Every finding on record at Aperion Care Dekalb

Based on observation, interview, and record review the facility failed to ensure resident meals were provided on time for 10 of 10 residents (R1-R7 and R10-R12) reviewed for resident rights in the sample of 12. The findings include: On 7/7/26 at 8:55 AM, R1 was seated in his room and said he likes to eat in the room. R1 said room trays are late all the time. Just last night I didn't get supper until after 7 PM. Trays are supposed to be down here by 6 PM. I get served late at least twice a week. I am still waiting on my breakfast tray for today even. On 7/7/26 at 9:10 AM, R2 was lying in bed with only a cup of coffee on her bedside table. R2 said my meals are never on time. Breakfast is at least 30 minutes late every day. It is the same for lunches and dinners. It is pretty much, they (trays) get here when they get here. I guess there is nothing I can do about it. Complaining doesn't change anything. I am still waiting for my breakfast. On 7/7/26 at 9:15 AM, V6 (Certified Nurse Aide) was observed passing resident room trays on the south unit. V6 said breakfast time is 8 AM. We are running late today. I am not sure why things are behind, the kitchen is just running late, I guess. On 7/7/26 at 9:17 AM, R3 was seated in a wheelchair in his room. R3 said his breakfast was just delivered now. They deliver it late every day. It takes forever to get my meals. Lunch gets here around 1:30 every day. Dinner is around 8 PM before someone brings me my tray. I like to eat my meals in my room. Maybe the dining room is quicker, but here in my room it is a long wait time. R4 and R5 (roommates) were observed eating freshly delivered breakfast trays in the room. R4 said lunch is delivered around 1:30 daily. On 7/7/26 at 9:31 AM, R6 and R7 (roommates) were observed eating breakfast in the their room. R6 said the room trays are late every day.On 7/7/26 at 10:31 AM, V10 (Dietary Manager) stated breakfast service starts around 7:30 AM, lunch starts at noon, and dinner starts at 5:30 PM. We don't post mealtimes but do an announcement overhead about 15 minutes prior to alert resident that the meals are going to start soon. We serve the dining rooms first then plate foods for resident rooms. We try to complete both dining rooms and all the unit carts within 45 minutes to one hour of meal start times. V10 said the dietary aides take carts to the units and nursing staff pass them to rooms. V10 stated our target time is 45 minutes to one hour to have everyone served. On 7/7/26 at 12:30 PM, R10, R11 and R12 were seated at the same table in the main dining room and waiting for lunch to be delivered. The residents stated it is a long wait for meals. We have to wait over an hour to be served. We are one of the last tables to be served. Most of the time, the first table people are done eating and gone while we are still sitting here waiting to be served. Just today at breakfast, everyone was out of the dining room and we were here still waiting to be served. We don't like it at all. R1-R7 and R10-R12 facility assessments were reviewed and showed no severe cognitive impairment/memory problems. On 7/7/26 at 1:10 PM, several resident room trays were observed still on the south unit cart waiting to be delivered. R6 was in her room and stated she still had not had her lunch delivered to the room. On 7/7/26 at 1:22 PM, V1 (Administrator) confirmed breakfast meal service begins at 8:00 AM, lunch begins at noon, and dinner begins at 5:30 PM. The facility's Dining Options for Meal Service policy dated 2020 states: 3. Mealtimes are listed below: a. The breakfast meal will be served from _____ to _____. b. The lunch meal will be served from _____ to _____. c. The evening meal will be served from _____ to _____. (All mealtimes were blank.) The Residents' Rights for People in Long-Term Care Facilities booklet and provided to each resident at admission states: You have the right to safety and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction.

Based on observation, interview and record review the facility failed to maintain a clean environment for seven residents. This applies to seven of ten residents (R1-R7) reviewed for environment in the sample of ten.The findings include:1. On 6/30/26 at 9:42 AM, R1 said a few days ago he got up at 6:30 AM to use the bathroom and the floor surrounding the toilet was covered with urine. V1 said there was so much urine he could not avoid it and his socks got saturated with urine. V1 said he asked the staff 6-7 times to clean it up and no one did. V1 said by 2:30 PM he had grown so frustrated, he used his cell phone and called the facility to report the urine on his bathroom floor. V1 said finally a staff member came to his room and cleaned it up. The facility assessment dated [DATE] shows him to be cognitively intact.2. On 6/30/26 at 8:50 AM, R2 said the housekeeping staff would just push the dirt around with the mop. R2 said the floor up against the walls is caked with black debris and she can't tell if it's dirty or black mold. The floor to R2's room was observed to have a black substance around the edges of the floor up against the sink and walls. The facility assessment dated [DATE] for R2 shows her to be cognitively intact.3. On 6/30/26 at 9:48 AM, R3 said the housekeepers usually don't clean his room on the weekends. R3 stated, Sometimes they do their jobs and sometimes they don't. The floors in R3's room were observed to have caked up debris along the edges of the floors along the walls and sink. The facility assessment dated [DATE] for R3 shows him to be cognitively intact.4. On 6/30/26 at 9:25 AM, R4 said the housekeepers do not clean her room every day. R4 said they tell her they are going to, but don't come back. The facility assessment dated [DATE] for R4 shows her to be cognitively intact.5. On 6/30/26 at 9:30 AM, R5 said the floors in her room are always dirty and the housekeepers only mop her floor occasionally. The floor in R5's room was observed to have black debris in the corners and around the floor trim. The facility assessment dated [DATE] for R5 shows her to be cognitively intact.6. On 6/30/26 at 9:40 AM, R6 said it is hard to tell if the floors are mopped in her room because they always look dirty. R6 said the staff don't always sweep and mop her floors. The floors in R6's room appeared dirty with numerous spots and garbage present on the floors. The facility assessment dated [DATE] for R6 shows her to be cognitively intact.7. On 6/30/26 at 9:40 AM, R7 said she is in the same room as R6 and agrees the housekeeping staff do not sweep or mop their floors every day. R7 said the floors always look dirty to her. The facility assessment dated [DATE] for R7 shows her to be cognitively intact.On 6/30/26 at 8:57 AM, V6 Housekeeper said the facility does not always get cleaned on the weekends.On 6/30/26 at 11:39 AM, V7 Housekeeping Supervisor said the floors in the facility need some TLC (tender loving care). V7 said the floors in the resident rooms need to be swept and mopped every day.On 6/30/26 at 1:27 PM, V5 Housekeeper said she mops every day, but is not sure what the other housekeepers are doing.On 6/30/26 at 1:29 PM, V4 Housekeeper said he is new to the facility and was trained to only mop the floors if they are sticky.On 6/30/26 at 1:50 PM, V3 [NAME] President of Clinical Operations said all resident rooms should be cleaned every day.The resident council meeting minutes for June 2026 show the residents stating there are days their rooms are only getting mopped but not swept.The undated facility policy for Housekeeping cleaning schedule shows to establish a schedule which ensures the building and equipment is maintained in a clean and sanitary manner. Daily cleaning of the resident room floors.

Based on observation, interview, and record review the facility failed to maintain the south shower room in a safe, sanitary, functional and comfortable condition for residents. This applies to 51 residents residing on the south wing. The findings include: The findings include:The facility census dated 3/31/26 showed 51 residents reside on the south hall. On 3/31/26 at 11:30 AM, R4 was sitting up on the edge of his bed. R4 said he takes a shower at the facility and when he first came to the facility he had to use the south shower room, but then he found out about the north shower room, and he prefers to use it. R4 said it would be nice if the shower room on this side of the building had warm water. I had to take a shower in there a few times and it was cold to luke warm water. That's no way to take a shower. R4 said we should be able to take a nice shower in warm water.On 3/31/26 at 11:41 AM, R6 said she gets showers, but she goes to the shower on the other side of the building (north) because the south shower doesn't have warm water. On 3/31/26 at 11:48 AM, V4 (Licensed Practical Nurse - LPN) entered the south shower room with the surveyor. There were black spots all over the shower room ceiling. The black growth was more concentrated near a rusted vent grate. The vent grate had peeling white paint and rust. The black spots/growth were spread across the ceiling and walls of the shower room. The was no shower stall, just a shower head in the corner of the small room. There was a musty odor to the entire room. V4 said the Certified Nursing Aides (CNAs) use the shower room for residents, but this was the first time she had been in there. The surveyor asked V4 what she thought the black spots/growths were. V4 replied, It looks like mold. V4 said there was an odor in here and it was probably from that, pointing to the mold on the ceiling and walls. On 3/31/26 at 11:55 AM, V6 (LPN) said she tries to prevent her residents from using that shower. V6 said most residents prefer using the other shower (North shower) for the reason you are here. V6 said you're hear for lack of hot water in there and the gross on the walls. V6 said it smells musty in there and there are black spots on the walls and ceiling. V6 said most of the residents refuse that shower room, but some CNAs and hospice CNAs do use that shower room (south). On 3/31/26 at 11:59 AM, V7 (Activities Aide) said that shower room had been like that since January 2026. V7 said the mold, smell, and lack of warm water have been brought to management. V7 said the residents shower in there and it's gross. On 3/31/26 at 12:00 PM, V9 (CNA) said we try not to use the south shower room, but sometimes it's necessary. V9 said the residents complain about the south shower. V9 said there are black spots all over the place in there, it smells musty all the time, and the water doesn't get very warm. V9 said the south shower room has been an ongoing issue. V9 said management has been notified and it doesn't seem like they are listening. On 3/31/26 at 12:05 PM, V9 (CNA) said she doesn't give showers in the south shower room because there is mold in there. There are black spots all over and it smells like mold in there. Everyone knows it, but I don't think anything is being done about it. The water also takes a long time to warm up.On 3/31/26 at 12:13 PM, V3 (Maintenance Director) entered the shower room with the surveyor. V3 turned on the shower head in the corner of the room. The surveyor pointed to the black spots/growths all over the ceiling (especially near the rusted vent grate) and the walls. The surveyor asked what that was. V3 replied, I think it's mildew from the water running and no ventilation. The surveyor asked if it could be mold. V3 replied, I'm not really sure the difference between mold and mildew. V3 said the exhaust fan was broken and it wasn't reported by the staff. V3 said he didn't find out until there was a grievance filed by a doctor's office. V3 said he came to the shower room to check. V3 said the exhaust fan wasn't working, so there was no ventilation. V3 said he had no idea how long the exhaust fan was broken. V3 said the warm, damp room with no ventilation caused the black spots to show up and the vent grate to rust. V3 said the smell is from the mildew. V3 said he fixed the fan last week or the week before but hadn't had a chance to fix the rest yet. At 12:19 PM (with the shower running for 6 minutes), V3 checked the running water in the shower. The water temperature was 89.2 degrees Fahrenheit (F). V3 said the water does get warmer, but it takes a while. The surveyor asked V3 if he would want to take a shower in that water. V3 replied, Hell no, I wouldn't want to take a shower in that. I wish I could make it warmer, but I can't. At 12:23 PM (with water running for 10 minutes), V3 checked the water temperature, and it reached 94 degrees. V3 stated, It shouldn't take this long. I wonder if there is an issue with the valve in this shower. V3 exited the shower room and checked the water temperature of the running sink in the room across the hall. The water temperature was 109 degrees F. V3 went back to the shower room and stated, Theory would say the water in the shower should be the same. I have the water turned all the way on hot. At 12:25 PM, V3 tested the water temperature, and it was 87.9 degrees F. V3 said he could feel the water get warmer and cooler when he held his hand under the water. V3 said I probably need to check the valves. On 3/31/26 at 3:49 PM, V2 (Director of Nursing - DON) said she was not aware of concerns with the south shower room having mold/mildew or water temperature issues. V2 said she goes in the shower room but doesn't look at the walls or the ceiling. V2 said she would not expect there to be mold/mildew in the shower room and it could put residents at risk for health concerns. V2 said if there were concerns with mold then corporate would make sure it was taken care of. V2 said if she was taking a shower she would want the water to be warm. V2 said all residents are encouraged to take showers and not bed baths. V2 said the shower on south hall hadn't been remodeled for many years, but the north shower was remodeled more recently and was nicer. On 3/31/26 at 4:08 PM, V1 (Administrator) said the facility did receive a grievance from doctor in the community. V1 said she didn't speak with the doctor directly but was called by her corporate office. V1 said a Grievance Form was completed, but she was told there was a black substance in the building. The surveyor asked V1 if she had been in the shower room. V1 said she had. V1 said she saw the black spots on the ceiling and walls of the shower room and the rusted vent. V1 said parts and paint were ordered. The surveyor asked if the black spots were mold. V1 replied, I was thinking more mildew.' V1 said the shower room should not look like that. The surveyor asked what the water temperature should be. V1 replied, the water temperatures should be no greater than 110 degrees F. The surveyor asked if she would want to take a shower in 89-degree F water. V1 said that doesn't sound like a very warm shower. V1 said she would expect the shower to be clean, functional, and warm for the residents. On 4/1/26 at 10:45 AM, V1 said the facility did not have a General Maintenance Policy or a Mold policy. The facility Grievance Form dated 3/20/26 showed a community physician had a concern of no hot water and mold noted in the facility. This form showed this was partially substantiated. This form showed, Hot is subjective to the individual. Our water temperatures are maintained at 120 degrees F or higher for infection control, and thermostatically mixed via a thermostatic mixing valve to achieve between 100-110 degrees F output temperatures at fixtures to prevent scalding. Several fixtures tested between 104-110 degrees F. Mold that was located due to a ventilation issue in the shower room is being remediated. This form was signed by V1 (Administrator) on 3/23/26. The surveyor requested policies for General Plant Maintenance and Mold, but none were received.

