitted with diagnoses of a urinary tract infection and benign prostatic hyperplasia with lower urinary tract symptoms. R39's care plan dated 6/5/24 showed R39 had a urinary catheter placed to drain his urine. On 9/9/24 at 9:03 AM, as this surveyor entered R39's room, V6 Certified Nursing Assistant (CNA) was repositioning R39 in his wheelchair. V6 then placed R39's (uncovered) urinary catheter drainage bag directly on the floor, underneath the seat of R39's wheelchair. On 9/10/24 at 9:35 AM, V2 Director of Nursing stated urinary catheter bags are to be kept off the floor for to prevent infection. The facility's Catheter Care Urinary policy revised September 2014 states, the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. The facility policy entitled Catheter Care Urinary revised 9/2013 show, The purpose of this procedure is to prevent catheter- associated urinary tract infections. 3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on observation, interview and record review the facility failed to wash hands and change gloves and failed to implement Enhance Barrier Precaution (EBP) for 2 of 25 residents ( R104, R39) reviewed for infection control in the sample of 25. The findings include: 1. On 9/9/24 at 9:10 AM, V11 (Certified Nursing Assistant-CNA) was providing incontinence care to R104. R104 had a bowel movement. After providing incontinence care and without changing her soiled gloves, V11 turned R104 side to side and applied new incontinent brief, applied R104's blanket, pulled the privacy curtain, opened R104's closet looking for clothings then said she needs to go out and get something. V11 then removed her soiled gloves and left R104's room without washing her hands. On 9/11/24 at 8:10 AM, V3 (Assistant Director of Nursing -ADON) said staff should change their gloves and wash their hands when completing dirty task to clean task, when the gloves is visibly soiled and when a tasks was completed wash hands to prevent the spread of infection. The Facility Policy entitled Personal Protective Equipment dated 9/2010 -Using gloves, Purpose the use of gloves, 1. To prevent the spread of infection. Handwashing/Hand Hygiene dated 8/2015 show, This facility considers hand hygiene the primary means to prevent the spread of infections. 35541 2. The facility's Residents on Enhanced Barrier Precautions list dated 9/9/24 showed R39 was on Enhanced Barrier Precautions (EBP) due to having a urinary catheter in place. On 9/9/24 at 9:03 AM, an EBP sign hung on the door to R39's room. As this surveyor entered R39's room, V6 Certified Nursing Assistant (CNA) was repositioning R39 in his wheelchair. V6 then placed R39's urinary catheter drainage bag on the floor, underneath the seat of R39's wheelchair. V6 CNA wore gloves but no gown. V6 stated, I just did catheter care and peri-care (incontinence care) on (R39). When V6 was asked if R39 was on Enhanced Barrier Precautions, V6 stated, No, (R39) is not. His roommate is because he (the roommate) has a (urinary) catheter. On 9/10/24 at 9:35 AM, V2 Director of Nursing stated, Anyone with wounds, IV lines (intravenous), or someone that has a (urinary) catheter should be on Enhanced Barrier Precautions. Staff are to wear gowns and gloves when providing cares to residents. The facility's Enhanced Barrier Precautions (EBP) policy dated 3/2023 showed, EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Indwelling medical devices, regardless of MDRO (multidrug-resistant organisms) colonization status (central lines, urinary catheters, feeding tubes, hemodialysis catheters, tracheostomies and ventilators) . The policy showed staff are to don a gown and gloves prior to providing high-contact activities, such as urinary catheter care or incontinence care, to residents.

Based on observation, interview, and record review the facility failed to ensure the residents received the correct portion size of fried potatoes, mixed vegetable, and pureed Italian sausage during the lunch meal for all residents receiving meals in the facility. The findings include: The facility data sheet dated 6/15/24 shows 126 residents reside in the facility. On 6/15/24 at 12:06PM, V5 (Dietary Aide) was plating the lunch meal. There were three large pans on the steam table: one with Italian sausage, one with mixed vegetable, one with shredded potatoes. There were four smaller pans, one with chopped/ground Italian sausage, pureed Italian sausage and bun, mashed potatoes, and pureed vegetables. The large pan of mixed vegetables had a spoodle with a white handle resting in it. V5 verified this spoodle was a 3 ounce serving size (not the recommended 4 ounce). V5 used the spoodle to scoop up a level serving size of the mixed vegetables and put it on the plates. V5 used his gloved hand to measure a handful of shredded potatoes and put the handful of potatoes on the plate. V5 filled several plates with an Italian sausage and bun, spoodle of vegetables, and a handful of potatoes. V5 was asked how much the serving size of potatoes should be and said, I just give them a handful. I give them a little more than I'm supposed to. The pureed mixed vegetable, mashed potatoes, and chopped Italian sausage had a blue ice cream like scoop in it that V5 used to plate the servings. The pureed bread and Italian sausage had a green handled ice cream like scoop that V5 used to serve this item. V5 said all the residents received the shredded potatoes, except the pureed diets who got mashed potatoes. All the residents got the mixed vegetable except those on pureed diet, who received the pureed mixed vegetable. On 6/15/24 at 12:22PM, V3 (Certified Dietary Manager) looked at the food items on the steam table and the utensils being used to measure the items. V3 verified the pureed vegetables had a blue scoop, measuring 2 ounce (1/4 cup)of vegetable, the meat had a green scoop measuring 2 2/3 ounce of meat/bread, and the spoodle in the regular vegetables measured 3 ounces. V3 said they should be following the recommended serving size listed in the book provided, which also included the menu and recipes for the food items. V3 looked in the book and said the serving size should have been 4 ounces, or 1/2 cup, for the mixed vegetables (not 3 ounces). The pureed mixed vegetables should have been 4 ounces (not the 2 ounces served). V3 said the pureed Italian sausage serving size should be two ounces. V3 said the pureed italian sausage also had the bun pureed with it. V3 was asked if the 2 ounce portion included adding the bun to the meat and serving them together? V3 said no, I'm not sure what the serving size would be then. On 6/15/24 at 12:35PM, V3 said [V5] should not have been measuring the shredded potatoes with his hand. He should be using the recommended scoop. V3 said yes the 2 ounce scoop would be the wrong size for the pureed sausage and bun because the bread was added to the meat and pureed together. The total volume of food changed. On 6/15/24 at 12:40PM, V5 said he should have followed the book to determine how much the serving size of each lunch item should have been. V5 said there is also a sheet hanging on the the wall that tells the serving sizes of utensils. V5 verified he pureed the bun and meat together, and verified he used the 2 ounce scoop (green handle) to dish the pureed meat and bread. V3 (Dietary Manager) was present and looked at the meat and bun pureed mixture. V3 looked at the scoop used for meal service and said it was 2 and 3/4 ounce. V3 said the correct serving size of the pureed Italian sausage and bun should have been 5 and 2/3 ounce or 3/4 cup. On 6/15/24 at 1:40PM, V4 (Registered Dietician) said the menus provided to the facility are created by a dietician. The menu and serving size is designed to ensure the recommended nutrients are given. The serving size is listed for each menu item and is contained in a book in the kitchen. The facility is expected to follow the menu, and the expected serving size. The facility is also supposed to serve food with the appropriate utensil. Utensils are consistent for portion control, hands would not be. V4 said if the facility pureed the Italian sausage and bun together, they would add the serving sizes for each item together, and this would tell them how much of the combined food item should be served. In this case, they would add the recommended portion size of the protein (Italian sausage), with the recommended serving size of the starch (bun) to determine how many ounces to give. V4 said, no 2 ounces would not be an appropriate serving size for the pureed Italian sausage and bun. The goal of the recommended serving size is to meet the nutritional needs, including the recommended vitamins, mineral, and protein needs of the resident. On 6/15/24 at 3:12PM, V2 (Director of Nursing) said yes, they should be following the recommenced serving sizes for the food items based off the menu recommendations. The menu dated 6/15/24 shows the lunch meal consisted of Italian sausage, fried potatoes with onions, seasoned zucchini, chilled pears, hot dog bun, ketchup/mustard, coffee/tea, condiments. The pureed bread serving recommendation in the dietary book shows pureed bread- serving size, 2 slices = # 8 scoop. The pureed Italian sausage serving recommendation in the dietary book shows serving size #12 scoop. This also includes directions to add liquid and thickener when pureeing. It does not include directions to add bread. The fried potatoes and onions serving recommendation in the dietary book shows serving size #8 scoop = 1/2 cup. The seasoned zucchini serving recommendation in the dietary book shows serving size: #8 scoop = 1/2 cup. The pureed seasoned zucchini serving recommendation in the dietary book shows serving size: #8 scoop (1/2 cup). The facility provided a dietary list printed 6/15/24, that showed all residents received regular, ground, or pureed lunch except R20 who is NPO. The facility policy dated 9/26/23 Menu & Nutritional Adequacy pureed Food Preparation shows 2. Standardized recipes will be sued to produce pureed food to maintain nutrient content. 6. Proper scoop sizes will be used. The facility policy dated 9/26/23 Portion Control shows: 1. Dietary staff will serve portions to residents based on planned menus that list the portion size for each food item. 3. Proper serving utensils (ie, scoops, ladles, or spoons) are used to assure accurate portions are served. The facility policy dated 9/25/23 Menu Requirements shows: Menus are developed to meet the Daily Recommended Intake national guidelines, regional food preferences, resident input, and regulatory parameters.

Based on observation, interview and record review the facility failed to have a narcotic pain patch available for a resident as ordered. This failure applies to one of three residents (R1) reviewed for pain medications in the sample of ten. The findings include: The facility face sheet for R1 shows he was admitted to the facility on [DATE] with diagnoses to include spinal stenosis, bipolar disorder, emphysema, and encephalopathy. The facility assessment dated [DATE] shows R1 to be cognitively intact and is dependent on staff for his care. The December 2023 Physician orders shows an order for a narcotic pain patch to be applied and replaced every 72 hours. The medication administration record for December 2023 shows no pain patch was applied on 12/24/23 or 12/25/23. On 1/10/24 at 1:00PM, R1 said he went without his pain patches for two days and was told the pharmacy had run out of them. On 1/10/24 at 9:30 AM, V9 Licensed Practical Nurse (LPN) said she had placed a pain patch on R1 on 12/26/23, the day the patches were delivered by the pharmacy. V9 said the patches had been reordered but not delivered. V9 said when one pain patch is left in his supply, they should be reordered from the pharmacy. On 1/10/24 at 12:25 PM, V11 LPN said when the pain patches need to be reordered when the supply is down to two to ensure they are delivered in time from the pharmacy. On 1/10/24 at 10:15 AM, V2 Director of Nursing (DON) said the patches were delayed at being delivered due to an insurance issue. V2 said she was unable to see when the pain patches were reordered. V2 said the facility will pay for the patches for R1 until the insurance authorizes them. V2 said the patches should be available for the residents use. On 1/10/24 at 11:09 AM, V10 facility pharmacist said they needed to get prior authorization from R1's insurance company and Physician when they were alerted R1 needed more pain patches. V10 said more patches can not be issued until they get the prior authorization from the insurance or the facility agrees to pay for them. The facility controlled drug receipt form shows the facility used the last pain patch for R1 on 12/21/23 and a new refill was not received until 12/26/23. The facility policy dated July 2016 for Medication and Treatment Orders shows orders for medications and treatments will be consistent with principles of safe and effective order writing. 11. Drugs and biological's that are required to be refilled must be reordered from the issuing pharmacy not less than 3 days prior to the last dosage being administered to ensure that refills are readily available.