Based on interview and record review the facility failed to provide adequate supervision to a resident with a history of falling for 1 of 3 residents (R1) reviewed for falls in the sample of 6. The findings include:The facility's Fall Report dated 10/31/25 to 3/31/26 showed R1 had un-witnessed falls on 2/1/26 at 10:15 AM, 2/10/26 at 2:20 PM, and 2/20/26 at 8:50 PM. R1's Facesheet dated 3/31/26 showed she had diagnoses to include, but not limited to unspecified fracture of right patella for closed fracture routine healing (1/15/26); diabetes; unsteadiness on feet; abnormalities of gait and mobility; fracture of right pubis (1/15/26); gastroesophageal reflux disease (GERD); chronic gout; history of falling; dementia; major depressive disorder; age related osteoporosis; osteoarthritis and hypertension. R1's facility assessment dated [DATE] showed she had severe cognitive impairment; required partial/moderate assistance with toilet hygiene and bed mobility; required substantial/max assist for shower/bathing, sit to lying, and lying to sitting; was dependent for transfers; was occasionally incontinent of urine and frequently incontinent of bowel. R1's Progress notes showed on 2/1/26 R1 was found sitting on the floor. This note showed R1 said she slid out of bed while sitting on the edge of the bed. R1 had a small abrasion to her right knee but denied pain. R1's Fall - Initial Occurrence note dated 2/10/26 showed R1 had an unwitnessed fall in her bathroom, and she was heard yelling help from the room. This note showed R1 was found sitting upright in the bathroom doorway. R1 said she didn't know what happened. R1's Social Service Note dated 2/18/26 showed R1's room was changed. (R1's new room was not near the nurses' station; it is around the corner and halfway down a long hall.) R1's Fall - Initial Occurrence note dated 2/21/26 showed R1 had an unwitnessed fall in her room on 2/20/26 at 8:50 PM. This note showed CNA reported resident was on the floor. This nurse went to R1's room and she was on her buttocks. This note showed R1 reported she was trying to get up and go to the bathroom, slipped, and ended up on the floor. This note showed R1 had an abrasion to her right knee, but no change in range of motion. This note showed R1 was assisted off the floor with a mechanical lift, placed in her wheelchair, and assisted to the bathroom. R1's Care Plan initiated 1/16/26 showed R1 had an Activities of Daily Living (ADLs) self-care deficit that may fluctuate with activity throughout the day related to a healing patella fracture with surgery. R1's Care Plan initiated 1/19/26 showed she was resistive to care and often refused to wear my (knee) brace related to dementia. R1's Fall Care Plan initiated 1/16/26 showed she was at risk for falls related to a fall at home with fracture of my patella. The interventions included place resident in high visible areas when not in bed; and anticipate and meet the resident's needs.R1's Fall Risk assessment dated [DATE] showed R1 was At Risk for Falls.On 3/31/26 at 11:34 AM, R5 said R1 had only been in her room a few days before she fell. R5 said R1 was always getting up when she wasn't supposed to. R5 said she would tell R1 not to get up on her own and to use her call light, but R1 would tell her she could do it. R5 said she would turn her call light on to get R1 help. R1 said she was sleeping that night (2/20/26) and when she turned her head she saw R1's feet on the floor, over by the entrance door and R1's side of the room. R5 said she asked R1 what happened, and she said she fell. R5 turned on the call light and they started yelling for help. R5 said R1 had some blood coming through her pants, on her knee. R5 said R1 wasn't complaining about pain after she fell, in fact R1 got up by herself again the next morning. On 3/31/26 at 12:05 PM, V9 (Certified Nursing Assistant - CNA) said she was familiar with R1. V9 said R1 frequently tried to get up unassisted. V9 said we redirected R1, but she would forget, and we'd have to remind her again. V9 said they tried to keep R1 in the common areas and activities, but if she was in her room then she did checks on her every 15 minutes. On 3/31/26 at 12:50 PM, V19 (R1's POA) said R1 had fallen in the community and was admitted to the facility for short-term rehab. V19 said R1 had fallen three times since she her admission on [DATE]. V19 said R1 was moved to a new room and the room was far away from the nurses' station. V19 said R1 couldn't remember to use her call light due to dementia, and she reminded the staff of that. V19 said she was concerned R1 was that far from the nurses' station and had to yell for help. V19 said R1 was transferring back and forth to the bathroom and bed all weekend. V19 said on Tuesday (3/24/26) R1 had a follow-up appointment with the orthopedic surgeon (V10), had X-rays, V10 had R1 admitted to the hospital and she had surgery the next day for a knee fracture. On 3/31/26 at 2:04 PM, V17 (CNA) said she didn't see R1 fall. V17 said she didn't know when R1 went to her room that night. V17 said she didn't witness R1's fall and she wasn't involved with the care after. On 3/31/26 at 2:09 PM, V15 (CNA) said she knows who R1 was, but wasn't on her assignment very often. V15 said she didn't go in R1's room at all on 2/20/26 and she doesn't know when R1 went back to her room that night. V15 said they had to keep a close eye on R1. V15 said R1 was a high fall risk and was usually out in the common areas to keep an eye on her. V15 said when R1 was in her room, they should round on check on her frequently. On 3/31/26 at 2:33 PM, V13 (CNA) said she wasn't working R1's assignment on 2/20/26. V13 said she's on the other side of the hall and that assignment keeps her busy. V13 said she doesn't know much about R1. On 3/31/26 at 3:06 PM, V14 (CNA) said she was working when R1 fell, but she didn't witness the fall. V14 said she's not sure when R1 went in her room. V14 said R1 was confused and would often try to get up on her own. On 3/31/26 at 3:35 PM, V12 (Registered Nurse - RN) said R1 had moved from the north hall to the south hall. V12 said R1 was a risk fall. V12 said R1 was only on the south hall for 3 days before she fell. V12 said R1's room was not close to the nurses' station. V12 said the decision for room placement is up to management. V12 said he saw R1 earlier in the shift, coloring in the common area. V12 said he doesn't know what time R1 went to her room. V12 said he saw her coloring and the next time he saw R1 she was on the floor. V12 said a CNA reported R1 was on the floor. V12 said when he went to the room R1 was sitting on her butt on the floor, a few steps from her bed. V12 said R1 had some bleeding from her knee. V12 said he checked range of motion and palpated her knee. V12 said he didn't see any bruises or deformities. V12 said R1 was able to transfer later with no issues. V12 said R1 was confused and always tried to transfer herself. On 3/31/26 at 3:07 PM, V16 (CNA) said she wasn't assigned R1 on 2/20/26. V16 said she doesn't know when R1 went back to her room, she didn't witness R1's fall, and she did respond to R1's fall. On 3/31/26 at 4:20 PM, V18 (CNA) said he saw R1 coloring earlier in the shift, but he didn't know when R1 went back to her room. R1 said he went in R1's room and she was on the floor on her knees. V18 said R1 was between her bed and the entry door to her room. V18 said she had some blood on her knee. V18 said he doesn't remember when he saw her before the fall. V18 said he was not sure if R1 was a fall risk or if she tried to self-transfer. On 3/31/26 at 3:49 PM, V2 (Director of Nursing - DON) said R1 was pleasantly confused and had three falls at the facility. V2 said R1 continuously removed her knee brace, could self-propel short distances, and would try to self-transfer. V2 said there was not a room closer to the nurses' station available when they moved R1. V2 said a room closer to the nurses' station would allow the staff to keep a closer eye on her.V2 said the staff should be following the facility fall protocol and the R1's care plan. The facility's Fall Prevention Program revised 12/17/25 showed the purpose is to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. This policy showed safety interventions will be implemented for each resident identified at risk.

Based on observation, interview, and record review the facility failed to provide ordered medications and failed to administer the correct medication. This applies to 2 of 5 (R5 & R1) reviewed for medications in the sample of 13.The findings include: 1. R5's admission Record showed diagnoses to include but not limited to stroke, heart failure, atrial fibrillation (rapid and irregular heartbeat). R5's December 2025 Medication Administration Record (MAR) showed her 12/18/25 diltiazem for her congestive heart failure 240 milligrams (mg) extended release medication was documented as not given. R5's MAR also showed her 12/18/25 duloxetine 30 mg for her depression was documented as not given. On 12/18/25 at 9:20 AM, V4 stated R5 was out of her duloxetine and diltiazem. V4 stated the medication refills were rejected by the pharmacy for an unknown reason. V4 said the diltiazem was rejected on 12/15/25 and the duloxetine was rejected on 12/17/25. V4 stated it is the policy that the nurses notify the Director of Nursing if medications are rejected. On 12/19/25 at 9:30 AM, R5's December 2025 MAR showed her 12/19/25 duloxetine and diltiazem had been documented as given. On 12/19/25 at 10:35 AM, V12 RN stated she had given R5 her last available dose of diltiazem and duloxetine from R5's medication cards. (The residents' prescription medications come in a foil-backed punch cards.) V12 was asked to provide R5's completed duloxetine and diltiazem cards. V12 was then made aware that V4 was not able to pass these medications the day prior due to the medications being unavailable. V12 then stated she borrowed these medications from other residents. V12 showed R11's medication card for duloxetine 30 mg stating she used this card. V12 then showed R12's diltiazem 60 mg tablets (not extended release) and stated she gave R5 this medication. On 12/19/25 at 10:45 AM, V12 stated she gave R5 three tablets of R12's 60 mg diltiazem. V12 then changed and said two tablets were given, then four tablets, then stated no, I gave two tablets. On 12/19/25 at 10:50 AM, V12 then approached this surveyor in the conference room and stated, At first I gave her two (tablets of Cardizem) then saw she was on 240 (mg dose) and then I gave her two more. On 12/19/25 at 10:55 AM, V12 approached this surveyor in the conference room and stated she only gave one tablet of R12's diltiazem to R5. R12's December 2025 MAR showed an order for diltiazem 60 mg (not extended release) to be given three times a day. On 12/19/25 at 11:10 AM, V2 Director of Nursing stated, They cannot take the meds from the other residents, it violates the 5 right of medications. They could give the wrong dose and then the other resident, depending on their insurance, they may not be able to get their medication filled when they need it. On 12/19/25 at 12:23 PM V2 stated, [Diltiazem] is a cardiac medication, and it is used to treat high blood pressure. It comes with parameters of when it can be given and if it needs to be held. Extended release and the regular diltiazem treat the same issues, but they cannot be interchanged. The nurses should not be making judgement calls when it comes to medications dosages. The facility's policy Medication Administration General Guidelines showed, Five Rights- Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended. The policy showed, If a medication with a current active order cannot be located in the medication cart/drawer, other areas of the medication cart.the pharmacy is contacted or the medication is removed from the emergency kit. The policy continued, Medications supplied for one resident are never administered to another resident. 2. R1's Face Sheet showed diagnoses to include but not limited to dysuria (difficult and/or painful urination), urinary tract infections, and kidney cancer. R1's Order Summary Report (Physician Order Sheet/POS; provided 12/19/25 at 12:55 PM) showed an active order for Mirabegron 50 milligrams daily for incontinence. R1's December 2025 Medication Administration Record (MAR, printed 12/19/25 at 1:00 PM) showed R1's mirabegron was documented as 9 Other/See Progress Notes on 12/3/25, 12/6/25, 12/7/25, 12/8/25, 12/9/25, 12/11/25, 12/14/25, 12/15/25, and 12/17/25. On 12/19/25 the medication was documented as Hold/See Progress Notes. On 12/18/25 at 8:51 AM, V3 Registered Nurse stated R1's mirabegron was not available, and she was not able to administer it. (At this time R1's MAR showed the Mirabegron was documented as given.) On 12/18/25 at 2:07 PM, V3 stated she has not looked to see if R1's mirabegron was available in the facilities emergency supply. On 12/18/25 at 2:20 PM, R1 was alert and oriented to person, place, time, and condition. R1 stated she was uncertain if she was on a medication for her bladder; however, R1 stated she has an overactive bladder and needed to use the bathroom frequently. R1 stated she would expect the staff to notify her if she is out of a medication. R1 stated she had not been notified of missing medications. On 12/23/25 at 1:10 PM, V2 Director of Nursing stated she expects staff to notify her if the pharmacy rejects filling a medication, so she can correct the reason for the rejection. V2 stated, lately, if a resident's medication is rejected, it is often related to insurance issues. V2 said, if she is notified, she can contact the provider for an alternative medication. V2 said R1's missing medication is for her overactive bladder. V2 said R1's medication was rejected by the pharmacy, and she was not notified of the rejection by nursing staff. V2 stated she was unable to determine the last day R1 received her mirabegron; however, if she had been notified some of the missed doses could have been prevented.

Based on interview and record review the facility failed to provide ordered wound care for 2 of 3 residents (R2 and R3) reviewed for nursing care/wound care in the sample of 13. The findings include: 1. R3's admission Record showed diagnoses to include but not limited to dementia, diabetes type 2, heart failure, and an antibiotic resistant organism infection. R3's 12/10/25 Wound Assessment Details Report showed he had an open venous stasis (poor venous circulation) ulcer to his left lower leg front measuring 7.5 centimeters (cm) by 2.0 cm by 0.1 cm deep. The wound assessment showed a second wound/skin tear to his right lower leg measuring 2.0 cm by 1.5 cm by 0.0 cm deep. R3's November 2025 Treatment Administration Record (TAR) showed an order for daily wound treatments to his left and right legs. The treatments consisted of cleansing, ointments, oil emulsion dressings, and gauze wraps. The order was started on 10/16/25. The TAR showed treatments were not documented as having been done on 11/3/25, 11/16/25, 11/20/25, 11/25/25, and 11/28/25. R3's December 2025 TAR showed the same ordered treatment for his right and left legs as the November 2025 TAR. The December 2025 TAR showed no documentation for these treatments on 12/11/25, 12/12/25, and 12/16/25. R3's December 2025 progress notes showed no documented treatments for these days and showed no explanation for the missing treatments. On 12/19/25 at 11:10 AM, V2 Director of Nursing stated wound care should be documented on the TAR when it is done. V2 stated if the resident refuses, he or she should educate and make another attempt, then document the refusal. V2 stated if the wound care is not documented on the TAR there is no proof the wound care was completed. V2 stated wound care is important for wound healing, infection prevention, and provides an opportunity to assess the wound. 2. R2's 12/10/25 Wound Assessment Details Report showed a skin tear to his left foot measuring 1.0 centimeters (cm) by 1.0 cm by 0.0 cm deep. The left foot wound was identified on 11/3/25. The wound report showed a second skin tear to his left knee measuring 0.8 cm by 0.5 cm by 0.0 cm. The left knee was identified on 12/3/25. R2's December 2025 Treatment Administration Record (TAR) showed an order for Monday, Wednesday, and Friday wound care. The treatments including normal saline cleansing, oil emulsion dressing, and a bordered dressing. The TAR showed not documented treatments on 12/12/25 and 12/15/25. The TAR showed an identical treatment and schedule for his left knee. The TAR showed the left knee treatments were not documented as being done on 12/12/25 and 12/15/25. On 12/19/25 at 12:49 PM, R2 stated Sometimes they are too busy to get to my wound treatments. On 12/19/25 a policy for wound care treatment was requested and was not provided.

Based on observation, interviews and record review, the facility failed to ensure that dietary support staff completed a food handler's training course within thirty days of hire and failed to have a policy in place to ensure dietary staff complete this required training for safe food handling per Illinois Department of Public Health (IDPH) regulations. This failure affects all 80 residents who currently reside at the facility.The findings include:Facility data sheet completed by V1 (Administrator) and dated 12/06/2025 indicated 80 residents currently reside at the facility. On 12/06/2025 from 12:05 to 12:38 PM, main dining room and kitchen observations were conducted. During this time, V5, V6, V7 (Dietary Aides) and V8 (Cook) were all observed preparing lunch trays and handling resident's food in the kitchen.On 12/06/2025 at 01:55 PM, V5 (Dietary Aide) said she is food handler certified then added that the course is about three hours long and included a lot of information related to safety in food service. On 12/06/2025 at 01:57 PM, V6 (Dietary Aide) said she has been employed by the facility for three months but does not have her food handler's certificate. V6 indicated she is in the process of getting it. When asked when the course was started, V6 could not indicate a start date. On 12/06/2025 at 02:00 PM, V7 (Dietary Aide) said she has been employed by the facility for three months but does not have her food handler's certificate. V7 then indicated she was not made aware that she needed to complete the course. On 12/06/2025 at 02:02 PM, V8 (Cook) said there hasn't been a dietary manager for about a month then indicated that V1 (Administrator) has been overseeing the dietary staff. V8 then said dietary staff should complete the food handlers' course for safety and cross contamination purposes and indicated that all resident meals are prepared by the dietary staff. On 12/06/2025 at 2:34 PM, V1 said she had to let the previous food service director go so she is currently the acting food service manager. V1 was aware that two of the three dietary aides currently working do not have their food handler's certificate. At 02:56 PM, V1 said all dietary aides should have their food handler's certificate for sanitation and infection control purposes in the safe handling of resident's food.On 12/06/2025 at 03:50 PM, V1 initially said dietary staff should have their food handlers certified within thirty days of hire, then recanted and said she was unsure of the timeframe. V1 then indicated the facility does not have a food handler's policy but they follow IDPH regulations.On 12/06/2025, reviewed food handler's certificates provided by V1. No certificate was provided for V6 or V7 (Dietary Aides).

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, and served in a manner to prevent cross-contamination and foodborne illness. This failure has the potential to affect all the residents in the facility. The findings include: The CMS (Center for Medicare and Medicaid Services) form 671, dated 6/24/2025, showed 70 residents resided in the facility. On 6/24/25 at 9:07 AM, V7 (Dietary Aide/Dietary Cook) took a container of test strips out to V15 (Dietary Aide) and informed her that this surveyor wanted her to test the chemical concentration in the sanitation bucket V15 was using to wipe down the tables after the breakfast meal. V15 tested the sanitation bucket, and the strip showed zero chlorine concentration was in the bucket. V7 came back into the dining room with Hydrion test strips and told V15 she gave her the wrong test strips because the Shurgard Plus sanitizer was used in the bucket. V15 tested the sanitation bucket again with the Hydrion test strips and said the chemical concentration was 150 parts per million (ppm) even though the strip went into the bucket an orange color, and when she pulled it out, it only turned a lighter shade of orange. V15 said it should be between 150-200 ppm. At 9:15 AM, V7 was shown the test strip from the sanitation bucket. V7 said the chemical concentration was too weak and there was not enough sanitation in the bucket. Neither V7, nor V15 added more chemical to the sanitation bucket. V15 continued to use the same bucket to clean the rest of the tables in the dining room. On 6/26/2025, The facility provided this surveyor with the container of Shurgard Plus for review. The label on the container showed Food Contact Surface Sanitization. When used as directed the product is an effective sanitizer at an active quaternary concentration of 200-400 ppm. The facility provided the test procedure for the QT-10 (Quaternary) Sanitizer Test. The document showed the results required should be between 150-400 ppm. The chart listed on the procedure test (and on the insert in the test strip container) showed the first bar on the chart was orange, signifying zero chemical concentration. The second bar was a brownish/burnt-orange color signifying 100 ppm chemical concentration. The third through the fifth bars were different variations of green signifying 200-400 ppm chemical concentration. The facility's 2020 policy and procedure titled Sanitizing and Disinfectant Solution showed employees shall refer to the manufacturer guidelines for the proper use of sanitizer and disinfectant solutions. 1. The employee will prepare sanitizer solution or disinfectant solution in accordance with manufacture guidelines .7. Sanitizing solutions are changed in accordance with manufacturer instructions or when they become visible soiled. In general, each shift should prepare fresh solutions. A test tape/paper should be used to verify the concentration. On 6/24/2025 at 9:17 AM, V7 was in the kitchen washing dirty dishes from the breakfast meal. V7 was not wearing gloves while handling the dirty dishes. V7 pulled a tray containing 2 pitchers and a gallon of milk into the kitchen, touched the handle of the milk, then walked over to the hand washing area, washed her hands, walked back over and picked up the gallon of milk by the handle, opened the door to the cooler and placed the milk inside the cooler. V14 (Cook) was on the clean side of the dish machine area picking up dishes and putting them away. V14 was not wearing gloves while touching the clean dishes. On 6/24/2025 at 9:28 AM, the temperature logs for the walk-in cooler, the 3 freezers, and the walk-in freezer had several missing entries on each of them. The temperature in the middle freezer showed a temperature of 60 degrees Fahrenheit. V14 (Cook) said the middle freezer was broken and the food in there needs to be thrown out. There was no sign on the door indicating that the freezer was out of order. At 9:34 AM, V1 (Administrator/person in charge of Dietary until the new Dietary Manager starts the following week) said she was not informed about the broken freezer. In the walk-in cooler there was a large ice coffee, from a local fast-food place, sitting on a shelf above food items for the residents. The iced coffee had a sticker with V7's (Dietary Aide/Cook) name on it. At 12:02 PM, the large, iced coffee was still in the walk-in cooler above food for the residents. V7 was asked if it was okay to keep their personal drinks in the cooler with residents' food. V7 said she had not been told that they could not do it. V7 went out of the kitchen, came back in and said she asked V1 (Administrator) and V1 said it needs to be labeled and covered, then it is okay. V14 (Dietary Cook) was standing next to this surveyor and said no, it is not okay to be in there. On 6/24/2025 at 1:10 PM, V1 (Administrator) said she would expect dietary staff to check to make sure the chemical concentration is within the recommended range in the sanitation buckets every time they change the water. She said she did not tell V7 it was okay to have her beverage in the cooler with the residents' food. It is not okay. On 6/26/2025 at 1:00 PM, V3 (Director of Nursing-DON) said the facility does not have a policy and procedure regarding staff not keeping their food and beverages in with the residents' food. V2 said she would not expect dietary staff to have their beverages in the cooler with residents' food. The facility's June 2025 Temperature Log showed no entries were recorded on day shift for the walk-in Fridge (cooler) on 6/16/2025. No entries on the PM shift from 6/9/2025 through 6/18/2025, 6/20/2025, and 6/23/2025. The facility's June 2025 Temperature Log for the walk-in Freezer showed no entries were documented for the PM shift from 6/14/2025 through 6/18/2025, 6/20/2025, and 6/23/2025. The facility's June 2025 Temperature Log for the Small Freezer 1 showed no entries were documented on the AM shift on 6/23/2025, and no entries were documented on the PM shift on 6/12/2025, 6/14/2025 through 6/18/2025, and on 6/23/2025. The facility's June 2025 Temperature Log for the Small Freezer 2 (the one that was reading 60 degrees Fahrenheit on 6/24/2025) showed no entries documented on the PM shift from 6/14/2025 through 6/18/2025, 6/20/2025, and on 6/23/2025. The log is circled as a freezer log and shows Fridges must be kept at 41 degrees F (Fahrenheit) through 33 degrees F (Fahrenheit), and freezers must be kept at zero degrees F (Fahrenheit) or below. The entries on the log showed temperatures ranging from 20 degrees Fahrenheit through 65 degrees Fahrenheit. The log showed a temperature of 60 degrees Fahrenheit on 6/20/2025 on the AM shift, and no entry for the PM shift. The facility's June 2025 Temperature log for the Small Freezer 3 showed no entries were documented on the PM shift from 6/1/2025 through 6/3/2025, on 6/6/2025, 6/10/2025 through 6/12/2025, 6/14/2025 through 6/18/2025, 6/20/2025, and on 6/23/2025. The log showed temperatures ranging from minus 30 degrees Fahrenheit through 68 degrees Fahrenheit. The log showed on 6/5/2025 a temperature of 60 degrees Fahrenheit on the AM shift, and 40 degrees Fahrenheit on the PM shift. A temperature of 68 degrees Fahrenheit on 6/6/2025 during the AM shift, and no documentation on the PM shift as to whether the freezer was out of order, or still being used. The log showed the freezer was off from 6/7/2025 through 6/9/2025. The facility's Food Temperature Logs from 6/1/2025 through 6/23/2025 were reviewed. The logs showed no temperatures were documented on the logs for the following days and meals: On 6/2/2025 no food temperatures were documented for the dinner meal. On 6/6/2025 no food temperature was documented for the meat during the dinner meal. On 6/9/2025 no food temperatures were documented for the dinner meal. On 6/10/2025 no food temperatures were documented for the lunch meal. On 6/11/2025 no food temperatures were documented for the breakfast or lunch meals. On 6/12/2025 no food temperatures were documented for the dinner meal. On 6/14/2025 no food temperatures were documented for the dinner meal. On 6/22/2025 no meat or starch temperatures were documented for the dinner meal. On 6/23/2025 no food temperatures were documented for the lunch or dinner meals. On 6/24/2025 at 11:08 AM, V14 (dietary Cook) was making the pureed meals for the lunch meal. V14 uncovered the cooked broccoli that was on the steam table and removed some for the pureed diets. V14 left the broccoli uncovered while making the pureed broccoli and pureed chicken for the pureed diets. At 11:27 AM, V14 covered the broccoli back up. At 1:10 PM V1 said food should be covered on the steam table until it is ready to be served. On 6/24/2025 at 12:10 PM, V7 was plating food for the residents in the South dining room. V7 was wearing gloves. V7 was touching the residents' meal tickets, the tray, the plates, meal tickets, and a loaf of bread were on, and then reached into the loaf of bread, removing a slice of bread and placing it on top of the food on the plate. V7 repeated this action with most plates she plated. At 12:13 PM, V7 touched the wet cloth that was sitting on the serving counter, then continued plating food and putting her same gloved hand in the loaf of bread, like the previous observations. V7 did not wash her hands or change her gloves while plating the food for the residents in the south dining room. At 12:35 PM, V1 (Administrator) said gloves should be worn when washing the dishes and putting them away. V1 said if washing dishes, gloves should be removed, and hands should be washed prior to touching anything to prevent cross-contamination and foodborne illness. V1 said it is not acceptable to touch the meal tickets, the tray the plates are on and the washcloth that is used to clean the steam table, then put your hand in a loaf of bread and serve it to the resident's. V1 said it is important not to do that, to prevent cross-contamination and foodborne illness. While talking with V1, V7 was placing plate covers on the residents' plates for the room trays. V7 put one of the plate covers against her stomach and flipped it over. That plate cover did not get used because that tray was not needed. V7 picked up another plate cover and fanned herself with it, then placed it back on top of 2 other covers when she was informed that they were done plating. V7 put the 3 plate covers on the shelf above the prep table. V1 (Administrator) told V7 to put the plate covers in the dish washing area because she used it to fan herself, she was not wearing gloves, and her hair net was half off. (V7's hair net was halfway off while plating the room trays). The facility's 2020 policy and procedure titled Code of Dress and Personal Appearance showed, all dining service employees will comply with printed and posted personal hygiene guidelines, sanitation practices, and dress codes of this community. 1. The following practices and guidelines will be enforced by the Dining Services Manager: a. Employees will use effective hair restraints, such as hairnets, hair bonnets, and beard guards to prevent contamination of food or food contact surfaces. B. Hands will be washed after touching face, hair, or personal effects .j. All eating will take place outside of the kitchen area. The facility's 2020 policy and procedure titled Proper Hand Washing and Glove Use showed, all employees will use proper hand washing procedures and glove usage in accordance with State and Federal sanitation guidelines .3. All employees will wash hands upon entering the kitchen from any other location, after all breaks (including bathroom and smoking breaks), and between tasks. Hand washing should occur at a minimum of every hour. 4. Employees will wash hands before and after handling food, after touching any part of the uniform, face, or hair, and before and after working with an individual resident. 5. Gloves are to be used whenever direct food contact is required. 6. Hands are washed before donning gloves and after removing gloves. 7. Gloves are changed any time hand washing would be required. This includes .if the gloves become contaminated by touching the face, hair, uniform, or other non-food contact surface, such as door handles and equipment. 8. Staff should be reminded that gloves become contaminated just as hands do and should be changed often. When in doubt, remove gloves and wash hands again. The facility's 2020 policy and procedure titled HACCP (Hazard Analysis Critical Control Point) and Foodborne Illness showed, common factors identified that are responsible for foodborne illness include, but are not limited to, holding food at improper temperatures, using contaminated equipment, and poor personal hygiene. The policy showed cross-contamination and poor personal hygiene can cause foodborne illness, and elderly people with weakened immune systems, people who are seriously ill, and people taking certain medications, such as antibiotics or immunosuppressants are High-risk populations and have a higher- risk of contracting a foodborne illness. The facility's 2020 policy and procedure titled Refrigerator and Freezer Temperatures showed To ensure all perishable foods stay fresh and palatable, temperatures will be recorded on all refrigerators and freezers in use, including unit refrigerators located in nourishment rooms .2. Each refrigeration and freezer unit in the main kitchen is checked at department opening and before any food product is used for the day. The employee ensures that all cold storage units are 41 degrees Fahrenheit or below for refrigeration or zero degrees Fahrenheit or below for freezers. Throughout the day staff that remove items from cold storage unit(s) ensures the temperature is in allowable range .3. The temperature of each refrigeration and freezer unit is checked by the staff member who is closing the department for the day .If the unit is not in the correct operating range, the staff member alerts management per facility policy. The staff member does not leave the department until correction action is verified in #5 .5. If the temperature on the thermometer located inside the refrigerator or freezer is outside of the acceptable range for safe food handling, the corrective action is: a. A food item (PHF/TCS-potentially hazardous foods/time and temperature control for safety) is selected and the temperature is taken. If this is the first check of the day, and the food item(s) are greater than 41 degrees Fahrenheit and cannot be validated to have been over 41 degrees Fahrenheit for less than 4 hours, the food is discarded .c. If the food is at less than 41 degrees Fahrenheit, the unit will be emptied, and the foodstuff transferred to another refrigerator/freezer and the unit locked out/tagged out per facility policy.