Based on observation, interview, and record review the facility failed to provide privacy to a resident while providing personal care. This applies to one of three residents (R1) reviewed for privacy in the sample of 16. Findings include: The facility face sheet for R1 shows diagnosis to include spinal stenosis, benign prostatic hyperplasia with lower urinary tract symptoms and schizoaffective disorder. The facility assessment dated [DATE] for R1 shows him to have severe cognitive impairment and requires maximum assistance with all care. On 11/15/23 at 11:00 AM, R1 was being provided perineal care by V8 and V9 both Certified Nursing Assistants (CNA). R1 was completely naked and being turned side to side. The privacy curtain between the two beds was not pulled. R1's room mate and V3 Hospice Registered Nurse (RN) were both in the room and had a clear view of the care being provided to R1. On 11/15/23 at 11:10 AM, V3 Hospice RN said she wished the staff had closed the privacy curtain while providing care to R1. V3 said the situation made her uncomfortable. On 11/15/23 at 11:05 AM, V8 CNA said she should have pulled the privacy curtain while providing care to R1 for his privacy. On 11/15/23 at 11:30 AM, V9 CNA said the privacy curtain should have been pulled while providing care to R1. On 11/15/23 at 1:10 PM, V2 Assistant Director of Nursing said she would expect the staff to close the privacy curtain while providing care to a resident to protect the residents privacy. The facility policy with a revision date of 10/2017 for personal privacy shows the facility will strive to protect the resident's privacy regarding his or her personal care.

Based on interview and record review the facility failed to continue an ordered antibiotic when a resident returned from the hospital. This applies to one of three residents (R1) reviewed for medications on the sample list of 16. Findings inlcude: The facility face sheet for R1 shows diagnosis to include spinal stenosis, benign prostatic hyperplasia with lower urinary tract symptoms and schizoaffective disorder. The facility assessment dated [DATE] for R1 shows him to have severe cognitive impairment and requires maximum assistance with all cares. The hospital records for R1 show he was in the hospital from 10/24/23 to 10/27/23 with a diagnosis of pyelonephritis (Kidney infection). The final discharge medication list from R1's 10/27/23 hospital discharge shows an order for cefdiner (antibiotic) to be given twice a day for the next 5 days starting on 10/27/23. The October Medication Administration Record (MAR) shows the medication was not started until 10/31/23. (4 days after the ordered start date) The Physician Order Sheet for R1 dated October 2023 shows the order for the antibiotic was not started until 10/31/23. On 11/15/23 at 10:35 AM, V2 Assistant Director of Nursing said when R1 came back from the hospital on 10/27/23 the order for the antibiotic was not transcribed onto the current orders and R1 did not receive his antibiotic right away. On 11/15/23 at 1:10 PM, V2 said she expects the staff to transcribe all ordered medications. On 11/16/23 at 1:30PM, V19 R1's Physician said the nurses should have started the antibiotic for R1 when he came back from the hospital as it was ordered. The facility policy with a revision date of July 2017 for reconciliation of medications on admission shows 2. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interuption, in the correct dosages and routes, during the admission/tranfer process.

Based on observation, interview, and record review the facility failed to ensure a resident was free from abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 7. This failure resulted in R2 showing visible distress when recalling the incident. The findings include: On 10/12/22 at 9:50 AM, V4 Certified Nursing Assistant stated I was on shift when R3 came up to me and said there is a black guy in there (motioning toward the dining room) touching a white lady where he shouldn't. V4 said she went to the dining room and R1 was sitting next to R2 side by side. V4 said she did not see any touching at that time, but pulled R2 to the side and asked her if R1 touched her. V4 said R2 said he brushed my chest with his hand. V4 said she reported this to the nurse. V4 said she interviewed R1 but he just stared at her. V4 said R1 has touched female staff in the past. On 10/12/22 at 9:55 AM, R3 said he was in the dining room and saw a black guy fondling a white woman R3 said the black guy was sitting right next to her, and she looked like she was out of it. R3 said he left the dining room and told a staff member. On 10/12/22 at 11:07 AM, R2 was in her room watching TV. R2 was talking to this surveyor and answering questions appropriately. R2 was friendly and alert with her head up and looking directly at this surveyor when talking about the activity page in front of her. R2 was in a good mood, easily conversing, and said she was happy with the staff and they helped her when she needed. When asked if anyone had touched her inappropriately before, R2 immediately lowered her head, avoiding eye contact, and quietly said yes, he touched me in my breast. R2 appeared visibly upset, closed her eyes, kept her head bent down, and would not respond to any more questions. R2 visibly shut down mid conversation. R2 nodded her head when asked if awake, but would not respond further. The facility's Resident Interview with R3 dated 9/12/22 shows He states he saw the male resident reach over and touch the female resident where he shouldn't have. The facility's Statement from V4 dated 9/11/22 shows resident came up to me and told me that he saw the black man in the dining room touch R2 where his is not supposed to. I immediately went to the dining room to separate the residents and they were both sitting at the table, but I did not personally see R1 touch R2. I took R2 into a private place to ask her what happened. She told me that she was sitting at the table with R1 and he reached over and swiped his hand across her boob. On 10/12/22 at 10:50 AM, V5 Registered Nurse said R3 is alert and oriented times three and has no behaviors or history of making false accusations. V5 said R2 is alert, answers questions appropriately and able to make her needs know. V5 said R1 is alert to self only, non verbal, and is able to propel self through the hallway. V5 said R1 likes to reach out and grab toward the bottom of your shirt. V5 stated you watch out for him and quickly move when he reaches out. On 10/12/22 at 11:00 AM, V6 Licensed Practical Nurse said R1 has behaviors of being sexually inappropriate toward staff. V6 said he tries to reach out and grab your bottom. V6 stated I know to watch out for R1. On 10/12/22 at 9:32 AM, V3 Certified Nursing Assistant said she heard that R1 touched R2 in the dining room. V3 said R1 has touched staff before and is mobile and able to reach out. R1's Care Plan dated shows The resident displays inappropriate sexual behaviors towards others .7/8/22 inappropriately grabbing at staff during showers .9/11/22 resident reached out and touched another residents chest .9/16/22 resident continues to attempt to inappropriately touch female staff during cares. R1's Progress Notes dated 9/18/22 shows writer standing at med cart, R1 propelling self past writer, than reached out in attempt to touch writer inappropriately. On 10/12/22 at 12:00 PM, V1 Administrator said didn't substantiate the abuse because the resident didn't remember doing it. V1 said based on one statement she obtained the touching happened. V1 said the intervention put in place after this event was to make sure residents were not left alone in common areas with R1. V1 said to her knowledge she was not aware of any behaviors since this incident. The facility's Abuse Policy dated 11/28/17 shows this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment.

Based on interview and record review, the facility failed to notify a resident's physician of a change in condition for 1 of 3 residents (R1) reviewed for physician notification in the sample of 3. This failure resulted in delay of treatment for [REDACTED]. The findings include: R1's electronic admission record printed on [DATE] showed R1 was admitted to the facility with [DIAGNOSES REDACTED]. R1's local hospital records dated [DATE] showed R1 was discharged from the hospital in fair condition and was alert and oriented x 4 with some confusion. R1 was not receiving oxygen treatment upon discharge from the local hospital. R1's nursing progress notes dated [DATE] showed at approximately 12:30 AM, V9 (Certified Nursing Assistant-CNA) informed V3 (Registered Nurse-RN) that (R1) complained of shortness of breath, oxygen saturation in low 80's. Increased oxygen to 3 liters, same oxygen blood level. Increased oxygen to 4 liters nasal cannula, oxygen blood level raised to ,[DATE]%. (R1) stated he felt better, breathing not as labored. Frequently check on (R1) and oxygen levels ranging from ,[DATE]% on 4 liters nasal cannula. At around 1:15 AM, V3 checked on (R1), noted labored breathing and oxygen saturation levels of 76% on 4 liters nasal cannula, V3 called V10 (facility medical director) at 1:22 AM to inform of situation, she ordered for (R1) to be sent to local hospital for evaluation. V3 went to assess (R1) and obtained vital signs. Blood pressure ,[DATE] and oxygen level 60%. V3 noted (R1) stopped breathing, performed sternum rubs. Local emergency response arrived at that time and initiated cardiopulmonary resuscitation and life saving measures. R1's physician death summary dated [DATE] showed R1 expired on [DATE] due to complications from cardiopulmonary arrest. On [DATE] at 3:00 PM, V3 stated, A change in condition is described as any change in vital signs, altered mental status or if a resident has any change from baseline. When a change in condition is identified, I check vital signs and then try to correct them if I am able to. We have standing orders to apply oxygen at 2 liters to keep oxygen levels above 90%. If we have to go above that, we administer the oxygen and call the physician. I would call the physician in the morning if I can get the resident stable even if I have to go above the 2 liters. On [DATE] at 3:35 PM, V9 CNA stated, We noticed (R1) was having a hard time breathing and V3 started monitoring him, she eventually called 911 but it wasn't for awhile after I reported the change to her. On [DATE] at 10:50 AM, V6 (Licensed Practical Nurse-LPN) stated, A resident that needs oxygen therapy titrated up to 4 liters is definitely a change in condition. Our policy is to assess the resident and then notify the patient's physician or on-call doctor. The entire process should only take about 5 minutes as this is an urgent situation. On [DATE] at 11:40 AM, V2 (Director of Nursing-DON) stated, For a resident with a change in condition, the physician should be notified as soon as possible. Standing orders can be initiated for all newly admitted residents. We do not have any type of standing orders that are specific to disease processes, just general admitting standing orders. Oxygen therapy is not on our standing orders. On [DATE] at 2:15 PM, V8 (Nurse Practitioner) stated, I would expect to be notified for the facility to obtain an order for [REDACTED]. The facility's Change in a Resident's Condition or Status policy with a revision date of ,[DATE] showed, Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status .d. significant change in the resident's physical/emotional/mental condition. e. need to alter the resident's medical treatment significantly .2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. b. Impacts more than one area of the resident's health status.

Based on interview and record review the facility failed to monitor a resident's skin under a medical device, asses a wound, identify a wound as a pressure injury, and put interventions in place to prevent a pressure injury. This failure resulted in R1 developing unstageable pressure injuries to R1's right foot from a medical device which required surgical intervention. This applies to 1 of 3 residents (R1) reviewed for pressure in the sample of 3. The findings include: On (MONTH) 30, 2019, at 10:50 AM, V6 (Director of Nursing) at the assisted living center where R1 is currently residing, said R1 was transferred here on (MONTH) 17, 2019, with what was reported as a blister on R1's right foot. V6 stated R1 had a horrible wound on R1's right foot, it was down to the bone and tendon. R1's wound was beyond a blister, it was unstageable. R1 has since had to be admitted to the hospital for surgery of that wound, a wound vac placed, and has had intravenous antibiotics. On (MONTH) 29, 2019, at 1:36 PM, V5 (Registered Nurse for R1's Orthopedic Doctor) said R1 had an open reduction internal fixation surgery on (MONTH) 6, 2019, to R1's right ankle. V5 said R1 had one surgical incision to the outer aspect of R1's right ankle. V5 said R1 had a soft cast initially after surgery which was removed at R1's follow up appointment on (MONTH) 19, 2019. V5 said at that follow up appointment, R1's sutures were removed and steri strips were applied to the incision. V5 said there was only the one surgical incision at that time and a surgical boot was applied. V5 stated on (MONTH) 26, 2019 ( 7 days after the surgical boot was applied) V5 received a phone call from V3 (facility Wound Licensed Practical Nurse -LPN) who stated they had not taken the surgical boot off of R1 or did (sic) a dressing change since (MONTH) 19, 2019, and asked V5 what should V3 do. V5 stated I told V3 to take off the boot and look at the incision and change the dressing. I told V3 the dressing should be changed daily and the boot should be removed at least daily to inspect the skin and then reapplied. There was no mention of any wounds at that point. V5 stated the expectation is the facility would remove the surgical boot daily to inspect the skin and complications of not removing the boot could be pressure injuries. V5 said R1 had a follow up appointment on (MONTH) 2, 2019, and R1 had a wound on R1's right outer foot. V5 stated the wound was not part of the surgical incision, it was a red, open blister like wound caused from the boot rubbing on R1's foot. The doctor gave orders to take the boot off at night and leave open to air, and put the boot on during the day. R1's wound is a pressure injury from the boot and by the time R1 left the facility, R1's tendon was exposed. R1 has had to have a wound vac applied to the wound and has had surgery done on the wound as well. On (MONTH) 29, 2019, at 9:56 AM, V4 (Registered Nurse) said R1 had a right ankle fracture and was at the facility for physical therapy. V4 stated R1 had a wound R1 got from the boot on R1's ankle. On (MONTH) 29, 2019, at 10:01 AM and 1:45 PM, V3 said R1 initially had a soft splint on her right lower leg (which was not to be removed) and then went to a follow up appointment on (MONTH) 19, 2019 and came back with a boot on. V3 stated she did not remove the boot on (MONTH) 19, 2019 to do an assessment of R1's surgical wound, the first time she removed the boot and did a skin assessment was on (MONTH) 26, 2019. V3 said when she did R1's wound assessment on (MONTH) 26, 2019, R1 had a surgical incision on her right outer ankle and a wound on her right outer foot. V3 stated R1's wound looked like a blister from the boot. On (MONTH) 29, 2019 at 1:45 PM, V3 stated yes R1's wounds could have developed during the period (MONTH) 19, 2019 through (MONTH) 26, 2019 (the 7 days without a wound assessment). R1's Progress Note dated (MONTH) 8, 2019, documents R1 was admitted to the facility on (MONTH) 8, 2019, with [DIAGNOSES REDACTED]. This same note documents R1 is alert and oriented times three (aware of person, place, and time) and is there (the Facility) for therapy and pain interventions and plans to go back home with R1's husband. R1's facility face sheet shows R1 was discharged on [DATE]. R1's Wound Assessment Details Report on (MONTH) 12, 2019, for R1's right lower leg front wound, shows a picture of R1's right lower extremity in a soft cast with wound information of surgical incision, present on admission, intact skin=100% and no measurements. R1's Wound Assessment Details Report on (MONTH) 19, 2019, for R1's right lower leg front wound, shows a picture of R1's right lower extremity in a surgical boot with wound information of surgical incision, present on admission, intact skin=100% and no measurements. R1's Wound Assessment Details Report on (MONTH) 26, 2019, for R1's right lower leg front wound, shows a picture of R1's right lower extremity with steri strips covering an incision on R1's right outer ankle and a second wound area distal to the surgical incision on R1's right outer foot containing 25% white [MEDICATION NAME] slough. This report did not identify the type of the distal wound. R1's Wound Assessment Details Report on (MONTH) 16, 2019, (the day before R1 discharged ) for R1's right lower leg front, shows the distal wound has deteriorated to 65% slough and 35% necrotic tissue. R1's Wound Assessment Detail Report for R1's right inner ankle dated (MONTH) 26, 2019, shows a wound measuring 6.0 by 1.0 by 0.1 cm (centimeters). R1's Wound Assessment Detail Report dated (MONTH) 1, 2019, shows the wound bed now has 70% slough. On (MONTH) 9, 2019, the Wound Assessment Detail Report shows the wound has now deteriorated to slough and necrotic tissue. The reports identify the wound as a surgical incision (per the orthopedic nurse the only surgical incision was on R1's right outer ankle). R1's Progress Notes and Daily Skilled Progress Notes from (MONTH) 19, 2019 through (MONTH) 26, 2019 (7 days) does not show R1's surgical boot was removed and R1's skin under the boot was assessed. R1's Telephone Encounter Note dated (MONTH) 26, 2019 ( a telephone conversation with V5 and V3) shows V3 stated the dressing has not been changed since the 19th of (MONTH) when the patient was seen by the orthopedic doctor, asked V3 if she has assessed the incision and V3 stated no because it was covered. R1's Admission Skin Review from the facility R1 transferred to on (MONTH) 17, 2019 shows R1 was admitted with an unstageable wound to anterior right foot. The facility's Skin and Wound Care Protocol Guidelines show the licensed nurse who admits a resident should complete a comprehensive skin assessment on all resident admissions if there are dressings, remove all dressings and measure all injuries .document all injuries. Include location, stage, width, length, depth, exudate. The facility's Pressure Ulcers/Injuries Overview Policy dated (MONTH) (YEAR) shows Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes the injury should be staged using the staging system.

A. Based on observation, interview and record review the facility neglected to follow their written policy/procedure for residents who develop pressure ulcers. The facility did not accurately document the presence of wounds, the effectiveness of the treatment provided or seek alternative treatment as the wounds worsened. R7 had no treatment orders for a STAGE II coccyx pressure ulcer which increased in size between 2/12/11 to 5/11/2011. The neglect for R7 ' s pressure ulcer began on 2/12/11 when treatment for [REDACTED]. R9 had an unstageable left heel pressure ulcer which had no pressure relieving measures in place and which showed no improvement between 4/21 to 6/1/11. The neglect of R9 ' s pressure ulcer began on 4/21/11 when the family notified nursing staff of the heel and the physician was not notified. This is for 2 residents reviewed for pressure ulcers in the sample of 10. The findings include: 1. R7's 10/26/10 Minimum Data Set documented severe cognitive impairment, but needing only supervision & limited assistance with ambulation, dressing, eating, and personal hygiene. R7 was continent of bowel and bladder. R7 was at risk for pressure ulcers but had no open areas at the time of this assessment. R7's 1/16/11 Nurse's Notes show a new physician's orders [REDACTED]. R7's January and February 2011 Treatment Administration Record showed the ointment was applied to the coccyx from 1/16/11 to 2/12/11 three times a day and then stopped with the notation that the area was healed. The first entry on R7's Weekly Comprehensive Wound Assessment Documentation was (19 days after the stage I area was noted) 2/4/11: Stage II pressure ulcer of the coccyx, 2.1 x 1 x <0.1 (centimeters) in size. From 2/4/11 to 4/21/11 the size increased to 4 x 2 x <0.1. Each of the above entries documented a small amount of serosanguinous drainage and stated the status as unchanged. On 6/2/11 at 10:55 AM, E23 (Treatment Nurse), stated, the area on R7's coccyx never healed and was open as documented in the wound assessments. Any treatments would be documented in the Physician order [REDACTED]. From 2/12/11 until discharge on [DATE], R7's Physician order [REDACTED]. R7's pressure ulcer risk assessment for 2/9/11 was marked moderate risk. R7's Care Plan did not address the pressure ulcer on the coccyx first noticed on 1/16/11. The undated problem/need of "at moderate risk" for skin breakdown listed an approach of skin checks 2 times a week and as needed. R7's Care Plan did not reflect a change to high risk for pressure ulcers until 4/27/11. R7's Monthly Summary by nursing stated: 1/23/11- Some redness to coccyx area, receives wound care. 1/27/11- Skin integrity intact. 2/2011- Area on coccyx healed as of 2/12/11. 3/11/11- Receives wound care. 4/18/11- Skin intact. R7 had Daily Skin Assessment/Wound Status forms completed for April and May 2011. April's form documented that R7's skin integrity was intact until 4/26 - 4/30/11 when an abrasion to the forehead and left hip was noted. The May form had three entries: 5/5: presently has wound on right face and right hip; 5/10: presently has pressure ulcer/wound- coccyx (was) black; 5/11: presently has wound (left blank, no comments). The facility's December 2010 - May 2011 Occurrence Report Logs show no reported pressure ulcers for R7. On 6/7/11 at 12:55 PM, E1 (Administrator) verified that all Unusual Occurrence Report sheets should get listed on the Log. The facility's 9/10 Protocols For Residents at Risk for pressure ulcers stated: The charge or treatment nurses should describe the effectiveness of the treatment interventions and resident's response to the treatment in the medical record weekly or as needed. Notify the Power of Attorney and physician of significant change in the ulcer. Assess the ulcer with each dressing change. 2. R9's Face Sheet showed an admission date of [DATE]. R9's 2/24/11 Admission Nursing Assessment included the following body observations: toe nails brittle, feet dry, no history of pressure sores, and skin unremarkable. R9's 2/24/11 pressure ulcer risk assessment was marked as very high risk. R9's 3/28/11 Podiatric Consultation noted brittle toe nails, dry feet, and no ulcers on the feet. On 5/31/11 at 8:30 PM, Z2 (R9's family) stated, "I found the bruise and blister on (R9's) heel (about a month ago). No one notified me. I showed them and they (facility staff) said 'we never saw it'. No one on the evening shift knew about it." On 6/1/11 at 11:05 AM, R9 was dressed sitting in her wheelchair and wearing ankle white socks and tennis shoes on both feet. At 11:15 AM, a large dark blister was observed on R9's inner aspect of the left heel. E24 (Alzheimer Unit Director, Registered Nurse) measured it as 5 x 7.2 cm. E24 said she had talked to the granddaughter about it before today. The facility's 6/1/11 Current Pressure Ulcers list did not include R9. On 6/2/11 at 1:25 PM, Z4 (Nursing Consultant, Wound Care) stated that R9 had an unstagable pressure sore on the left heel. The area was dry with no drainage. Z4 left recommendations to call the doctor for orders for a transparent dressing to cover the area, off-loading boots to be worn, keep feet elevated on pillows, and should have diabetic socks that are not tight and restricting. Treatment to pressure sores should be evaluated for effectiveness and changed when no improvement is noted in 10 - 14 days. R9's 4/21/11 Medicare Charting documented, "Dry area noted to buttock. Cream applied." "11:30 AM, Old blister noted to left inner aspect of heel. Granddaughter here and aware." R9's 4/21/11 Nurses's Notes at 10:00 PM documented, "Resident does have a 2 inch slit from coccyx up." "Left foot has 7 cm x 5 cm on the outer aspect of heel where a blister may have formed and healed. Area also very mushy. Area is beige in color with pink surroundings." "Will relay message to treatment nurse in the morning and will continue to monitor closely." R9's 4/21/11 Skin Narrative Documentation (used for skin issues other than pressure ulcers) stated, "Floor nurse pointed out blister to the top outer area of residents foot. No open area, blister is flat with no fluid underneath. Measures approximately 3.5 cm round." "Will skin prep per protocol until healed." This did not say if 3.5 cm blister was on the right or left foot. On 6/1/11 at 2:45 PM, E3 (Assistant Director of Nursing) stated if a nurse got a report of an open skin area the nurse is responsible for looking at it, measuring, and documenting the findings. Then check the protocol for treatment options and call the doctor for treatment orders for the wound right away. "If a wound is found on a Friday night or weekend, we can't just leave it for the treatment nurse to deal with on Monday. A wound needs a treatment order right away." On 6/1/11 at 12:25 PM, E24 (Alzheimer Unit Director, Registered