Based on observation, interview, and record review the facility failed to sanitize a glucometer and remove gloves after use to prevent cross contamination for 12 of 12 residents (R32, R6, R37, R61, R43, R17, R30, R11, R38, R16, R221, and R41) reviewed for infection control in the sample of 42. The findings include: The facility supplied list of residents residing on the southeast unit with orders for blood sugar checks included R32, R6, R37, R61, R43, R17, R30, R11, R38, R16, R221, and R41. On 6/25/25 at 3:45 PM, V4 (Registered Nurse) donned a pair of gloves and prepared the glucometer for use (handheld device for measuring the concentration of glucose in the blood, using a small drop of blood placed on a disposable test strip). V4 entered R32's room and obtained a blood sample from the left hand finger. V4 completed the medication pass for R32 and exited the room. V4 continued wearing the contaminated gloves and placed the used glucometer on top of the medication cart. V4 wore the same gloves while charting on the computer, touching multiple medications inside the cart, and preparing the next resident's medication pass (R43). V4 did not remove her gloves until V1 (Administrator) passed by and told her to do so. On 6/25/25 at 4:03 PM, V4 used the same glucometer to obtain a blood sample for R43. V4 completed the medication pass for R43 and exited the room. V4 laid the contaminated glucometer on top of the cart and prepared medications for the next resident. At no time during the observations did V4 clean or sanitize the glucometer in any way. On 6/26/25 at 9:40 AM, V9 (Infection Control Preventionist) stated gloves should only be used in resident rooms. Staff need to remove them prior to leaving the room. It reduces the spread of infection. Gloves are needed during any type of care task, including blood sugar checks. There is the potential for cross contamination of germs and blood borne pathogens. All blood is assumed contaminated. Staff are educated on correct technique and should be following it all the time. V9 said all the medication carts are stocked with two glucometers. The glucometers should be sanitized with wipes after every use and let sit for three minutes. Nurses should be using the spare one while the other one is drying. It is important to sanitize in between each resident to stop cross contamination. V9 said all residents on the southeast unit use the same glucometers and medication cart. The facility's Glove Use-Nursing policy revision dated 1/31/18 states: 5. Gloves used for contact shall be removed and discarded after each contact with each person, fluid item, or surface. The facility's Glucometer Cleaning policy revision dated 11/17/17 states: 4. Wipe meter with 1:10 solution bleach wipe/towel until all surfaces of the glucometer are visibly wet. Do not wipe inside battery compartment, code chip port or test strip port. 5. Discard bleach wipe/towel. 6. Place glucometer on a clean surface such as a paper towel and allow to air dry for not less than 3 minutes or according to manufacturer instructions. The facility provided manufacturer information related to the use of the Micro-Kill Bleach Germicidal Bleach wipes which are stocked on each medication cart. The information showed the wipes were premoistened with a solution equivalent to 1:10 dilution of 6.5% bleach and effective against 62 microorganisms.

Based on observation, interview and record review the facility failed to address grievances with the resident council. This applies to 3 of 3 residents (R43, R57, R222) in the sample of 42 reviewed for grievances. The findings include: On 6/25/25 at 10:00 AM, during the resident council meeting with the residents, R222 said the same complaints are brought up every month about the cleanliness of the facility and the staff using their cell phones and ear buds while working. R57 agreed with this statement and said nothing gets any better. R43 said the housekeeping may get better for a short time and then it goes back to the same problems. The call lights are still not answered in a timely manner. The facility face sheet for R222 shows he was admitted with diagnosis of surgical aftercare following surgery on the genitourinary system. The facility assessment dated [DATE] shows R222 to be cognitively intact. The facility face sheet for R57 shows she was admitted to the facility with a diagnosis of chronic obstructive pulmonary disease. The facility assessment dated [DATE] shows her to be cognitively intact. The facility face sheet for R43 shows she was admitted to the facility with a diagnosis of asthma and diabetes mellitus. The facility assessment dated [DATE] shows her to be cognitively intact. On 6/26/25 at 2:41 PM, V11 Activity Director said she attends the monthly resident council meeting and when the residents have a complaint about something, she writes out a grievance slip and gives it to the social service department to follow-up. On 5/26/25 at 2:47 PM, V12 Social Service Director said she gives any grievances to the department heads and they are responsible for fixing the problems. On 6/26/25 at 9:50 AM, V13 Housekeeping Supervisor said when she gets a grievance, she inservices the staff. V13 said she makes rounds all the time and observes how her staff are cleaning. The resident rooms are cleaned everyday, including the bathrooms. V13 said when she was told of the resident complaints, It's probably the same resident always complaining about something. V13 said, I guess we will need to improve our cleaning services to meet the resident high standards. On 6/26/25 at 10:10 AM, V2 Director of Nursing said any grievance should be dealt with immediately. On 6/26/25 at 11:15 AM, V1 Administrator said when a grievance is brought out of a resident council meeting, it is sent to the department heads to investigate and resolve. V1 said it is a never ending problem with the staff using their cell phones and ear buds while at work. V1 said when a complaint comes from the resident council, it's harder to investigate and resolve because their are different residents at the meetings each month and the grievance does not say which resident made the statement. V1 said, It may have come from one of my chronic complainers. The resident council meeting minutes for the last six months were reviewed and showed complaints about the housekeeping staff picking up the garbage, but not cleaning their bathrooms or floors and the residents having to wait a long time for their call light to be answered in January 2025. In February 2025 a complaint was made stating the bathroom sinks were not cleaned. The March 2025 resident council minutes showed a long wait for their call lights to be answered, the staff wearing ear buds while caring for the residents, not cleaning good, just picking up the garbage and leaving without cleaning and the floors are dirty and not getting cleaned. In April 2025 the minutes showed the call lights are still not being answered, the week-end housekeeping staff are not cleaning as well as they do during the week. The May 2025 minutes showed the baseboards in the resident rooms and door jams are dirty and not cleaned. The June 2025 resident council meeting minutes showed the staff are still wearing ear buds while working, the residents are frustrated with the long call wait times, the baseboards were cleaned once but not being kept up on a regular basis. The undated facility housekeeping guidelines purpose is to maintain a safe and sanitary environment for residents . 6. Housekeeping personnel shall adhere to a daily cleaning assignments developed so to maintain the facility in a clean and orderly manner. The undated daily housekeeping policy shows daily cleaning will be conducted in the resident room using written housekeeping procedures. (The written housekeeping procedure was requested and not provided by the facility.) The facility grievance policy with a revision date of 9/25/2017 shows the resident has the right to voice grievances to the facility . Every effort will be made to resolve the grievance in a timely manner.

Based on observation, interview, and record review the facility failed to ensure a multi-dose medication vial was dated when opened and failed to dispose of an expired medication for 2 of 2 residents (R50, R42) reviewed for medication storage in the sample of 42. The findings include: 1. R50's June 2025 order summary report showed an order for: Lorazepam (anti-anxiety medication) give 0.5 milliliters by mouth every 2 hours as needed for anxiety, agitation . On 6/25/25 at 1:20 PM, R50 had a bottle of liquid Lorazepam in the medication refrigerator. The bottle was opened, and the corresponding count sheet showed 23.5 milliliters of the 30 milliliter bottle had been used. V3 (Registered Nurse) was present and stated the date when it was opened is missing. V3 said Lorazepam is only good for so long and without the open date we can't tell when it has gone bad. 2. R42's June 2025 order summary report showed an order for: Lorazepam (anti-anxiety medication) give 0.25 milliliters by mouth every 4 hours as needed for anxiety, agitation . On 6/25/25 at 1:38 PM, R42 had a bottle of liquid Lorazepam in the medication refrigerator. The bottle was labeled with an expiration date of 5/25/25. V8 (Registered Nurse) was present and stated that needs to be tossed out so it doesn't get used. Expired medications have the potential to not work or cause an adverse reaction. On 6/25/25 at 3:26 PM, V2 (Director of Nurses) stated Lorazepam is only good for 90 days. Nurses should be dating the bottle, so they know when that time is up. If medications are not labeled there is the potential for use after it is expired. Expired medication could be less potent. Expired medications should be destroyed or sent back to the pharmacy within just a few days. The facility's undated Guidelines for the Storing of Medications policy states: 3. All discontinued, outdated, or deteriorated medications will be destroyed or sent back to the pharmacy. The facility provided a Medication Guide Lorazepam Oral Concentrate document that stated: Store Lorazepam Oral Concentrate at cold temperature .Discard opened bottle after 90 days.