Nurse) stated, "I can't say it (the area on R9's left heel) is a pressure ulcer." "I can't call the doctor, that's not how it's done here. The treatment nurse and the corporate nurse consultant evaluate the area and then the treatment nurse calls the doctor. We do have a nursing order for skin prep to the area." R9's Physician order [REDACTED]. R9's May 2011 Treatment Administration Record had an entry for "Skin prep to heels every day and as needed- nursing order". The April Record had no nursing order documented for the heel. R9 had no Daily Skin Assessments for February or March, 2011. The April 2011 form documented R9's skin integrity to be intact-no change to skin condition for the entire month. The May 2011 form made a note to "see Weekly Wound Assessment Form" about the left heel for all but seven days. For six days (May 6, 7, 10, 12, 13, & 18) it is documented that skin integrity is intact. May 5th documentation is: Presently has pressure ulcer left heel, dark/soft, not open. R9 did not have any Weekly Wound Assessment Forms completed since her admission. R9 had a Comprehensive Skin Assessment done on 2/24/11 for Admission. On 6/1/11 at 2:35 PM, E23 (Treatment Nurse) said, R9 did not have a pressure ulcer that she was aware of so that was the reason R9 was not on the current pressure ulcer list. The Weekly Wound Assessment Form is completed only for pressure ulcers, so R9 did not have any and why R9 had no further Comprehensive Skin Assessments done after admission. Any resident identified as high risk by the pressure ulcer risk assessment get daily skin checks per the protocol. On 5/31/11 at 8:55 PM, E25 (LPN), stated, "I think I have one pressure ulcer." E25 did not know the resident's name. On 6/1/11 at 9:55 AM, E9 Licensed Practical Nurse (LPN) stated, "I think this unit maybe has 2 pressure ulcers, (R18 & R19)." R18 and R19 are not on the 6/1/11 Current Pressure Ulcers list. On 6/1/11 at 11:25 AM, E29 (Certified Nursing Assistant) said she had heard about the area on the left heel when R9's granddaughter had first brought it up about a month ago. E29 was not sure of any treatment being done but asked, "Is it good to have those tennis shoes on?" R9's Care Plan for pressure ulcer risk / risk for impaired skin integrity has not been revised since 3/25/11 and did not include any skin issues addressed in the nursing notes. The facility's 9/10 Protocols For Residents at Risk for pressure ulcers shows, Definition: Those residents who score very high or high on the assessment form or have a history of pressure ulcers. Guidelines for Care Interventions: 1. Minimize and/or eliminate the effects of the casual/contributing factors 2. Observe skin at least daily. 3. Assess for reddened areas, [MEDICAL CONDITION], and fluctuant or blistered areas. Recommended Plans of Care: 1. Teach resident and family the importance of changing position 2. Maintain activity and mobility -encourage small frequent changes in position to alter pressure points, -when in bed, turn and reposition every 2 hours; use pillow to separate pressure areas between knees, ankles, etc. -when in chair ask the resident to stand or change position, assist as needed. 3. Elevate heels completely off the bed surface; use pillows or foot off-loading boots or devices. Friction/Shear: 1. Heel and elbow protectors should only be used to reduce friction forces. These devices do not provide adequate redistribution of pressure. Nutrition: The dietitian should assess all residents with pressure ulcers Documentation: 1. The charge or treatment nurses should describe the effectiveness of the treatment interventions and resident's response to the treatment in the medical record weekly or as needed. 2. Specific interventions such as potion changes, incontinence care, equipment usage, should be recorded on the flow sheet. 3. Notify the Power of Attorney and physician of significant change in the ulcer. 4. Assess the ulcer with each dressing change. The facility's undated Procedure When New Pressure Sore is Identified states, "I. Pressure sore must be measured when it is reported by staff. II. Document the size and appearance of the pressure area. III. Notify the physician and get orders for treatment using the facility protocols--you must begin a treatment right away. IV. Notify the family. V. Fill out an Occurrence Report. VI. Document the entire procedure in the Nurses' notes. VII. Notify the treatment Nurse." The facility's 9/10 Comprehensive Skin Assessment Skin Care Protocol states, "To assess residents who score at very high risk or high risk for skin breakdown within 72 hours of admission, readmission or who have a decline in condition or acquire pressure ulcers." B. Based on observation, interview and record review the facility neglected to follow their written policies/procedures for fall prevention for R7. The facility failed to conduct fall investigations showing tracking and trending and include subsequent actions to minimize/ eliminate future falls. R7 had a 4th fall in 7 weeks on 4/23/11. There was a 4 day delay between the fall and the [DIAGNOSES REDACTED]. The neglect for R7 began on 3/7/11 when R7 had the first fall. This is for 1 of 10 residents in the sample. The findings include: R7's Unusual Occurrence Reports document falls on 3/7, 3/25, 3/31, and 4/23/11. Only the 3/25 fall was witnessed. R7's Unusual Occurrence Reports did not list any investigation that was completed after each fall or immediate interventions put in place. R7's 3/7/11 9:00 PM Nurse's Notes state, "Nurse heard a loud noise and (R7) was laying on her back on the floor in the dining room. (R7) had bleeding to the back of her head." Neurological assessments were completed for 72 hours following the fall. This fall was not addressed on R7's Care Plan and no further interventions put into place for prevention. R7's Care Plan had no additions to the fall risk problem after the first fall on 3/7/11. R7's 3/25/11 3:00 PM Nurse's Notes state, "(R7) sitting in wheelchair in foyer of Alzheimer's unit. Leaned forward in wheelchair and fell out onto floor on hands and knees." R7's Care Plan added the following interventions on 3/25/11: reclining wheelchair to prevent falls, chair and bed alarm ordered and in place to warn staff, and put resident in a common area for supervision while awake. R7's 3/31/11 12:00 noon Nurse's Notes state, "(R7) found sitting on the floor at the end of her bed." There was no mention if a chair or bed alarm was in use, or why R7 was in the bedroom at lunch time. R7's Care Plan added the following on 3/31/11: Mat put on the floor by bed for safety. R7's 4/23/11 10:00 PM Nurse's Notes state, "(R7) is alert and staff was hearing alarm on chair go off. (R7) was sitting on the floor near her wheelchair. (R7) had a skin tear to the left cheek." R7's 4/23/11 Unusual Occurrence Report documents the fall happened in the TV room and was not witnessed. Three hours later, on 4/24/11 at 1:00 AM, R7's Nurses's Notes state, "Skin tear open area right hip. 1.8 cm width x 3.9 cm length x <0.1 cm depth." R7's 4/24/11 1:30 PM Nurse's Notes state, "Complaints of left leg pain and was given Tylenol 650 mg." After the fall on 4/23/11 there were no additions to R7's Care Plan until 4/27/11 (4 days after the fall) that state, "(R7) complained of left hip pain with Xray showing [MEDICAL CONDITION] after fall". The interventions listed were for treating the fracture. R7's 4/27/11 radiology report states, Left Hip: Impacted [MEDICAL CONDITION] of the femur with varus deformity at the fracture site. On 5/25/11 at 9:50 AM, E15 (Care Plan Coordinator) said every fall is to be addressed on the care plan. On 5/25/11 at 12:25 PM, E18 (Restorative Nurse) said each fall is reviewed and interventions are put into place right away. The Safety Committee also reviews individual residents to: check for medication reduction, check for medical problems like infections, see if bed or chair alarms may be helpful, use floor mats at the bedside, increase times and assistance with toileting, check activities- may need something to occupy more time, and try to find out what may have precipitated the fall. On 6/14/11 at 3:35 PM, E18 said the only notes kept from the Safety Committee reflect what staff attended and which residents were discussed. There are no formal notes or documents on further investigations of falls. The facility's undated Resident Fall Protocol shows, The program must be interdisciplinary and comprehensive. All staff in the facility must have a sense of ownership and be provided feedback. The Safety Committee has over sight responsibility for fall monitoring, tracking and trending. The nursing department is responsible for executing clinical interventions. All staff at the facility are responsible for observation, monitoring and executing environmental interventions. Documentation is consistent, comprehensive and clearly articulates interventions based on assessed risks. On a daily basis, the facility interdisciplinary team will review all resident falls. This team provides that falls are investigated and that unique interventions have been implemented and then documented consistently. This is an essential part of the falls prevention procedure. Any resident who experiences a fall is immediately considered at risk for further falls.

A. Based on interview and record review the facility failed to do a complete body assessment after R7 fell on [DATE] resulting in a 4 day delay before a left [MEDICAL CONDITION] was identified and a three hour delay before a skin tear on the right hip was identified & treated. This is for 1 resident reviewed in the sample of 10. The findings include: R7's 10/26/10 Minimum Data Set (MDS) documented severe cognitive impairment, but needing only supervision & limited assistance with ambulation, dressing, eating, and personal hygiene. R7's 2/10/11 MDS/Care Plan Note states, "(R7) is ambulatory and confused. Needs assist with Activities of Daily Living." R7's 4/23/11 10:00 PM Nurse's Notes state, "(R7) is alert and staff was hearing alarm on chair go off. (R7) was sitting on the floor near her wheelchair. (R7) had a skin tear to the left cheek. (R7) could weight bear and moved upper and lower extremities. No complaints of pain or discomfort." Three hours later, on 4/24/11 at 1:00 AM, R7's Nurses's Notes state, "Skin tear open area right hip. 1.8 cm width x 3.9 cm length x <0.1 cm depth." R7's 4/24/11 1:30 PM Nurse's Notes state, "(R7) up in wheelchair for meals. Ate 50% being fed by niece. Complaints of left leg pain and was given Tylenol 650 mg. (R7) fell asleep in less than an hour." Nurse's Notes of 4/25 & 4/26/11 show R7 continued to get up in the wheelchair and bear weight on both legs. R7's 4/27/11 Hospice Additional Visit Notes show: 12:00 PM- Went to assist R7 in getting up for lunch. She was lying down in bed napping. Upon waking, R7 was yelling out 'help me, it hurts' and touched both legs. Left hip felt different than right hip and left leg was inches shorter. Asked Nurse Practitioner to stop and see R7. An Xray was ordered. On 6/1/11 at 10:05 AM, Z3 (Hospice Nurse) said the facility did not notify hospice of the fall on 4/23/11. R7's Power of Attorney called Z3 to tell of the fall. Z3 had the Nurse Practitioner do a visual assessment and order the Xray. "At times it feels I do the care instead of assisting. I generally have to follow up on issues to make sure it gets done when issues are reported to the charge nurses and unit director." R7's Care Plan had no additions to the fall risk problem until 4/27/11 (4 days after the fall) that state, "(R7) complained of left hip pain with Xray showing [MEDICAL CONDITION] after fall". The interventions listed were for treating the fracture. R7's 4/27/11 radiology report states, Left Hip: Impacted [MEDICAL CONDITION] of the femur with varus deformity at the fracture site. B. The facility failed to offer/provide therapeutic interventions to promote bowel evacuation when R9 went three days without a bowel movement on three different occasions. This is for 1 resident reviewed in the sample of 10. The findings include: The Output Tracking Sheets for March & May 2011 show R9 went three or more consecutive days without a BM, on 3 occasions; twice in March 2011 on 2, 3, 4, and 16, 17, 18 and once in May on 1, 2, 3. R9's Nurse's Notes and Physician order [REDACTED]. Davis's Drug Guide For Nurses, 12th edition, states a side effect of [MEDICATION NAME] can be constipation. R9's 2/25/11 Care Plan as well as March, April, and May 2011 Nurse's Notes, Medicare Charting, Physician order [REDACTED]. On 6/1/11 at 9:55 AM, E9 (Licensed Practical Nurse) said if a resident goes without a BM for 2-3 days then an assessment of bowel sounds should be done and medications given. On 6/1/11 at 11:25 AM, E29 (Certified Nursing Assistant) said R9 usually has a BM every day and tells us when she needs to use the the toilet. The facility's undated Bowel Management Program states, the program is individualized, designed to promote regular bowel evacuation and relieve pain and/or discomfort. 1. Identify the time of day the resident usually has a bowel movement. 2. Evaluate diet, exercise, former use of medications for bowel evacuation. 3. Consult with dietary and the physician to adjust diet or medications. 4. Use verbal cueing/reminders for resident to go to the bathroom before and after meals; at bedtime and with night rounds. 5. Establish a regular bowel routine by adding as needed: -prune juice or fruit or vegetables to diet. -increase the amount of water consumed, if allowed. -a stool softener daily. -a bulk former daily or up to three times a day. - a mild laxative approximately 8 hours before initiation of defecation. - insert a suppository just before digital stimulation. 10. Document in the treatment book. 11. Include the bowel management program in the care plan.

Based on observation, interview and record review the facility failed to obtain treatment orders for a left heel and coccyx pressure ulcer, failed to off-load heel pressure, failed to care plan pressure ulcer treatment, and failed to assess & document residents skin condition. These failures resulted in R7's coccyx pressure ulcer increasing in size and R9's heel ulcer showing no improvement. This is for 2 of 2 residents reviewed with pressure ulcers in a sample of 10. The findings include: 1. R7's 10/26/10 Minimum Data Set documented severe cognitive impairment, but needing only supervision & limited assistance with ambulation, dressing, eating, and personal hygiene. R7 was continent of bowel and bladder. R7 was at risk for pressure ulcers but had no open areas at the time of this assessment. R7's 1/16/11 Nurse's Notes show a new physician's orders [REDACTED]. R7's January and February 2011 Treatment Administration Record showed the ointment was applied to the coccyx from 1/16/11 to 2/12/11 three times a day and then stopped with the notation that the area was healed. The first entry on R7's Weekly Comprehensive Wound Assessment Documentation was (19 days after the stage I area was noted) 2/4/11: Stage II pressure ulcer of the coccyx, 2.1 x 1 x <0.1 (centimeters) in size. The wound bed was 100% granulation tissue with a small amount of serosanguinous drainage. The wound status was documented as unchanged and R7's functional ability is noted as needing assistance with ADL's (Activity of Daily Living), but able to turn and reposition self. The second entry on 2/18/11 (6 days after the TAR indicated the area as healed and treatment was stopped) showed an increase of size: 2.8 x 1.6 x <0.1 and all other categories remained the same. The third entry on 2/25/11 showed the stage, measurements, wound bed, drainage, and status had no changes, but the functional ability category documented that R7 still needed assistance with ADL's but needed staff to turn and reposition her. Further consecutive entries documented the following changes: 3/17/11: Wound bed changed to 60% granulation tissue and 40% [MEDICATION NAME] slough 3/31/11: Size increased to 3.6 x 1.6 x <0.1, Margin of wound uneven and attached to wound bed, wound bed now superficial-abrasion blister, shallow crater with 80% granulation tissue and 20% slough 4/7/11: Size increased to 3.8 x 1.6 x <0.1 4/21/11: Size increased to 4 x 2 x <0.1, 100% gray slough 4/28/11: 100% Eschar- gray Each of the above entries documented a small amount of serosanguinous drainage and stated the status as unchanged. On 6/2/11 at 10:55 AM, E23 (Treatment Nurse), stated, the area on R7's coccyx never healed and was open as documented in the wound assessments. Any treatments would be documented in the Physician order [REDACTED]. From 2/12/11 until discharge on [DATE], R7's Physician order [REDACTED]. R7's pressure ulcer risk assessment for 2/9/11 was marked moderate risk. R7's Care Plan did not address the pressure ulcer on the coccyx first noticed on 1/16/11. The undated problem/need of "at moderate risk" for skin breakdown listed an approach of skin checks 2 times a week and as needed. R7's Care Plan did not reflect a change to high risk for pressure ulcers until 4/27/11. R7's Monthly Summary by nursing stated: 1/23/11- Some redness to coccyx area, receives wound care. 1/27/11- Skin integrity intact. 2/2011- Area on coccyx healed as of 2/12/11. 3/11/11- Receives wound care. 4/18/11- Skin intact. R7 had Daily Skin Assessment/Wound Status forms completed for April and May 2011. April's form documented that R7's skin integrity was intact until 4/26 - 4/30/11 when an abrasion to the forehead and left hip was noted. The May form had three entries: 5/5: presently has wound on right face and right hip; 5/10: presently has pressure ulcer/wound- coccyx (was) black; 5/11: presently has wound (left blank, no comments). The facility's December 2010 - May 2011 Occurrence Report Logs show no reported pressure ulcers for R7. On 6/7/11 at 12:55 PM, E1 (Administrator) verified that all Unusual Occurrence Report sheets should get listed on the Log. The facility's 9/10 Protocols For Residents at Risk for pressure ulcers stated: The charge or treatment nurses should describe the effectiveness of the treatment interventions and resident's response to the treatment in the medical record weekly or as needed. Notify the Power of Attorney and physician of significant change in the ulcer. Assess the ulcer with each dressing change. 2. R9's Face Sheet showed an admission date of [DATE]. R9's 2/24/11 Admission Nursing Assessment included the following body observations: toe nails brittle, feet dry, no history of pressure sores, and skin unremarkable. R9's 2/24/11 pressure ulcer risk assessment was marked as very high risk. R9's 3/28/11 Podiatric Consultation noted brittle toe nails, dry feet, and no ulcers on the feet. On 5/31/11 at 8:30 PM, Z2 (R9's family) stated, "I found the bruise and blister on (R9's) heel (about a month ago). No one notified me. I showed them and they (facility staff) said 'we never saw it'. No one on the evening shift knew about it." On 6/1/11 at 11:05 AM, R9 was dressed sitting in her wheelchair and wearing ankle white socks and tennis shoes on both feet. At 11:15 AM, a large dark blister was observed on R9's inner aspect of the left heel. E24 (Alzheimer Unit Director, Registered Nurse) measured it as 5 x 7.2 cm. E24 said she had talked to the granddaughter about it before today. The facility's 6/1/11 Current Pressure Ulcers list did not include R9. On 6/2/11 at 1:25 PM, Z4 (Nursing Consultant, Wound Care) stated that R9 had an unstagable pressure sore on the left heel. The area was dry with no drainage. Z4 left recommendations to call the doctor for orders for a transparent dressing to cover the area, off-loading boots to be worn, keep feet elevated on pillows, and should have diabetic socks that are not tight and restricting. Treatment to pressure sores should be evaluated for effectiveness and changed when no improvement is noted in 10 - 14 days. R9's 4/21/11 Medicare Charting documented, "Dry area noted to buttock. Cream applied." "11:30 AM, Old blister noted to left inner aspect of heel. Granddaughter here and aware." R9's 4/21/11 Nurses's Notes at 10:00 PM documented, "Resident does have a 2 inch slit from coccyx up." "Left foot has 7 cm x 5 cm on the outer aspect of heel where a blister may have formed and healed. Area also very mushy. Area is beige in color with pink surroundings." "Will relay message to treatment nurse in the morning and will continue to monitor closely." R9's 4/21/11 Skin Narrative Documentation (used for skin issues other than pressure ulcers) stated, "Floor nurse pointed out blister to the top outer area of residents foot. No open area, blister is flat with no fluid underneath. Measures approximately 3.5 cm round." "Will skin prep per protocol until healed." This did not say if 3.5 cm blister was on the right or left foot. On 6/1/11 at 2:45 PM, E3 (Assistant Director of Nursing) stated if a nurse got a report of an open skin area the nurse is responsible for looking at it, measuring, and documenting the findings. Then check the protocol for treatment options and call the doctor for treatment orders for the wound right away. "If a wound is found on a Friday night or weekend, we can't just leave it for the treatment nurse to deal with on Monday. A wound needs a treatment order right away." On 6/1/11 at 12:25 PM, E24 (Alzheimer Unit Director, Registered Nurse) stated, "I can't say it (the area on R9's left heel) is a pressure ulcer." "I can't call the doctor, that's not how it's done here. The treatment nurse and the corporate nurse consultant evaluate the area and then the treatment nurse calls the doctor. We do have a nursing order for skin prep to the area." R9's Physician order [REDACTED]. R9's May 2011 Treatment Administration Record had an entry for "Skin prep to heels every day and as needed- nursing order". The April Record had no nursing order documented for the heel. R9 had no Daily Skin Assessments for February or March, 2011. The April 2011 form documented R9's skin integrity to be intact-no change to skin condition for the entire month. The May 2011 form made a note to "see Weekly Wound Assessment Form" about the left heel for all but seven days. For six days (May 6, 7, 10, 12, 13, & 18) it is documented that skin integrity is intact. May 5th documentation is: Presently has pressure ulcer left heel, dark/soft, not open. R9 did not have any Weekly Wound Assessment Forms completed since her admission. R9 had a Comprehensive Skin Assessment done on 2/24/11 for Admission. On 6/1/11 at 2:35 PM, E23 (Treatment Nurse) said, R9 did not have a pressure ulcer that she was aware of so that was the reason R9 was not on the current pressure ulcer list. The Weekly Wound Assessment Form is completed only for pressure ulcers, so R9 did not have any and why R9 had no further Comprehensive Skin Assessments done after admission. Any resident identified as high risk by the pressure ulcer risk assessment get daily skin checks per the protocol. On 5/31/11 at 8:55 PM, E25 (LPN), stated, "I think I have one pressure ulcer." E25 did not know the resident's name. On 6/1/11 at 9:55 AM, E9 Licensed Practical Nurse (LPN) stated, "I think this unit maybe has 2 pressure ulcers, (R18 & R19)." R18 and R19 are not on the 6/1/11 Current Pressure Ulcers list. On 6/1/11 at 11:25 AM, E29 (Certified Nursing Assistant) said she had heard about the area on the left heel when R9's granddaughter had first brought it up about a month ago. E29 was not sure of any treatment being done but asked, "Is it good to have those tennis shoes on?" R9's Care Plan for pressure ulcer risk / risk for impaired skin integrity has not been revised since 3/25/11 and did not include any skin issues addressed in the nursing notes. The facility's 9/10 Protocols For Residents at Risk for pressure ulcers shows, Definition: Those residents who score very high or high on the assessment form or have a history of pressure ulcers. Guidelines for Care Interventions: 1. Minimize and/or eliminate the effects of the casual/contributing factors 2. Observe skin at least daily. 3. Assess for reddened areas, [MEDICAL CONDITION], and fluctuant or blistered areas. Recommended Plans of Care: 1. Teach resident and family the importance of changing position 2. Maintain activity and mobility -encourage small frequent changes in position to alter pressure points, -when in bed, turn and reposition every 2 hours; use pillow to separate pressure areas between knees, ankles, etc. -when in chair ask the resident to stand or change position, assist as needed. 3. Elevate heels completely off the bed surface; use pillows or foot off-loading boots or devices. Friction/Shear: 1. Heel and elbow protectors should only be used to reduce friction forces. These devices do not provide adequate redistribution of pressure. Nutrition: The dietitian should assess all residents with pressure ulcers Documentation: 1. The charge or treatment nurses should describe the effectiveness of the treatment interventions and resident's response to the treatment in the medical record weekly or as needed. 2. Specific interventions such as potion changes, incontinence care, equipment usage, should be recorded on the flow sheet. 3. Notify the Power of Attorney and physician of significant change in the ulcer. 4. Assess the ulcer with each dressing change. The facility's undated Procedure When New Pressure Sore is Identified states, "I. Pressure sore must be measured when it is reported by staff. II. Document the size and appearance of the pressure area. III. Notify the physician and get orders for treatment using the facility protocols--you must begin a treatment right away. IV. Notify the family. V. Fill out an Occurrence Report. VI. Document the entire procedure in the Nurses' notes. VII. Notify the treatment Nurse." The facility's 9/10 Comprehensive Skin Assessment Skin Care Protocol states, "To assess residents who score at very high risk or high risk for skin breakdown within 72 hours of admission, readmission or who have a decline in condition or acquire pressure ulcers."