Based on observation, interview, and record review the facility failed to provide the physician prescribed diet to a resident for 1 of 1 resident (R67) reviewed for food in the sample of 42. The findings include: On 6/24/25 at 9:25 AM, R67 was seated in his wheelchair in his room. R67 had limited movement of his left arm. R67 was slow to respond and had difficulty finding words but was able to express himself. R67 was able to convey to the surveyor that the kitchen kept messing up his food. R67 became agitated and repeated messing it up! and stated, Keep doing it! and makes me mad. At 12:13 PM, R67 was seated in the south dining room. R67 looked at the surveyor and pointed to his plate. R67 told the surveyor he wanted a different potato and other food. R67's meal was a mechanical soft texture. V5 (Activity Aide) said that happened to you yesterday too. R67 said yes and pointed his finger at V5. V5 said R67 had been changed to a regular diet, but the dietary staff are not used to it yet. V7 (Dietary Aide/Cook) was serving the resident trays from the dining room window. V5 did not inform V7 that R67 was served the wrong diet. R67 watched V6 (Certified Nursing Assistant - CNA) serve trays to other residents and became increasingly frustrated. At 12:20 PM, R67 got up from the dining room table, took his ice cream and walked out of the dining room. R67's jaw was set, and he was visibly irritated. V6 followed R67 and asked, Don't you want to eat your lunch? and R67 said No. R67 was not served a regular texture diet (as prescribed by the physician on 6/13/25). The facility's Tuesday (6/24/25) menu showed that lunch consisted of ranch-style chicken, baked potato with sour cream, Italian blend vegetables, and gelatin with whipped topping. R67's Facesheet dated 6/25/25 showed he had diagnoses to include, but not limited to left side weakness and aphasia following a stroke; severe protein-calorie malnutrition; major depressive disorder; adjustment disorder with anxiety; and hypertension. R67's Physician Order Sheet dated 6/25/25 showed R1's diet was changed to General, regular texture on 6/13/25. R67's order showed he was to have 1:1 supervision during meals and no straws. The surveyor requested R7's Diet Order Communication Form dated 6/13/25. The facility was unable to provide it. R67 had two Meal Tickets for lunch on 6/25/25. One diet ticket showed Regular, mechanical soft diet. A second ticket dated 6/25/25 for the lunch meal showed Regular texture diet. This ticket had a handwritten not in blue marker that said, Update One. (The updated ticket was provided after the surveyor was interviewing staff regarding R67's diet). R67's Progress Note dated 6/13/25 showed, Diet order upgraded to regular/TL (thin liquids). R67's Care Plan initiated 5/30/25 showed, I have a nutritional problem or potential nutritional problem related to need for mechanically altered diet, cerebral infarction (stroke), HTN (hypertension), and adjustment disorder with anxiety . Interventions . Provide, serve diet as ordered . This care plan was not updated after his 6/13/25 diet change. On 6/24/25 at 12:23 PM, V7 was preparing room trays. The surveyor asked V7 how the dietary staff are aware a resident's diet was changed. V7 replied, the nurse will give dietary a paper showing the diet change. V7 said they hadn't received any diet changes for residents lately. V7 said they had received diet forms for new admissions, but no diet changes. On 6/25/25 at 12:15 PM, V8 (Registered Nurse - RN) said there is a form the nurse completes when there is a new diet order. V8 went the medication cart and obtained a half sheet of paper labeled, Diet Order Communication Form. V8 said this is how nursing communicates the diet change with the kitchen. V8 said the kitchen doesn't check the orders in the Electronic Medical Record (EMR). V8 said the nurse sends the form to the dietary department and enters the order into the EMR. V8 said it's an order, so R67 should get the prescribed diet. V8 said if the diet upgrade order was entered 6/13/25, then I would expect the diet to be upgraded on the 13th. V8 stated, Once I send form to the kitchen, I'm not sure how they process it. I'm sure [R67] was upset, he worked really hard for that (upgraded) diet. On 6/25/25 at 12:40 PM, the surveyor approached the south kitchen window and requested R67's menu ticket. There were two menu tickets for R67. V7 said R67 had a diet change it was updated today, that's why there are two tickets. V7 said the kitchen just received the diet change form and updated it (after the surveyor started interviewing about R67's diet). V7 said the kitchen staff doesn't have access to the EMR and the form is how the kitchen is aware of a diet change. V7 said the kitchen staff use the form to update the resident menus. On 6/25/25 at 12:55 PM, V1 (Administrator) said the process for a diet change was the nursing completes a diet order communication form when they receive the order, and the form is typically given to the dietary manager. V1 said she is the acting dietary manager at this time. V1 said she thought there had been a flow from the nurses to the dietary department. V1 stated, I would expect the (diet) change to take place and the resident to receive the meal change as soon as dietary gets the communication form. Nine days is not acceptable. V1 said the staff should have looked into R67's concerns, checked his orders, noticed that his diet was upgraded to regular texture, and ensured he was provided the prescribed diet. The facility's Diet Orders Policy dated 2020 showed, Each resident will have a diet order prescribed by the physician . and documented in the health record . Procedure: 1. Diet orders are clearly communicated, using the designated diet order communication form, to Dining Services. In some cases, the electronic medical record (EMR) used will generate a diet order communication which is used in lieu of a paper form .5. All diet order communication forms received by Dining Services are confirmed for accuracy by the Dining Services Manager or designee and kept on file in a systematic way in the dining department . 6. Diet orders are checked for accuracy regularly, at the quarterly care plan meeting, by comparing diet orders on file in Dining Services with the Physician Order Sheet (POS) in the health record. If the diet order is not consistent, the Dining Services Manager or designee will make the necessary changes to ensure the correct diet is on the Physician Order Sheet and resident meal card .

Based on observation, interview and record review the facility failed to ensure a resident's room was clean and homelike for 1 of 1 resident (R1) reviewed for clean, comfortable and homelike environment in the sample of 42. The findings include: R1's admission record shows she was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease and diabetes. On 6/24/25 at 10:00 AM, R1 was dressed in a hospital gown lying in her bed with oxygen per nasal cannula. She was alert and oriented and able to make her needs known. She said the housekeeping staff need to clean her room. She said there had been spills on the floor and dirty dishes on her bedside tray. She said, if you think this is dirty, you should see the bathroom. She said they do not clean the bathroom, and she has to walk in there with bare feet. A riser was observed over the toilet, and the seat of the riser had visible feces along the backside, and the toilet ring and outside of the bowl had dried feces. The floor was wet with pieces of toilet paper on the floor, and a canister of wipes. A bedpan was wedged between the handrail and the wall. On 6/24/25 at 12:14 PM, housekeeping had placed a sign for a wet floor in R1's room, and the bedroom floor area was clean. The bathroom was observed to remain soiled. The floor was not clean, and the toilet and riser were still soiled. R1 was observed in bed with toilet paper stuck to her feet. She said she had just returned to her bed from the bathroom. On 6/26/25 at 8:38 AM, V16 Housekeeper said there are usually 4 housekeepers on duty but this day she was by herself until the second housekeeper comes in at 9:00 AM, until then she had the whole building. She said there needs to be more housekeeping staff; it is hard for 1 person to get everything done. Each of the resident rooms should be cleaned everyday, and that includes sweeping and mopping, and cleaning the bathrooms and bedside tables. She said if a bathroom is soiled, and the toilet has feces, any staff that sees that should be cleaning it up, and the housekeeper should be cleaning the bathroom when doing the room. The resident council meeting minutes were reviewed for 2025. In January the residents had concerns with staff not cleaning the bathroom or the floors, and trash was not getting picked up. In February the sinks were not being cleaned. In March the resident's noted housekeeping was not cleaning very good and they would just grab the trash and go, and the floors were not cleaned very well, and same for the bathrooms. The minutes show the residents observed the lack of cleaning to be worse on the weekends. On 6/26/25 at 9:50 AM V13 Housekeeping Supervisor said, Resident forms from the council meetings are given to me and then we go from there. I will have an in-service with the staff about the complaints. I look in the rooms all the time to see if they are cleaning the way they should be. We go in every day and clean the rooms. We clean the toilets, the sinks, and the bathrooms every day. It's probably just one resident making those same complaints every time. The toilets are cleaned every day, you probably saw the dirty toilet after a resident used it. I guess we will need to improve our cleaning services to meet the residents' standards. My staff are only here until 3:00 PM, and I have 5 total staff and only have all 5 here maybe 2 days a week. Weekends are covered with only 2-3 on duty. The facility's undated daily housekeeping policy states 4. Daily cleaning will be conducted in the resident room using written house-keeping procedures. A daily cleaning schedule was requested but none provided.

Based on observation, interview, and record review the facility failed to follow wound treatment orders for 1 of 3 residents (R1) reviewed for wounds in the sample of 3. This failure resulted in R1's wound deteriorating and requiring R1 to be hospitalized and recieve a surgical intervention. The findings include: On 6/17/25 at 9:00 AM, R1 was in bed with an intravenous antibiotic infusing to a peripherally inserted central catheter in his left arm. R1's left leg was amputated below the knee and was wrapped in a dressing with a wound vacuum attached. R1 said he originally had surgery on his knee back around the Superbowl of this year. R1 said the wound had been infected and he has had pills and shots and surgery and now this. R1 said the wound became infected and he was sent to the hospital and the surgeon did a procedure a couple weeks ago. R1 said he was in the hospital for 6 days where they jabbed him with more needles. R1 said now they have him hooked up to the antibiotics and the wound vac machine. On 6/17/25 at 9:07 AM, V3 Wound Nurse Practitioner said she has been following R1 since 4/29/25. R1's surgical incision started off as covered eschar. V3 said one side of the eschar had tunneling underneath with some slough. V3 said at first there were no signs or symptoms of infection, but then the wound had some drainage. V3 said R1 was started on oral antibiotics which seemed to improve but then the tunneling appeared worse and she did an x-ray to rule out osteomyelitis. V3 said the x-ray came back suspicious for osteomyelitis so she gave orders to send R1 to the hospital. On 6/17/25 at 10:15 AM, V4 Wound Licensed Practical Nurse said R1's wound had an area that was open and had tunneling. V4 said V3's wound treatment orders were packing the wound with iodoform packing on Monday, Wednesday, and Fridays. V4 said the wound had increased drainage and the packing would be soaked. V4 said V3 ordered an X-ray to check for osteomyelitis and the x-ray came back suspected osteomyelitis. V4 said V3 had R1 sent to the hospital. V4 said at the hospital, R1 had testing which showed an abscess. V4 said R1 had an incision and drainage procedure with the surgeon to wash out the wound. V4 said R1 returned to the facility with a wound vac and on intravenous antibiotics. On 6/17/25 at 1:12 PM, V3 said R1's treatment orders for the tunneling in his wound was iodoform packing to be done daily. V3 said wound packing is almost always done daily in order to be effective. V3 said she never orders packing a wound only Monday, Wednesday, and Fridays. V3 said wound packing helps the wound heal from the inside out and packing [NAME] the wound drainage out of the wound. V3 said daily packing changes prevents a bacterial bio film from forming in the wound cavity. V3 said the bacterial bio film increases the risk for infection especially someone already colonized with Methicillin-resistant Staphylococcus aureus (MRSA) like R1. V3 said her expectation is for treatment orders to be completed as ordered. V3 said not doing daily packing wound dressing changes could cause a delay in healing, increase the risk for infection and lead to deterioration of the wound. V3 said she was not aware that R1's wound packing dressing was not being done daily. R1's Wound MD Progress Note Details dated 5/6/25 shows Anterior lower leg full thickness surgical wound measuring 1.5 x 12.0 x 0.2 cm with moderate purulent drainage. Wound Orders: cleanse with wound cleanser/ Dakin's solution, apply Santyl to wound to slough, apply calcium alginate, abd pad, kerlix, secure with tape daily. The facility transcribed the order as; R1's Physician Orders dated 5/8/25 shows Wound care left lower leg suture site. Cleanse with Dakin's wash. Apply Medihoney to wound slough. Apply calcium alginate packing to wound. Cover with abd pad and wrap with kerlix as needed for wound care. Change daily and as needed. R1's Verbal Physician Orders dated 5/13/25 shows Wound care left lower leg suture site. Cleanse with Dakin's wash. Apply dermasyn silver antibacterial wound gel. Cover with abd pad and wrap with kerlix and ace wrap as needed for wound care and every day shift every Monday, Wednesday, Friday for wound care. (There is no calcium alginate packing included in order). R1's Verbal Physician Orders dated 5/16/25 shows Wound care left lower leg suture site. Cleanse with Dakin's wash. Apply dermasyn silver antibacterial wound gel. Cover with abd pad and wrap with kerlix and ace wrap as needed for wound care and every day shift every Monday, Wednesday, Friday for wound care. (There is no calcium alginate packing included in order). R1's Progress Note Details dated 5/20/25 shows Anterior lower leg full thickness surgical wound measuring 2.0 x 11.0 x 0.5 cm with moderate sero-sanguineous drainage. Wound Orders: cleanse with wound cleanser, apply dermasyn silver antibacterial wound gel. Apply calcium alginate packing strip, abd pad, kerlix, daily and as needed. The facility transcribed the order as; R1's Physician Orders dated 5/20/25 shows Wound care left lower leg suture site. Cleanse with wound cleanser. Pack wound to 2 o'clock with iodoform. Apply dermasyn silver antibacterial wound gel to wound bed. Cover with abd pad and wrap with kerlix as needed for wound care and every day shift every Monday, Wednesday, Friday for wound care. R1's Verbal Physician Orders dated 5/27/25 shows Wound care left lower leg suture site. Cleanse with wound cleanser. Pack wound to 2 o'clock, 7 o'clock, and 9 o'clock position with iodoform. Apply dermasyn silver antibacterial wound gel to wound bed. Cover with abd pad and wrap with kerlix as needed for wound care and every day shift every Monday, Wednesday, Friday for wound care. R1's Wound MD Progress Note Details dated 5/28/2025 shows Anterior lower leg full thickness surgical wound measuring 2. 0x10.ox 2.0 cm with large serosanguinous drainage with tunneling at eleven o'clock position of 3.5 cm, seven o'clock position was 3.0 cm and nine o'clock position was 5.5 cm. The wound is deteriorating. Wound orders: Cleanse with wound cleanser, Apply the dermasyn silver antibacterial wound gel. Apply packing strip. Cover with ABD and kerlix apply tape. Change daily and as needed. R1's Hospitalist Progress Note dated 6/3/25 shows Arrival date: 5/29/25, Assessment: Principal Problem: infection of amputation stump/abscess of left lower extremity. Plan: Infection of amputation stump of left lower extremity, Infectious Disease on consult, Cellulitis of left below the knee amputation, 5/30/25 intra operative cultures showed Enterococcus faecalis, Staphylococcus aureus and Corynebacterium stratum, washout left below-knee amputations site. 5/30/25 Cat Scan left lower extremity shows possible abscess measuring 2.1 x 5.1 x 4.0 cm. Underlying osteomyelitis is possible. Wound vac placed. R1's Care Plan shows Wound Management-Left lower leg suture sites- provide wound care per treatment order. On 6/17/25 at 2:00 PM, V4 said he did not review V3's written treatment orders. The facility's Skin Condition Assessment and Monitoring Pressure and Non-Pressure Policy dated 6/8/18 shows Adherent or semi-permeable membranous dressing used for debriding or healing purposes will be removed at lease weekly or more often in accordance with physician's orders.