A. Based on observation, interview, and record review the facility failed to implement, evaluate, and modify fall prevention measures for R7. These failures contributed to R7's fourth fall in 7 weeks resulting in a fractured left hip. This is for 1 resident reviewed in a sample of 10. The findings include: R7's Unusual Occurrence Reports document falls on 3/7, 3/25, 3/31, and 4/23/11. Only the 3/25 fall was witnessed. R7's Unusual Occurrence Reports did not list any investigation that was completed after each fall or immediate interventions put in place. R7's 3/7/11 9:00 PM Nurse's Notes state, "Nurse heard a loud noise and (R7) was laying on her back on the floor in the dining room. (R7) had bleeding to the back of her head." Neurological assessments were completed for 72 hours following the fall. This fall was not addressed on R7's Care Plan and no further interventions put into place for prevention. R7's Care Plan had no additions to the fall risk problem after the first fall on 3/7/11. R7's 3/25/11 3:00 PM Nurse's Notes state, "(R7) sitting in wheelchair in foyer of Alzheimer's unit. Leaned forward in wheelchair and fell out onto floor on hands and knees." R7's Care Plan added the following interventions on 3/25/11: reclining wheelchair to prevent falls, chair and bed alarm ordered and in place to warn staff, and put resident in a common area for supervision while awake. R7's 3/31/11 12:00 noon Nurse's Notes state, "(R7) found sitting on the floor at the end of her bed." There was no mention if a chair or bed alarm was in use, or why R7 was in the bedroom at lunch time. R7's Care Plan added the following on 3/31/11: Mat put on the floor by bed for safety. R7's 4/23/11 10:00 PM Nurse's Notes state, "(R7) is alert and staff was hearing alarm on chair go off. (R7) was sitting on the floor near her wheelchair. (R7) had a skin tear to the left cheek." R7's 4/23/11 Unusual Occurrence Report documents the fall happened in the TV room and was not witnessed. Three hours later, on 4/24/11 at 1:00 AM, R7's Nurses's Notes state, "Skin tear open area right hip. 1.8 cm width x 3.9 cm length x <0.1 cm depth." R7's 4/24/11 1:30 PM Nurse's Notes state, "Complaints of left leg pain and was given Tylenol 650 mg." After the fall on 4/23/11 there were no additions to R7's Care Plan until 4/27/11 (4 days after the fall) that state, "(R7) complained of left hip pain with Xray showing hip fracture after fall". The interventions listed were for treating the fracture. R7's 4/27/11 radiology report states, Left Hip: Impacted fracture of the neck of the femur with varus deformity at the fracture site. On 5/25/11 at 9:50 AM, E15 (Care Plan Coordinator) said every fall is to be addressed on the care plan. On 5/25/11 at 12:25 PM, E18 (Restorative Nurse) said each fall is reviewed and interventions are put into place right away. The Safety Committee also reviews individual residents to: check for medication reduction, check for medical problems like infections, see if bed or chair alarms may be helpful, use floor mats at the bedside, increase times and assistance with toileting, check activities- may need something to occupy more time, and try to find out what may have precipitated the fall. On 6/14/11 at 3:35 PM, E18 said the only notes kept from the Safety Committee reflect what staff attended and which residents were discussed. There are no formal notes or documents on further investigations of falls. The facility's undated Resident Fall Protocol shows, The program must be interdisciplinary and comprehensive. All staff in the facility must have a sense of ownership and be provided feedback. The Safety Committee has over sight responsibility for fall monitoring, tracking and trending. The nursing department is responsible for executing clinical interventions. All staff at the facility are responsible for observation, monitoring and executing environmental interventions. Documentation is consistent, comprehensive and clearly articulates interventions based on assessed risks. On a daily basis, the facility interdisciplinary team will review all resident falls. This team provides that falls are investigated and that unique interventions have been implemented and then documented consistently. This is an essential part of the falls prevention procedure. Any resident who experiences a fall is immediately considered at risk for further falls. B. Based on observation, interview, and record review, the facility failed to provide supervision to prevent accidents during activities on the facility's Alzheimer certified unit. This is for 1 resident (R9) reviewed in the sample of 10 and 9 in the supplemental sample. (R6, R10-17) The findings include: On 5/31/11 at 7:30 PM, R6, R10, R11, R12, R13, and R14 were sitting in the Alzheimer's unit TV room. All were in wheelchairs arranged in a semicircle around the TV. No electric light was on, but the room was bright with sunshine through the windows. R11 held her hands up to shade her eyes and stated, "It's hard to see with the sun on my face." No staff were present in the room or were in line of sight. In the dining room next door, R9 (with family present), R15, and R17 sat in wheelchairs at the tables. R16 was ambulating about the room picking things up and setting them back down. No staff were present in the room. On 5/31/11 at 7:40 PM, E25 (Licensed Practical Nurse) yelled out to a Certified Nursing Assistant (CNA) to help tell this surveyor each resident's name in the TV room. In the dining room E25 did not know the last name's of R9 and R17 and did not notice that R16 was ambulating in the room. E25 did not acknowledge or talk to the family in the room. On 5/31/11 at 7:50 PM, Z2 (family of R9), said staff leave residents alone in the activity room and dining room without supervision. On 5/31/11 at 8:40 PM, E27 and E28, Certified Nursing Assistants (CNA) sat in the dark TV room with R6, R10, R13, and R14. No light was turned on. At 8:45 PM, the CNA's left the room and the residents were unattended. At 9:05 PM, R6, R10, R13, and R14 remained in the dark TV room and the TV was playing only static. No staff were present. E26 (CNA) stated, "They like it like that." On 5/31/11 at 9:05 PM, E1 (Administrator), said that staff should be supervising in the activity/dining areas. Residents should not be left alone in the dark. The facility's Alzheimer's Special Care Unit Model of Care shows: The unit will have ability-centered care programming, and the environment (cultural, social, and physical) will support the functioning of residents. It will accommodate behaviors, maximize functional abilities, promote safety, and encourage residents' independence by compensating for losses resulting from the disease process. Our care plans for residents on the unit will be individualized and ability centered in focus. The Care Planning and Communication section states, "the Special Care Unit Coordinator, or designee will communicate information within departments, between shifts, between units and with the resident's family or representative." The facility's undated Resident Fall Protocol states, On a daily basis, the facility interdisciplinary team will review all resident falls. This team provides that falls are investigated and that unique interventions have been implemented and then documented consistently. This is an essential part of the falls prevention procedure. Any resident who experiences a fall is immediately considered at risk for further falls. C. Based on observation, interview and record review, the facility failed to assure the safety of two residents who left the facility unknown to facility staff. One of the two residents reside on the Alzheimer's unit (R21). This applies to 2 of 10 residents in the sample (R20, R21). The findings include: 1. The physician's orders [REDACTED]. The nurse's note dated 5/17/11 documented "R20 can't understand call light system. Got up to use toilet, (he) felt unstable and sat himself on the ground." R20's Social Service Progress Sheet dated 5/17/11 showed, "He is not able to communicate his thoughts and needs." The nurse's note dated 5/18 at 7:00am documented "R20 found on the floor at 4am, doesn't know why." Initial Activity Note dated 5/19/11 documented R20 is alert and oriented to name, sometimes place. He can propel himself in his wheel chair and is constantly standing and walking away from his wheel chair, not remembering he is up walking. R20's Progress Note dated 5/26/11 at 1045am documented, "R20 is alert to self. Answers questions appropriately." The nurse's note dated 5/27/11 for 3rd shift, showed, "R20 up all night but 2-1/2 hours. Removes chair alarm several times per hour. Resident does not follow command to please stay in wheel chair." The nurse's note date 5/29/11 for 3rd shift showed, "R20 slept 2 hours only, awake rest of shift. 6:45am, (R20) up naked in hallway. Had large BM (bowel movement) in room. Room and resident cleaned." R20's nurse's note dated 6/5/11 at 10:15pm, "Writer and staff heard alarms go off, CNA (Certified Nursing Assistant) looked at the doors with another staff member and did not see anyone. Several staff went out to look for him on foot and by car. Resident had taken a suitcase with him. 10:45pm, Resident was brought back by kitchen staff. He was found close to (his) home. His wife had been called and was also looking for him and came to the facility. Wife said he has been unusually restless lately." The Mapquest.com website showed R20's house was 1.29 miles away from the facility. The nurse's note of 6/7/11 at 5:30am showed R20 up and about 6 times this shift, 2 times made to go out alarmed doors. The nurse's notes of 6/8/11 at 4:30am, show (R20) ambulating about the unit setting off alarms, very hard to redirect, pleasant but uncooperative. R20's MDS/care plan note (no date) documented, "When in his wheel chair he has on alarm and in non-compliant with alarms. Takes them off himself. Is on the elopement risk program." The care plan for physical and psychosocial needs dated 5/24/11 showed, R20 presents with decreased strength, poor balance, impaired ambulation, secondary to subdural hematoma and brain hemorrhage. Symptoms and problems are manifested by: Generalized weakness, increased risk for falls, cognitive impairment and decresed ability to follow directions. The Minimum Data Set (MDS) assessment reference date of 5/26/11 assessed R20 as severely impaired in cognitive skills for decision making and having long and short term memory problems. R20 has a behavior of wandering 1-3 days and this behavior places the resident at significant risk of getting to a potentially dangerous place (e.g. stairs, outside). R20 required limited assistance of 1 off of the unit. R20 was assessed as not steady when walking and turning around. The assessment showed R20 had a history of [REDACTED]. On 6/13/11 at 2:30pm, E2 (Director of Nurses-DON) said, "R20 goes out with his wife, but he went out once (without anyone) and they (staff) got him back." On 6/13/11 at 3:20pm, R20 was observed participating in a group activity on the facility's locked Alzheimer's unit. On 6/13/11 at 4:20pm, during an interview with R20. R20 said, He lives in town, has a wife and a son. He used to work as a CNA in town. R20 said he goes to his house with his wife. R20 indicated he was going home a few nights ago with his suitcase. Someone from the facility picked him up. E3 (Assistant Director of Nursing-ADON) was present during the interview. R20 knew E3's name. R20's gait was unsteady and E3 walked beside him to steady him. On 6/14/11 at 2:40pm Z5 said, "He looks normal and talks normal but his memory is not good. He had a brain hemmorrhage. He tries to talk sensical but doesn't make sense. He used to work in a nursing home as a CNA. He knows the workings of a nursing home and how to sneak around. He has only been there about 3 weeks. They called me when he got out. He was gone only for a little bit." 2. The physician's orders [REDACTED]. R21's Psychiatrist Note dated 3/9/11 documented, "Patient doing well. Has episodic comprehension episodes and gets aggressive at other times. He seems to be coherent and oriented X 3 and orientation is much better on (pschoactive medications)." The Physician's Progress note dated 6/3/11 showed, R21 declines to take his medications at times due to his Dementia. Alzheimer's Disease is moderate. The nurse's note dated 6/4/11 at 3:45am documented, "The resident kept yelling about not being allowed to do anything on his own." The note says, R21 shook his fist in the nurse's face and stated, "If I do this to a couple of people, they will send me to the psych hospital." Nurse left the room due to the R21's behavior. The nurse's note dated 6/11/11 at 8:00pm documented, "R21 went to (local department store) per self and purchased a new cell phone. R21's Power of Attorney (POA) was notified of his shopping and that he returned to the facility with a CNA at 8:45pm. Supervisors aware along with Administrator and DON that R21 contacted a (local cab company) and rode to the store." On 6/13/11 at 2:30pm, E2 (DON) said R21 called a cab and went out to the (local department store) because his son didn't want to take him. R21 lives on (the facility's locked Alzheimer's unit). On 6/13/11 at 3:20pm, R21 was seated in a wheelchair in his room (locked Alzheimer's unit)facing the window. R21 stated, "Yes, I went out to get my stuff done. When they tell me I can't, I can't, I can't and I've been doing it all my life. When E2 told R21 the staff was worried about him and he should sign out and tell the nurse before leaving. R21 said, "I am sorry I scared someone." On 6/13/11 at 3:30pm, E30 said, "R21 went to (local department store) because he said he was wanting to get food and a cell phone. Staff kept telling him he couldn't so, he called a cab. He used his walker, so staff saw his wheel chair here(at the facility). Staff was sent over and brought him back."