Based on interview and record review the facility failed to ensure a resident was not verbally abused by staff. This applies to 1 of 4 (R1) reviewed for abuse in the sample of 4. The findings include: On 5/12/2025 at 9:55AM, V7 Certified Nursing Assistant (CNA) said she was working on 5/2/2025 on the evening shift with [V3 CNA]. V7 said [V3] seemed to be frustrated that day. V7 said [V3] was helping [R1] with her communication device and the device fell on to the resident's leg. V7 said [R1] was crying and [V3] was saying sorry to [R1]. V7 said [R1] wasn't communicating with staff and [V3] started mocking her with fake crying and copying what the resident was saying. On 5/12/2025 at 10:06AM, V3 said she was working on 5/2/2025 and was caring for [R1] that day. V3 said [R1] wanted her communication device, and she was trying to help her with that. V3 said the latch slipped and the monitor fell out on the resident's shin/foot area. V3 said [R1] was crying, and she went to get her an ice pack. V3 said the resident would not stop crying. V3 said she told [R1] you need to be quiet. V3 said she did not yell at the resident but did raise her voice at [R1] because she was crying and screaming. V3 said she was trying to see if [R1] would stop crying. On 5/12/2025 at 10:49AM, V10 Registered Nurse (RN) said he was working on the evening shift on 5/2/2025. V10 said he was in a room with another resident and heard [R1] crying. V10 said he couldn't make out everything that was being said but it was a little loud and it was a female's voice. V10 said when he talks to [R1] he doesn't need to speak up she has good hearing. On 5/12/2025 at 1:25PM, V9 RN said he was working on the unit on the evening shift on 5/2/2025. V9 said he heard a staff member mocking [R1] but didn't see it. V9 said he found out later it was [V3] who was mocking [R1]. On 5/12/2025 at 1:33PM, V8 CNA said she was working on 5/2/2025. V8 said she did hear [R1] crying that day and a female voice telling her to be quiet. V8 said she didn't hear the specifics of the conversation because she was down the hallway in another room. On 5/12/2025 at 11:37AM, V2 Director of Nursing (DON) said if staff begin to feel frustrated with a resident, they should excuse themselves, get someone else, or reapproach later. V2 said you should not yell at a resident because it can be seen as verbal abuse. V2 said you should not mock a resident because it can be seen as verbal abuse or a dignity concern. V2 said [R1] has trouble communicating with staff and the staff should not be mocking her condition. R1's current Care Plan dated 5/12/2025 shows . I have a communication device to help communicate my needs. The facility provided Abuse Prevention and Reporting - Illinois policy revised 10/24/2022, states . the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment.

Based on interview and record review the facility failed to safely reposition a resident in bed for one of three residents (R1) reviewed for safety/supervision in the sample of three. This failure resulted in R1 rolling out of bed onto the floor and experiencing increased pain and a humeral fracture. This past noncompliance occurred from March 11, 2025- March 17, 2025. The findings include: R1's Face Sheet dated March 19, 2025, shows she was admitted to the facility on [DATE], with diagnoses including hemiplegia, dysphagia, aphasia, unsteadiness on feet, contracture left knee, low back pain, adjustment disorder with anxiety, depression, and heart failure. R1's Care Plan initiated December 8, 2022, shows R1 had an ADL self care performance deficit related to a stroke with left side effected. R1 was at risk for falls. R1's MDS (Minimum Data Set) dated March 4, 2025, shows, R1 had an impairment to one side of her upper and lower extremities. R1 was dependent on staff for toileting hygiene. R1 required substantial/maximal assistance from staff for rolling left and right. R1's Fall-Initial Occurrence Note dated March 11, 2025, shows, Resident had a witnessed fall March 11, 2025, 3:15 AM. CNA (Certified Nursing Assistant) called this writer and saw that the CNA was holding the resident on the floor on a sitting position. CNA said that she was changing the resident when her legs went out of the bed and fell . R1's Nurses Note dated March 11, 2025, shows R1 complained of left arm pain. The doctor was notified and gave an order for an X-Ray. R1's X-Ray report dated March 11, 2025, shows, Transverse fracture lucency in the surgical neck of the humerus with minor displacement. Generalized extremity edema. On March 19, 2024, at 8:47 AM, V2 DON (Director of Nursing) said R1 was admitted to hospice services on March 1, 2025. V2 said R1 had a history of a stroke and could not use her left arm or left leg. V2 said that R1 was a two person assist for bed mobility. V2 said when residents have had a stroke and are on a low air loss mattress should always use two staff members for assistance. V2 said V5 CNA (Certified Nursing Assistant) was the CNA that was caring for R1 when R1 fell out of bed. V2 said V5 rolled R1 onto her right side, which was away from the CNA. R1's weak side was up when R1's legs slid off of the bed. V2 said R1 slid off of the side where no staff was present. V2 said R1 would not have been able to grab the side rail because R1 couldn't use her left arm. V2 said R1's family and hospice decided not to send R1 to the hospital. V2 said R1 was a thin resident that had a decreasing appetite. V2 said R1 was complaining of left arm pain at lunch time so the doctor ordered an Xray and that's when they found out R1 had a fracture to her left arm. V2 said that R1's morphine pain medication was increased after her fall due to the increase in R1's pain. V2 said as long as R1 was still, she did not have any pain. V2 said staff were in-serviced on if residents have a low air loss mattress, then to use two staff members to assist with care. V2 said if two staff members were present during R1's fall out of bed, then the fall could have possibly been prevented. On March 19, 2025, at 2:04 PM, V6 RN (Registered Nurse) said he was called into R1's room. V6 said he saw R1 kneeling next to her bed on the floor with V5 holding R1 up. V6 said R1 had an abrasion to her left knee that was bleeding, so he put a dressing on that. V6 said he gave R1 morphine for her pain after the fall. V6 said V5 told him that R1 fell out of the bed while V5 was trying to change R1. V6 said he did not know that R1 required two staff assistance for cares. V6 said he has been in-serviced on using two staff members while changing dependent residents. A message was left for V5 CNA on March 19, 2025. On March 19, 2025, at 11:00 AM, V3 CNA said she took care of R1 a lot prior to her fall. V3 said two staff members were always used to reposition R1 because she was a difficult resident to care for. V3 said R1 was always a nervous person and always fearful she was going to get hurt. V3 said R1 was not able to reposition herself. R1's MAR (Medication Administration Record) shows she had an order for morphine sulfate 20 MG/ML give 0.5 ML by mouth every four hours as needed for pain/air hunger prior to her fall. There was an order entered after R1's fall and fracture for morphine every two hours for pain. R1 was rating her pain 5-8 on a 0-10 pain scale after her fall occurred. R1 complained of pain one time prior to her fall in March. The facility's Fall Prevention Program revised November 21, 2017, shows, To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Prior to the survey date of March 19, 2025, the facility had taken the following actions to correct the noncompliance: -Resident was assessed for injuries -Resident care plan updated and fall assessments updated -Nursing staff have been re-educated on proper bed mobility and care of residents that require extensive assistance -A QA tool has been implemented to monitor compliance with proper assistance with ADL (Activities of Daily Living) care. DON (Director of Nursing) or designee will conduct daily audits of five residents a week. -Reviewed current bed mobility and transfer needs to ensure they are accurate and updated if needed. -Reviewed current residents fall risk score for accuracy and updated if needed. -Resident has been assessed for pain and has a pain management plan in place. -Facility has reviewed agency usage and communication of resident needs to agency staff.

Based on observation, interview, and record review the facility failed to identify a wound prior to becoming an unstageable wound, failed to have pressure ulcer interventions in place, and failed to ensure wound treatment orders were in place for 2 of 3 residents (R1, R2) reviewed for pressure ulcers in the sample of 3. These failures resulted in R1 being at an increased risk of infection and delayed wound healing. The findings include: 1. R1's face sheet printed on 3/6/25 showed diagnoses including but not limited to encephalopathy, atrial fibrillation, diabetes mellitus, malnutrition, Alzheimer disease, and chronic kidney disease. R1's facility assessment dated [DATE] showed severe cognitive impairment and total staff assistance required for hygiene, transfers, and bed mobility. The same assessment showed R1 is always incontinent of urine and bowel. R1's pressure ulcer risk assessment dated [DATE] showed a moderate risk for pressure ulcer development. R1's medical record showed an original facility admission on 1/28/25. The record showed R1 was sent to the local hospital on 2/25 and returned 2/28. R1's hospital records showed a wound consult on 2/27/25. An unstageable coccyx pressure ulcer (lower back/upper buttocks area) measuring 4.5 cm x 2 cm (centimeters) was present. On 3/6/25 at 8:33 AM, R1 was lying in bed while V5 and V6 (CNAs-Certified Nurse Aides) performed morning cares. R1 was incontinent of urine and bowel. R1 was rolled to her side and a damp dressing was on her coccyx area. V5 removed the dressing, and an egg size open area was observed with a smaller quarter size area next to it. The aides completed peri care and alerted the nurse of the need for a new dressing. V6 stated R1 is completely dependent on staff for all daily cares. V6 stated the CNAs do skin checks during all care and on every shower day. Any skin changes should be found and reported to the nurse immediately. On 3/6/25 at 9:05 AM, V4 (Registered Nurse) provided wound care to R1's coccyx. V4 stated the nurses do weekly skin observations and the CNAs do daily checks on every shift. That way any skin changes can be found early, and treatment can get started. V4 said she was unsure how long the coccyx wound had been there, but it was sometime after she came back from the hospital. R1's progress notes were reviewed from the date of admission to current. There were no weekly skin observations done by a nurse until she returned from the hospital (no observations from 1/28 to 3/1). R1's last 30 days of CNA skin checks were reviewed. The task tab showed no skin issues observed, including every day after the unstageable pressure ulcer was found. On 3/6/25 at 10:37 AM, V3 (WCN-Wound Care Nurse) stated R1 is at high risk for pressure ulcers based on her low cognition, low mobility, and is bed fast most of the time. V3 said all residents are assessed weekly by the floor nurses from head to toe for any skin changes. The skin checks are documented in progress notes. The aides check resident skin during daily cares. It is important the checks are done to ensure they are found at an early stage. All skin changes need care orders and interventions put in place right away. There is the risk of infection and delayed wound healing when open areas are found at more advanced stages. V3 reviewed R1's electronic record and was unable to locate any weekly skin observations done by the floor nurses prior to her going out. V3 said he did not know why the aides' daily skin checks are still being recorded as no skin issues. V3 stated R1's unstageable coccyx wound was not found until she was sent to the hospital. R1's wound assessment done upon return to the facility and dated 3/1/25 (by V3) showed a 2 cm x 4.5 cm unstageable pressure ulcer located on the coccyx. R1's care plan was reviewed and showed no focus areas or interventions in place related to the potential for skin impairment or pressure ulcer development until she returned from the hospital. On 3/6/25 at 11:16 AM, V7 (VP of Clinical Operations) stated R1's daughter notified the facility of the coccyx wound when the hospital discovered it. That was the first time anyone realized R1 had an open area on her coccyx. V7 said R1 was seen by the corporate wound consultant sometime this week, but there is no record of any assessment or that the visit occurred. V7 stated pressure ulcer prevention interventions were in place but the care plan does not reflect that until after she came back from the hospital. On 3/6/25 at 3:21 PM, V2 (DON-Director of Nurses) stated it is important to check residents' skin and find changes early. Skin issues are easier to treat the sooner they are found. V2 said she could not say how long R1's coccyx wound had been there. The lack of weekly observations makes it impossible to know. V2 said it wasn't until R1's daughter called and alerted them to the wound after the hospital found it. V2 said it should have been found by the facility staff prior to becoming an unstageable wound. On 3/7/25 at 1:16 PM, V9 (Wound Physician Assistant) stated R1's coccyx wound absolutely should have been found earlier. There is a huge potential for delayed wound healing or to not heal at all. Wounds that are found at advanced stages could already be infected. R1 is incontinent and given the locale of her wound she is at a high risk of osteomyelitis (bone infection). The facility's Pressure Injury and Skin Condition Assessment policy revision dated 1/17/18 stated: 2. Residents identified (at risk for pressure ulcers) will have a weekly skin assessment by a licensed nurse. 4. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA . 6. Care givers are responsible for promptly notifying the charge nurse of skin breakdown. 2. On 3/6/25 at 8:56 AM, R2 was lying on her bed while V5 and V6 (CNAs) prepared to do a mechanical lift transfer. V5 removed R2's socks and a dressing was observed on her right heel. The dressing date and signature were both illegible and hard to read. V5 stated R2 did have a black sore on that heel but was unsure if it was still there or had healed. R2's wound assessment dated [DATE] showed a right heel DTI (deep tissue pressure injury) measuring 2.5 cm x 2.5 cm. The assessment showed it was identified on 2/13/25. R2's February 2025 TAR (Treatment Administration Record) was reviewed and showed an order discontinued on 2/27/25 for: Right heel-apply boarder foam dressing to DTI in the morning every Tues, Fri, Sun for prophylaxis. The TAR showed the last treatment was done on Tuesday, 2/25/25. R2's March 2025 physician orders and TAR were reviewed. There were no treatment orders related to the right heel DTI. On 3/6/25 at 10:37 AM, V3 (WCN) reviewed R2's medical record and was unable to locate any wound treatment order for the right heel. V3 said the DTI is still on her heel. V3 said orders are needed so the nurses know how to care for the wound. The orders should include how and when to treat the wound, how to clean and cover the wound. V3 stated he did not know why there were no treatment orders for her DTI. On 3/6/25 at 2:40 PM, V2 (DON) stated R2's wound treatments were discontinued by the wound doctor in February and V2 did not know if that was what was intended. V2 said staff should have followed up with the wound team before today. It needs to be clarified right away. Wounds have a higher risk of infection and delayed healing when treatments do not get done. On 3/6/25 at 3:05 PM, V3 (WCN) stated he just received the correct order for R2's heel wound. It should have continued into March with cleansing and a gauze dressing three times a week and as needed. V3 said there is nothing to show that her heel wound has been treated since 2/25/25 (9 days ago). R2's physician order showed the current wound order for the right heel DTI was just start dated on 3/6/25 (day of survey). The facility's Pressure Injury and Skin Condition Assessment policy last revision dated 1/17/18 states: 18. Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration.