I. Based on observation, interview and record review the facility failed to ensure that a resident with a fractured left hip received pain medication to control complaints of severe pain upon movement. This failure resulted in R2 experiencing severe pain during patient care procedures starting on 11/17/10 after his return from the hospital for a left [MEDICAL CONDITION] repair. This applies to 1 resident in the sample of 21 with uncontrolled pain. (R2) The examples include: 1. The physician's orders [REDACTED]. This same document shows that R2 has orders for [MEDICATION NAME] 12 mcg every 72 hours, [MEDICATION NAME] 10/325 mg 2 tabs at 6 AM and 6 PM, and [MEDICATION NAME] 0.5 mg 3 x a day. Nurse's Notes(NN) dated 11/17/10 state, " Says movement hurts left arm and left hip/leg." NN dated 11/24/10 state, " In bed this shift due to pain." NN dated 11/26/10 state, "(R2) moaning and grimacing with hip pain. [MEDICATION NAME] given at 12:30 AM with little relief." NN dated 12/6/10 state, "(R2) complained of pain." and "Pain pills given x 3 this shift." NN dated 12/10/10 state, "(R2) complains of pain in left leg whenever it is moved...., pain of 10 on 1-10 scale..." NN dated 12/15/state, "Yelled out in pain every time the CNA checked on him. NN dated 12/25/10 state, "(R2) groaning at beginning of shift complains of left hip/leg pain. 2 [MEDICATION NAME] given. Resident yells out with repositioning." NN dated 12/25/10 state, "(R2) in pain, gave meds x 2 with small relief." NN dated 12/26/10 state, "(R2) in pain. Gave prn x 2, gave [MEDICATION NAME] (muscle relaxant), massaged legs. (R2) had minimal relief." R2's pain assessment dated [DATE] shows that R2 has Chronic, Internal, Constant, pain for Hours at a Pain Scale Rating of 10. The rest of the pain assessment form is not completed. On 1/3/11 at 11:40 AM, E13 and E14 (CNAs) were observed as they transferred R2 from his reclining wheelchair to his bed. R2 was yelling out throughout the entire transfer. At 11:45 AM, E14 stated, "Every time you touch him he screams. It makes it difficult to perform the procedure due to him screaming. He has been like this for the 2 months that I have had him." At 2:20 PM, E22(RN) stated, "Ever since he broke his hip he has had pain. He has scheduled [MEDICATION NAME] and [MEDICATION NAME] and as needed but he just doesn't tolerate being touched." On 1/4/11 at 3:20 PM, E22 stated, "He has been to the hospital 3 times for pain management. I don't know what else they can do with him, short of knocking him out." On 1/5/11 at 10:05 AM, E15 and E16 (CNAs) were observed as they transferred R2 from his reclining wheelchair to his bed. R2 yelled out when E16 removed the pillow from under his right leg. R2 continued to yell, "No,No!" as he was turned from side to side in the bed. R2 became very agitated and angry with E15 and stated, "I'm going to punch you!" On 1/5/11, at 10:20 AM, E22 came into R2's room to care for his pressure sores. E22 stated, "I'm going to give him something for pain. I will do his treatment at 11:00 AM." At 11:00 AM, E22 stated, "I just went in and pulled the covers back and he yelled. It should have taken effect by now. I'm just going to have to do it." On 1/5/11 at 1:10 PM, Z3 (Occupational Therapist) stated, "We have been thinking about discharging him. His pain level is something we really need to be aware of. We typically talk to the nurse to work around his pain medication. He is not ever comfortable." II. Based on record review, interview and observation the facility failed to obtain an order for [REDACTED]. The facility failed to ensure that a resident was medicated for pain prior to the dressing change. This applies to one resident in the sample of 21 (R15) and1 resident in the supplemental sample (R23). The example includes: 1. R23's January, 2011 physician's orders [REDACTED]. an order written [REDACTED]. Wound Care Nursing to assess 12/30/10." No order for cleansing the extremity was documented. A hospital transfer sheet showed that R23 was transferred to the nursing home on 12/29/10. Another order written on 1/3/11 by the CNP documented "ok to use A and D ointment with [MEDICATION NAME] to left lower extremity until Xeroform comes in. A hospital Surgical Consultation dated 12/24/10 documented that R23 had extreme left lower extremity swelling and pain. R23's leg was very [DIAGNOSES REDACTED]tous, red, and weeping. A surgical consultation was requested for [MEDICAL CONDITION] and left lower extremity wound care. The recommendations at this time was documented as Curlex gauze and 4x4's over weeping areas, and keep the leg elevated. The facility Admission Nursing assessment dated [DATE] documented that R23's left lower leg was " slits and blisters." An admission assessment completed by E12 Licensed Practical Nurse documented that R23 had multiple peeling areas on the shin and top of foot, and calf, and multiple blisters. The same assessment is not completed in the area of co-morbidities and risk factors. On 1/4/10 E3 Assistant Director of Nursing said that she was not sure if R23 had a wound consultation done. (No information was documented on R23's record that he had one, or that one had been arranged ) E12 LPN was interviewed and said that Z1 had ordered a wound care nurse consult and that meant that she (E12) should do the consult. E12 said she called Z1 the next day and asked her to continue the order. E12 said that her training to date has been attendance at some seminars on wound care. On 1/4/10 E12 was observed changing the dressing to R23's left, lower, leg. R23 said that he was unable to walk in therapy due to pain. R23 said "they want me to walk, but it's too tough, it hurts." R23 grimaced and pulled his foot upward each time E12 lifted it to remove the dressings. E12 said that she was using [MEDICATION NAME] today because "we ran out of Xeroform." E12 wet the end of a towel and placed it on the leg, then dried then patted the same area with a dry towel. E12 said that the leg is to be washed with soap and water unless something else is ordered. R23's Left, lower leg was red, moist, and had blisters (partial thickness wounds) along the anterior portion of the leg with some weeping. Large sheets of devitalized tissue was hanging on the leg in multiple areas, with areas of maceration. The facility protocol Based on Formulary showed that for stage II ( would include blisters) wounds will be cleansed with Normal Saline. Another document entitled Pressure Ulcer Treatment Options based on formulary showed under lower leg ulcer (partial thickness grade I ) to cleanse with Normal Saline. According to Bryant, R., Nix, D. Acute and Chronic Wounds third edition. 2007, Pg. 52, Skin Cleansers and soaps should be used sparingly to avoid disruption of the skin's normal acid pH. Pg. 420, Since bacteria cannot invade health tissue unless they first adhere or attach to it wound-cleansing techniques that physically remove surface bacteria serve a preventative role. The physical removal of bacteria does not necessarily require the use of an antiseptic agent. Normal Saline is an effective cleansing agent when delivered to wound site with adequate force to agitate and wash away surface debris and devitalized tissue that may harbor bacteria. Irrigation is a common method of delivering the wound cleanings solution to the wound surface. Pg. 341, Maceration: Overhydration of the skin characterized by a white, "waterlogged" appearance. Pg. 342, The prolonged presence of moisture on the skin will precipitate maceration. Such overhydration of the stratum corneum weakens the collagen, promotes overgrowth of bacterial and fungal species of skin flora,, and decreases the skin's ability to resist trauma. According to The Long Term Care Nursing Desk Reference, 2009 Pg. 89, Cleansing the wound with normal saline or a gentle pH-neutral wound cleanser to remove debris should be done before the applying a dressing. Be gentle to prevent pain and trauma to healing tissue. (Cleansing Wounds) Pg. 92, Use only Normal Saline or pH-neutral wound cleansers. (Managing Wound Pain) 2. On 1/3/11 at 10:30 AM, R15 was observed in the wheelchair in his room. An open wound was observed on R15's left elbow. E13 (CNA) stated, "I have no idea what caused that (wound)." The wound on the elbow was approximately 10 cm x 4 cm in size. The outer edges were pink and moist, and had a large scabbed center. On 1/4/11 at 10:45 AM, R15 was observed lying in bed with full padded side rails up. The left elbow wound was open to air. A small amount of bloody drainage was noted on the padded siderail near R15's left elbow wound. On 1/3/11 at 2:30 PM, E24 (Licensed Practical Nurse - LPN) stated, "The treatment record would show the current treatment and dressing change orders (for R15's elbow wound). The wound comes from him picking at it and it rubs on the siderails." E24 stated she could not exactly remember how long R15 has had the wound but stated, "He's had that for quite a while." The treatment record dated 12/1/10 for R15 documents to use, "Dry protective dressing to the left elbow to protect scabbed area, change daily. No Allevyn or adhesive." On 1/5/11 at 1:20 PM, E13 (CNA) showed R15's left elbow to the surveyor. A border gauze dressing with adhesive edges was in place over the wound. The facility protocol, "Other skin problems and management protocol" states, "Apply a non-adherent dressing and wrap with gauze."

I. Based on record review and interview, the facility failed to analyze the cause of a resident's multiple falls and develop alternative approaches to prevent further falls. These failures resulted in R19 falling 3 times in [DATE]. On [DATE], R19 was admitted to the hospital with [REDACTED]. This applies to 1 of 3 discharged residents reviewed who had multiple falls (R9). The example includes: 1. The physician's orders [REDACTED]. Prior to R19's hospitalization on [DATE], nurse's notes document R19 fell 3 times [DATE] at 2:30am, [DATE] (right eye swollen shut) at 10:45am and [DATE] at 2:45am. All of the falls occurred when R19 was trying to toilet himself. The nurse's notes for the month of [DATE] showed daily documentation of how R19 was up ambulating on his own, refused to sit in the wheelchair and refused to keep the chair or bed alarm on. "Has to be reminded to stay seated in the wheelchair." The facility's incident reports for R19 showed falls out of bed on [DATE] and [DATE] where R19 sustained a fractured rib on left lateral side. The falls care plan dated [DATE] showed, R19 had "decreased cognition and removes own chair alarm to ambulate." The use of the bed alarm and low bed was added to the care plan on [DATE]. A written note dated [DATE] and added to the falls care plan documented, "Incontinent and self transfers, reassess bed alarm." The facility's fax transmission to the physician dated [DATE] showed, "Need order for geri chair to prevent falls." The Minimum Data Set (MDS) reference assessment date of [DATE] showed R19 was moderately impaired in decision making skills with short and long term memory loss. R19 required total care for all Activities of Daily Living (ADL's). R19 was incontinent of bowel and bladder. R19 did not walk during the assessment period and was dependent on staff for locomtion in the wheelchair. The assessment showed R19 was not able to maintain standing balance without physical help and required partial physical support to stand. The assessment showed R19 fell in the past ,[DATE] days. The Activity of Daily Living (ADL) Resident Assessment Protocol (RAP) for R19 dated [DATE] documented, "readmitted with a Intracranial Bleed, Seizures and Depression. He has had a deterioration in his physical and mental abilities. He is x2 for turning side to side and moving up in bed and right to left. He is x2 staff total lift to (reclining wheelchair) for transfers. R19 is no longer able to ambulate and staff is needed to push him in the chair. He is total care for bathing and dressing. He is no longer able to feed himself and incontinent of bowel and bladder. He has speech deficits and is verbally unaware what his needs are. He has loss of voluntary movement of his neck and keeps it to the left. He continues to have partial loss of voluntary movement to the right lower extremity also." Physical Restraint Resident Assessment Protocol (RAP) dated [DATE] documented, "R19 is using a (reclining wheelchair) at this time for positioning while up in the chair with table in front due to resident inablility to not understand that he is unable to self transfer and self ambulate duee to decreased balance and unsteady gait. Has bed/chair alarm." Falls Assessment Raps dated [DATE] showed R19 "has increased risk for falls due to decreased mobility and unsafe transferring. Resident is total care for all transfers and bed mobility. Resident is now using (reclining wheelchair) for correct positioning when up. R19's nurse's notes on [DATE] at 9:45am documented, "Resident found on the floor in the room, lying on the face. Blood coming from right eyebrow." Nurse's notes dated [DATE] at 7:15pm documented, "(R19) in hall in (reclining wheelchair)-tray (table) not on. Slid to the floor." The facility's discharge summary showed R19 passed away on [DATE]. On [DATE] at 1:50pm, E1 (Administrator) confirmed R19 did not go to the hospital for the falls in April. II. Based on Interview and Record Review the facility failed to provide supervision for R21 on [DATE] by not knowing where R21 was from 5:30pm to 9:00pm (3.5 hours). On [DATE] at 9:10pm, R21 was found deceased and "stiff" on the floor in his bathroom. The facility failed to provide a safe transfer for R14 when being transferred using a mechanical lift by making sure R14's head does not hit the lift bar or headboard on his bed. This is for 1 resident with supervision needs (R21) and 1 resident's unsafe transfer with a mechanical lift (R14) of the 21 residents in the sample. The examples are: 1. R21's Nurses Notes dated [DATE] at 9:00pm showed, "Unable to locate R21 at dinner meal. Certified Nursing Assistant (CNA) reported to this nurse that R21 is out on pass with his brother, which is normal routine for resident. At approximately 8:30pm, I questioned if R21 was still on pass with his brother. Phoned brother and he states he did not pick R21 up today. CNA's instructed to go room to room to look for R21. CNA went into residents room and opened the bathroom door. R21 observed laying on left side on the floor stiff, without respirations, without pulse. This nurse paged nurses for immediate assistance, Registered Nurse (RN) and Licensed Practical Nurse ( LPN) responded. 911 called. Upon arrival paramedics deemed R21 expired previously. Fire department phoned the police and they responded. E2 (Director of Nursing) notified and en route. Police notified the coroner. R21's brother returned call and notified. Brother en route. Medical doctor notified by E2 (DON)." On [DATE] at 9:00am, Z5 stated, "At dinner around 5:30pm they could not find R21. I was not notified until 9:00pm that they were looking for R21 and then they found him. I had taken R21 out of the building the night before. I would sign R21 out every time I took him out. I would usually see R21 every other night. One time I took him out and he had a seizure on the way back to the facility because they had lowered his Dilantin. When I came back I noticed that the sheet I had signed him out on was missing. On the night R21 died I went to the nursing home and saw him. I got there around 11:30pm. R21 had banged his head and injured his arm. I got there around 11:30pm and R21's color had changed and rigormortis had set in. I went to verify everything. They think he tried to get up from the toilet, banged his head, hit the floor and then had died . I was not given the option of an autopsy. They (Director of Nursing and Doctor) had conferred together and decided what the cause of his death was. They said he could have died from a stroke, seizure or heart attack." On [DATE] at 10:25am, E8 (CNA) stated, "If they (residents) leave they will sign out in the book. If we don't see a resident when we do rounds every 2 hours we will check the sign out book to see if they have left." On [DATE] at 8:50am, E1 (Administrator) stated, "We don't keep the sign out logs together like we do a medical record. I am not quite sure what happens to them. They are probably sitting in a stack somewhere with E11 (CNA/Medial Records). On [DATE] at 10:20am, E11 (CNA/Medical Records) gave the surveyor one sheet of paper with dates and times on it for June and [DATE] (6 total entries) shoing when R21 left the building with his brother or one additional person. E11 stated, "This is all I have. Unfortunately it's not for the months you were looking for." The last Nurses Note for R21, previous to the nurses note on [DATE], was dated [DATE] at 2:05pm and showed, "R21 at reception desk asking to go outside. Explained that the CNA's and Activities and Restorative were busy at this time and that it wasn't safe for him to go out alone due to the high risk for falls. R21 became agitated and states, "I have a strong leg to kick the door!" Explained to R21 that becoming agitated would not help. Another resident and family went out door and this resident followed." The Facility Discharge Summary dated [DATE] for R21 showed, "Date of Admission: [DATE]; Date of Discharge: [DATE]; admitting [DIAGNOSES REDACTED].; Discharge Status: Expired. R21 found in bathroom having bowel movement and fell forward off the toilet.; Final Diagnoses: [REDACTED]." R21's Care Plan dated [DATE] showed, "At risk for Cerebral Vascular Accident (CVA) due to history of CVA and [DIAGNOSES REDACTED]." R21's Care Plan dated [DATE] showed, "Risk for Decreased Tissue Perfusion related to Coronary Artery Disease, Hypertension, Cardiomegaly and History of Myocardial Infarction. Monitor for shortness of breath. Monitor for nonverbal signs and symptoms of chest pain - wincing, clutching chest, moaning. Monitor blood pressure as needed/as ordered.Monitor for episodes of lethargy and changes in baseline mentation. Monitor temperature of extremities by using touch; feeling for cool extremities with discoloration. Monitor nail beds for cyanosis. Monitor for uneven and labored breathing patterns. Monitor for signs and symptoms of chest pain. Monitor oxygen saturation. Monitor for left arm pain, jaw pain and pain radiating to the back as needed." R21's Care Plan dated [DATE] showed, "Restricted mobility due to left sided [DIAGNOSES REDACTED]/hemiparesis related to Cerebral Vascilar Accident. Praise resident's efforts at maintaining/improving mobility." R21's Care Plan dated [DATE] showed, "Risk for falls related to Left Hemiparesis, Psychotropic Medications, Poor Eyesight and Seizure Disorder.; Goal - Patient will experience no fall related injuries through next review date.; Approach: Keep personal care items and call light within reach. Encourage and remind resident to use call light when requiring assistance. Assist with transfers as needed. Anticipate needs to prevent falls. Remind resident to use bathroom every 2 hours and as needed. Monitor Dilantin levels as necessary and report results to doctor." The Physician order [REDACTED].; Celexa 20mg by mouth every day.; Dilantin 50mg by mouth twice a day, take along with 200mg.; Keppra 500mg by mouth twice a day. Dilantin 100mg, take 2 capsules by mouth twice a day with 50mg = 250mg.; Aggrenox 1 capsule by mouth twice daily" and other medications. R21's Care Plan dated [DATE] showed, "Risk for injury related to seizure disorder.; Goal: Resident will exhibit no signs and symptoms of injuries related to seizure activity through the next review date.; Approach: Monitor for signs and symptoms of seizure activity. Notify primary doctor if a seizure should occur. Remove items from the area that may cause injury. Place pillow/towel under head during event to prevent head trauma. Document time and length of seizure. Monitor for Dilantin toxicity: confusion, diplopia, slurred speech, decreased coordination, jaundice." R21's Care Plan dated [DATE] showed, "R21 demonstrates short term memory deficits secondary to [DIAGNOSES REDACTED]. Provide set up for care and other tasks as needed. encourage resident to follow one or two step directions. Avoid asking questions that rely on memory." The Social Service Progress Sheet dated [DATE] showed, "R21 is alert and oriented x 3 (person, time and place). He remains a full code. He can be physically and verbally abusive to others. R21 has gotten angry and thrown his walker at the wall. He has changed rooms due to issues with his roommate. R21 has a [DIAGNOSES REDACTED]. R21 is critical of others. His care plan and placement remains appropriate." R21's Minimum Data Set with and Assessment Reference date of [DATE] showed impairment of short term memory, long term memory and cognition.; Supervision required for ambulation and dressing.; Limited assistance required for personal hygiene.; Extensive assistance required for bathing." R21's Care Plan dated [DATE] showed, "R21 is verbally and physically abusive to others. He will yell and threaten others. He will throw his walker if agitated.; R21 has difficulty with word finding related to CVA. He also stutters at times.; R21 wears glasses due to vision deficit. R21 has tunnel vision. R21 has had multiple strokes that have affected his vision." 2. On [DATE] at 1:39pm, E6 (Certified Nursing Assistant - CNA) and E7 (CNA) were observed transferring R14 from his wheelchair to his bed using a mechanical lift. During the transfer R14 hit his head on the mechanical lift bar twice. R14 stated, "Ouch" and E6 stated, "Keep your head back!" R14 was lowered onto his bed using the mechanical lift. During this time the back of R14's head close to his neck hit the headboard of his bed. R14 stated, "That hurts (his head), you need to move me down (in bed)." E7 stated, "By the time we roll you back and forth your head won't be on there." E7 then left the room with the mechanical lift. R14 asked E6 if she would put a pillow under his head. E6 placed a pillow under R14's head and left the room. When E6 came back into R14's room he stated, "My head is still on there (headboard). You girls don't realize I have feelings too!" R14's Physician order [REDACTED]. R14's Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] showed extensive assistance required for bed mobility, transfers, dressing, personal hygiene and bathing. The Resident Assessment Profile dated [DATE] for R14 showed, "Restorative Assessment: R14 transferred from another facility. R14 needs x2 extensive assist with bed mobility and transfers to wheelchair with a mechanical lift due to morbid obesity. R14 is extensive assistance with activities of dialy living...." R14's Care Plan dated [DATE] showed, "Risk for falls related to unsteady gait and needs to use mechanical lift for transfer with extensive assist from staff." R14's Care Plan dated [DATE] showed, "Risk for decline due to limitation in range of motion with partial/full loss of voluntary movement. Use mechanical lift for all transfers with 2 person assist." The facility did not provide the survey team with a policy related to the use of mechanical lifts and transfers during the survey, when asked, from [DATE] through [DATE].