Based on interview, and record review the facility failed to notify a resident representative of an advanced stage wound for 1 of 3 residents (R1) reviewed for notification of changes in the sample of 3. The findings include: R1's face sheet printed on 3/6/25 showed diagnoses including but not limited to encephalopathy, atrial fibrillation, diabetes mellitus, malnutrition, Alzheimer disease, and chronic kidney disease. R1's facility assessment dated [DATE] showed severe cognitive impairment and total staff assistance required for hygiene, transfers, and bed mobility. The same assessment showed R1 is always incontinent of urine and bowel. R1's medical record showed an original facility admission on 1/28/25. The record showed R1 was sent to the local hospital on 2/25 and returned 2/28. R1's hospital records showed a wound consult on 2/27/25. An unstageable coccyx pressure ulcer (lower back/upper buttocks area) measuring 4.5 cm x 2 cm (centimeters) was present. The note showed the wound was present upon admission to the hospital. On 3/5/25 at 1:23 PM, V8 (R1's daughter) stated she was told R1 had an open sore on her buttocks when she was sent there by the facility. V8 said the hospital called her and said the sore was very bad and looked like it had been there while. V8 said she visits R1 almost daily and facility staff never told her of any open skin areas. On 3/6/25 at 10:37 AM, V3 (Wound Care Nurse) stated any new or worsening wound should be reported to the physician and family as soon as possible. Family needs to be kept up to date and educated on resident status, especially anything new. On 3/6/25 at 3:21 PM, V2 (Director of Nurses) stated R1's family member was not notified of the coccyx wound by the facility. The hospital notified V8 the day it was assessed. The facility's Physician-Family Notification-Change in Condition policy last revision dated 11/13/18 states: The facility will inform the resident .notify the resident's legal representative or an interested family member when there is: (B) A significant change in the resident's physical, mental, or psychosocial status (i.e. deterioration in health .).

Based on interview and record review, the facility failed to identify that a resident who is at risk for developing pressure injuries and who had a pressure injury would be at a higher risk for developing a second pressure injury; and failed to implement preventative measures and adequate skin assessments for 1 of 4 residents (R1) reviewed for wounds in a sample size of 7. This failure resulted in R1 developing two pressure injuries to the back of his ears that were both identified at a stage 3 when found. Findings include: R1's face sheet indicated that resident admitted to the facility on [DATE] with a past medical history not limited to sepsis, acute respiratory failure, pneumonitis, encephalopathy, scoliosis, dysphagia; and discharged to an acute care hospital on 02/18/2025. R1's admission pressure ulcer risk assessment dated [DATE] showed R1 is at moderate risk for developing pressure injuries. R1's Minimum Data Set (MDS) Resident Assessment and Care Screening, dated 02/03/2025 documented that R1 was dependent on staff for bathing, personal hygiene, dressing, bed mobilities and transferring in/out of bed. R1's care plan with date initiated 02/10/2024 documented: pressure ulcer to left ear related to immobility with last revision on 02/10/2025; pressure ulcer to right ear related to immobility with last revision on 02/21/2025. Interventions included but not limited to oxygen cannula will have ear protectors to alleviate pressure on the ear and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Order summary report with print date of 02/21/2025 showed the following orders for R1: oxygen (O2) inhalation via mask at 3 liters to maintain oxygen saturation above 90%, every shift for oxygen therapy, start date 01/30/2025; left ear pressure ulcer treatment, cleanse then apply [medical-grade honey] sheet in the evening, start date 02/04/2025; left ear pressure ulcer treatment, cleanse then apply [medical-grade honey] to affected area and cover with dressing in the evening, start date 02/18/2025; right ear pressure ulcer treatment, cleanse then apply [medical-grade honey] sheet, start date 02/21/2025. R1's wound round assessment dated [DATE] documented stage 2 pressure ulceration to R1's left ear with measurements in centimeters (cm) of 3.00 x 2.00 x unknown (lengthxwidthxdepth). R1's wound round assessment dated [DATE] documented stage 3 pressure ulceration to R1's left ear with measurements of 3.00cm x 2.00cm x unknown. Wound assessment detail report dated 02/11/2025 documented the same assessment, indicated R1's wound was facility-acquired and that R1 was provided with cushions to alleviate the pressure. Review of nurse's note dated 02/04/2025 documented a fax was received back from V11 (Primary Care Physician/Medical Director) related to wound stating, local wound care. No documentation found that indicated R1 was seen by a wound physician. R1' s wound round assessment dated [DATE] documented stage 3 pressure ulceration to R1's right ear with measurements of 1.00cm x 1.00cm x 0.20cm. Wound assessment detail report dated 02/17/2025 documented the same assessment, indicated R1's wound was facility-acquired and a new wound assessed, new ear protectors added. Review of repeat pressure ulcer risk assessment dated [DATE] continued to show that R1 is at moderate risk for developing pressure injuries. No repeat skin risk assessment was completed after identifying the second pressure injury to the right ear on 02/17/2025. No evidence was found of ongoing assessments to affected skin areas, any effective preventative measures and/or interventions to prevent further development of pressure injuries such as turn/reposition every two hours, pressure relieving mattress, protective dressing to area behind ears, daily skin assessments, etc. Review of nurse's note dated 02/18/2025 documented new pressure ulcer noted to the right ear where the cannula sits. Protectors were already in place although they were changed for new ones. [Medical Doctor] and guardian notified. New wound care orders to include right ear entered. On 02/20/2025 at 01:38 PM, V2 (Director of Nursing) said R1 did not admit with any skin issues or irritation to his ears upon admission but developed pressure injuries to both ears from the straps of the oxygen mask. V2 added that R1 was at moderate risk for pressure injury upon admission. On 02/21/2025 at 11:02 AM, V8 (Wound Care Nurse) said upon admission on 01/30/25, R1 did not admit with any skin issues but he was at risk for developing a pressure injury with a [pressure ulcer risk assessment] score was 14. V8 then said on 02/03/2025, he first identified a stage 3 pressure injury to R1's left ear that measured 3cm x 2cm (length x width), was unable to determine any depth and started a treatment for Medi honey then cover with bordered foam. V8 said he provided wound care Monday through Friday, and the floor nurse would provide wound care on the weekends. V8 added that R1 had weekly skin assessments in place. V8 then said on 02/17/2025, he identified a stage 3 pressure ulcer to R1's right ear that measured 1cm x 1cm x 0.2 cm (length x width x depth) and started treatment for Medi honey sheet. V8 (Wound Care Nurse) added that he didn't see an issue or believed that R1 would develop pressure injuries to his ears from the mask straps so when he recognized an issue to the first ear, he applied protectors to both sides of mask straps as a preventative. V8 also said that at times when he would see R1, the mask would be pulled down and the strap would fold his ear downward then indicated moving forward, interventions should be implemented due to mask movement that could cause friction. On 02/21/2025 at 11:49 AM, V2 (Director of Nursing) said ear protectors were not applied initially to R1 because they did not suspect it was a high area of skin breakdown, but moving forward, any resident who admits in a similar condition and identified as high risk for developing pressure injuries will have ear protectors placed. On 02/21/2025 at 1:19 PM, called the office of R1's physician V11 (Primary Care Physician/Medical Director) and was informed by receptionist that V11 was out for the week, not reachable and will not return until Monday. On 02/21/2025 at 2:23 PM, when asked if R1's pressure injuries should have been recognized sooner than a stage 3, V2 (Director of Nursing) said staff performed weekly skin assessments and should have looked at R1's face and skin every shift, when providing care or readjusting R1's mask, and when they observed his ear folded down from the mask strap. V2 then said a resident who develops a pressure injury would be considered at higher risk for skin breakdown and if a resident is not able to adjust themselves, they also would be at increased risk for developing a pressure injury. When asked if a pressure ulcer risk assessment should have been completed for R1 after the second injury was identified, V2 (DON) said she would need to follow-up with V8 (Wound Care Nurse) because he may have done one that could be within R1's wound documentation. (No additional pressure ulcer risk assessments were provided.) Pressure Injury and Skin Condition Assessment policy last revised 01/17/2028 reads is part: to establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented .a skin condition assessment and pressure ulcer risk assessment (Braden) will be completed at the time of admission/readmission. The pressure ulcer risk assessment will be updated quarterly and as necessary .each resident will be observed for skin breakdown daily during care and on the assigned bath day the CNA (certified nursing assistant) .care givers are responsible for promptly notifying the charge nurse of skin breakdown .at the earliest sign of a pressure injury or other skin problem, the resident, legal representative, and attending physician will be notified.

Based on interview and record review the facility failed to notify the physician of an ongoing change in condition in a timely manner. This applies to 1 of 3 residents (R1) reviewed for notification of changes in the sample of 5. The findings include: R1's eINTERACT change in condition evaluation dated December 18, 2024, shows, she had a change in condition of weakness that started the morning of December 18, 2024. The same evaluation continues to show, V5 Nurse Practitioner (NP) was notified of the changes, and nothing was ordered or done. On January 8, 2024, at 12:48 PM, V5 NP stated she did not recall if she was notified of R1's change in condition or not. There was nothing documented in R1's chart that showed she was. I get so many messages; I can't remember them all. R1's progress notes continue to show, her condition stays the same with no changes. R1's electronic medical records did not show any other documentation that R1's primary care physician or Nurse Practitioner were notified of any changes in condition from December 18th - December 22, 2024. On January 8, 2024, at 11:42 AM, V6 Registered Nurse (RN) stated, she worked with R1 on December 18th and 21st. R1 was having some weakness. She reported the original change in condition on December 18, 2024, to V5 NP however when she saw R1 again, she was the same as she was on the 18th. There was no improvement. She did not call the doctor on that day to update them on R1's condition. On January 8, 2024, at 12:13 PM, V9 RN stated, he worked with R1 on December 19th and 20th. He did not contact the doctor or let anyone know of her condition. As far as I know, my colleague did. The facility's physician-family notification-change in condition policy dated November 13, 2018, shows, Purpose: To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner. Guidelines: The facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is: (B) A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); Life-threatening conditions are such things as heart attack or stroke. Clinical complications are such things as development of a stage II pressure sore, onset of recurrent periods of delirium, recurrent urinary tract infection, or onset of depression .

Based on interview and record review the facility failed to ensure a resident with dementia and exit seeking behaviors was supervised and failed to ensure a service door was alarmed or monitored. These failures resulted in R1exiting the building through the non supervised and non alarmed door and was found approximately 0.3 miles from the facility by staff at a local school. This applies to 1 of 5 residents (R1) reviewed for safety/supervision in the sample of 5. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 4/26/23, when the facility failed to provide adequate supervision to R1 during a vendor supply delivery. The service door alarm was turned off during the delivery and R1 and the delivery door were left unsupervised. R1 was able to exit through the door and walk approximately 0.3 miles to a nearby school. R1's where abouts were unknown to the facility for approximately 15 minutes. The Immediate Jeopardy was identified on 5/1/23. V1 (Administrator) was notified of the Immediate Jeopardy on 5/2/23 at 9:08 AM. This surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 5/2/23 however, noncompliance, remains at a level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R1's face sheet shows she is a [AGE] year old female who was admitted to the facility on [DATE]. R1 has diagnoses including: Alzheimer's Disease, unspecified dementia, altered mental status, and adult failure to thrive. R1's active fall risk care plan initiated on 12/7/22 shows she is at risk for falls and requires the use of a wheelchair. R1's activity of daily living (ADL) care plan initiated 12/7/22 shows she requires staff assistance and a gait belt for all ADL activities. R1's impaired cognition care plan initiated on 12/7/22 shows she has short term and long term memory impairments and her decision making is impaired. R1's elopement risk/wanderer risk care plan initiated on 1/31/23 shows she is at risk for elopement due to dementia, she is disoriented to place, and exit seeking with an impaired safety awareness. R1's facility assessment completed on 1/31/23 shows her cognition is severely impaired, her gait is unsteady, and she requires the use of a wheelchair and 1 staff assistance with transfers. R1's Progress notes from her electronic medical record shows the following: 4/4/23- 1:08 PM, a social service note states, Spoke with health surrogate pertaining to {R1's} need of a secure unit due to increased wandering and exit seeking. 4/7/23- 4:00 PM, a nursing note states, This RN saw the resident from the nurses' station trying to get up from her wheelchair and walk by herself when she lost her balance and ended up falling. Resident reminded on the importance of using her wheelchair and not to walk alone without assistance. 4/10/23- 4:53 PM, a behavior note states, The resident keeps standing from her chair, going out through the alarmed door, refusing and fighting back when asked to sit back on her chair. This resident needs a 1:1 care. 4/10/23- 10:22 PM, a nursing note states, Resident wandered, walked without assistance and went from one resident's room to another. A CNA (Certified Nursing Assistant) has been assigned to monitor the resident. 4/11/23 1:00 PM, a behavior note states, Resident had an episode of restlessness and agitation, upon entering other resident's room, trying to stand up on her chair and putting her at risk to fall. 4/19/22 at 6:15 PM, a nursing note states, This writer notes resident restless, anxious showing signs of aggression and elopement behaviors, she is at risk for hurting herself or harming other residents. 4/20/23 at 3:04 PM, care plan meeting note shows a care plan was held and states, Also discussed elopement risk due to recent nicer weather and resident desire to exit facility. 4/21/23 at 10:33 PM, a behavior note states, Resident started roaming around after dinner and tried to go out the exit doors twice. 4/22/23 at 12:36 PM, a psychiatric note states, Patient appears mostly confused. 4/23/23 at 5:28 AM, a behavior note states, She {R1} wanted to go out with her mum, she attempted going out twice. 4/24/23 at 5:21 AM, a nursing note states, Resident has made requests to go out and smoke, go out for breakfast and believes the call light ringing is a phone. A Wandering Risk Scale assessment was completed for R1 on 4/24/23 at 10:19 AM and shows she is at risk for wandering. The facility's 15 minute monitoring sheets show R1 was started on 15 minute checks on 4/19/23. On 4/26/23 the 11:45 and 12:00 checks show R1 as Missing. An Elopement incident report was completed by V5 (Registered Nurse/RN) on 4/26/23 and shows at 11:50AM, V5 was alerted by a CNA {V10} that she could not find R1. The incident report states, CNA notified this writer that {R1} is not at the nurses station. This writer went with CNA to check the resident's room and common bathroom where this resident usually also (go), but resident is nowhere to be found. Call the receptionists to initiate code pink to alarm all staff that the above mentioned resident is missing. All rooms were checked, and several staff went out to search for the resident. The resident was found at a park next to the facility. On 4/28/23 at 1:10 PM, V8 (local school employee) said she was outside of the school on 4/26/23 (at around 11:56 AM), during a student recess period and noticed an elderly woman (later identified as R1) pushing a wheelchair on school grounds. V8 said at first, she thought the woman was a student's grandparent because a class field trip had just returned to the school. V8 said the woman was walking around by the door to the school, she saw another staff person go up and talk to her. A few minutes later the principle then came out and spoke to the woman and then went back inside the school. V8 said the woman (R1) then began walking again pushing her wheelchair down the sidewalk along the building. V8 said she started thinking something is not right, she went up to the woman and started talking with her and realized that the woman was very confused mentally and kept asking to go inside because she was cold and shivering. She said the woman also appeared unsteady while she was trying to walk. V8 said the woman was wearing a short sleeved shirt, no jacket, and it was a chilly day that day. V8 could not recall what footwear if any that the woman had on. V8 said she contacted inside the building to the principle and recommended that they call the nursing facility down the street to make sure they were not missing anyone. V8 said shortly after that (around 12:08 PM), 2 staff from the nursing facility came running towards them and confirmed the woman was a resident of the facility. Google maps show from the middle of the facility to the main entrance of the local school that R1 walked to is approximately 0.3 miles and a 5 minute walk. On 5/1/23 the surveyor observed the route from the facility to the school. The school is on the same side of the street as the facility and there is a concrete sidewalk with several uneven (raised) areas. The school had multiple entrance doors and a playground in front of and to the side of the school. Wunderground,com a weather history website shows the weather in [NAME], Illinois on 4/26/23 at 11:55 AM, was 48 degrees and cloudy skies. The facility's elopement risk resident binder show R1 is at active risk for elopement. On 5/1/23 at 8:20 AM, V4 (Receptionist) said on 4/26/23 she was asked by several CNA's at the facility if she had seen R1 and she had not. The facility staff were not able to find R1, so a Code Pink was paged over head to alert all staff of a missing resident. V4 said R1 is a wanderer, and everyone knows you have to watch her close. She said it is presumed that R1 got out of the building through a service door that was not alarmed. V4 said she did not hear any door alarms go off around the time R1 left the facility. V4 said staff were all looking for R1 and then the local school called her to ask if they were missing a resident, so staff were alerted and went immediately to get R1. On 5/1/23 at 8:50 AM, V6 (CNA) said on 4/26/23 at around lunch time she was getting another resident up and when she came out of that residents room the nurse was looking for R1 and asked if she had seen her. V6 said the nurse had been in the hallway passing medications so no one was directly observing R1. V6 said the last time she had seen R1 was approximately 11:45-11:50 AM sitting in a wheelchair by the nurses station. V6 said the staff checked the north side of the building in resident rooms and bathrooms and they couldn't find her, so a Code Pink was called. V6 said she heard that R1 went out a service door that was not alarmed. V6 confirmed that no alarm went off around the time R1 exited the building. On 5/1/23 at 8:35 AM, V7 (CNA) said on 4/26/23 she was assigned to resident showers, after giving a shower she observed the franticness between a nurse and a CNA looking for R1. She said the staff searched the north unit resident rooms and bathrooms and realized she was not there so they searched the south unit and could not find R1, so a Code Pink was called. V7 said staff went outside and began looking for R1. She was alerted that R1 was found at the school, and she ran as fast as she could towards the school where she found R1 walking and pushing her wheelchair. V7 said R1 is extremely confused and requires more frequent monitoring. V7 should not be walking without staff assistance she is not steady. On 5/1/23 at 9:10 AM, V5 (RN) said on 4/26/23 he was doing his noon medication pass around 11:50 AM and was alerted by a agency CNA (V10) that she could not find R1. V5 said R1 was on 15 minute checks due to her behaviors and wandering. V5 said R1 had been seen by exit doors attempting to get out but this is the first time he is aware of that R1 successfully got out of the facility. V5 said the Code Pink was called around 12:00 PM after staff had searched both sides of the building without locating R1. He said V5 exited the building through a security door on the north side of the building that was not alarmed. R1 was found at the school and returned sometime around 12:05. On 5/1/23 at 9:30 AM, V3 (Maintenance Director) said all deliveries from vendors are made through either the front door or the service door which is down the hallway where the north dining area is. V3 said sometimes the door alarm to the service door is turned off while they carry in the deliveries, but a staff member should stay and monitor the door. V3 said after R1 exited the door it was found that the alarm to that door was turned off. He said only 4 facility personnel had a key to deactivate the alarm to that service door. V3 took the surveyor to the service door which is down the hallway towards the north nursing station and across from the dining area. The entry way consists of 2 sets of double doors. The interior doors are not alarmed but the second set of doors which lead outside had an alarm with a key code and box on the wall for a key to turn off or disable the alarm. V3 said he could not recall exactly what company had delivered supplies that day, but the alarm would have sounded if it was turned on. On 5/1/23 at 9:45 AM, V2 (DON) said she was alerted on 4/26/23 that R1 was missing from the facility. V2 said after R1 was found at the local school, V1 (Administrator) called an all staff meeting. It is believed R1 went through the service door that was not monitored or alarmed. V2 said R1 was on 15 minute checks due to behaviors and the facility believes R1 needs to be at a facility with a locked memory care unit. V2 said the service door should be monitored if the alarm is turned off. At 11:45 AM, V2 said that R1 had been having exit seeking behaviors for the past few weeks prior to her elopement from the facility. On 5/1/23 at 11:45 AM, V10 (Agency CNA) said she was assigned to R1 on 4/26/23 and it was the first time she had worked with her. V10 was unable to recall times but said she check on R1 right before her lunch break and R1 was in her room. After her lunch break, she went to get R1 up and ready for lunch and she knew something was wrong because R1's shoes were there but R1 was not. V10 said she remained at the facility while staff were searching for R1. When R1 was brought back to the facility she did not have shoes on her feet. V10 said she was unaware of the service door alarm being turned off, but she did see a delivery truck outside at the time R1 was missing. On 5/1/23 at 12:02 PM, V11 (Medical Director) said R1 is very confused and is not safe to be out of the facility alone in her current condition, especially if she was not appropriately dressed. V11 asked the surveyor why the service door would be open and the alarm not on. On 5/1/23 at 10:26 AM, V9 (local school employee) said she had seen R1 on the cameras they have at the school, and she was on grounds for about 10 minutes or so. V9 said R1 was trying to enter the school because she was cold, and it was chilly out. V9 said a couple staff from the facility all spoke with R1 and then she called over to the nursing facility down the street from them to see if they were missing someone. She said the facility staff answered the phone and said, oh my god you have her {R1}, we will send someone right over. On 5/1/23 at 1:33 PM, V1 (Administrator) said after R1 got out it was identified that a mattress company had been there delivering mattresses and the service door alarm they used to unload the supplies was turned off. V1 said the alarm requires a barrel key to disable it and only certain staff have access to that key. V1 said the facility cameras do not record so the exact time R1 exited through the door is not certain. The facility's undated Elopement Risk Assessment policy states, A Social Service Department will conduct the elopement assessment during the admission process, when there is a significant change in mood or behavior(s), and quarterly. 3. Should an elopement risk be determined; interventions will be immediately initiated to protect the resident in a reasonable manner and as approved by the physician. 6. The Social Service Department will notify facility staff and initiate interventions to protect the resident. Interventions include, however, are not limited to the following: relocation to secure unit, bed alarm and /or chair alarm, use sign in/out record, psychological consultation, personal alarm arm or ankle bracelet, 15 minute to 1 hour observations, one-on-one observation, behavior management. The Immediate Jeopardy that began on 4/26/2023 was removed on 5/2/2023, when the facility took the following actions to remove the immediacy: 1. All staff were in-serviced on elopement and how to know residents who are at risk for elopement along with their elopement interventions. Training was initiated on 5/1/23 by the Administrator and anyone on leave or not available will be educated via phone before their next scheduled shift. 2. All residents were assessed for elopement risk and residents that are at high risk were care planned on 5/1/23 and will continue for all newly admitted residents. 3. A lock box was placed at the service door over the barrel key access that only the Administrator and maintenance will have access to on 5/1/23. Preventing the service door alarm from being disabled by other staff during deliveries. 4. During any vendor delivery staff will always stand guard at the service door. Staff educated on 5/2/23 and ongoing. 5. Elopement binders at the nursing stations and front desk were updated on 5/1/23 and will be updated on an ongoing basis. 6. Audits will be conducted daily by nursing management for 6 months to ensure doors are alarmed after any vendor delivery and will be discussed in IDT meetings starting 5/1/23 and ongoing. 7. All door secured alarms with alarm system were checked on 5/1/23 for functionality and are in working order. 8. Nursing management assessed current residents for elopement precautions and ensured they are in place on 5/1/23 and will continue as ongoing residents are admitted . 9. A Code Pink drill was done on all shifts on 5/2/23. 10. R1 was re-assessed for any injuries on 5/1/23. 11. Emergency QAPI plan has been implemented with all required parties. Any member unavailable was contacted by phone. Including the Medical Director on 5/2/23. 12. All staff had comprehensive elopement quizzes on 5/1/23. 13. All managers were in serviced on monitoring service doors during delivery and at all times on 5/2/23. 14. On weekends the MOD (Manager on Duty) will monitor the service door effective 5/2/23.

Based on interview and record review the facility failed to ensure necessary care and services were given to a resident at risk for aspiration, failed to provide on-going assessments after a resident aspirated, and failed to notify the physician appropriately after an aspiration incident for 1 of 3 residents (R1) reviewed for care and services in the sample of 4. This failure resulted in R1 being found with bacon in her mouth from the breakfast meal at 12:30 PM on [DATE], aspirating on that food, and not being sent to the hospital for treatment until approximately 7:30 PM. R1 remains hospitalized and receiving intravenous antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] The findings include: R1's face sheet showed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's facility assessment dated [DATE] showed she has severe cognitive deficits, requires extensive assistance with bed mobility, requires total assistance with transfers, and set up and supervision for eating. On [DATE] at 2:35 PM, V12 (R1's Power of Attorney) said R1 remains in the hospital on intravenous antibiotics for aspiration pneumonia. V12 said the V5 (Registered Nurse-RN) called her at 1:15 PM on [DATE] and told her R1 had aspirated on her lunch meal. V12 said she asked if R1 had been up in a chair for her lunch and they told no, she was eating in bed. V12 said she had previously discussed with the facility to make sure R1 was not eating in bed because it was not safe. V12 said the problem is that R1 cannot tolerate being up in the chair for long periods of time and the staff do not want to transfer her back to bed right away so they just leave her in bed. V12 said when they called her at 1:15 PM they said R1 was stable and did not need to go to the hospital. V12 said she then spoke with V2 (Director of Nursing-DON) and told her she does not want R1 eating in her bed. V12 said it was discussed during that conversation with the DON that R1 was not to be offered her meal tray in bed. V12 said she called the facility at about 7:00 PM on [DATE] to check on R1 and asked the nurse if she was assisted up to the chair for supper. V12 said the nurse told her R1 was given her meal tray in bed again. V12 said she requested to talk with R1 on the phone and when R1 was given the phone she was crying and stating she did not feel well. V12 said it was then that she requested for R1 to be sent to the hospital for evaluation. V12 said R1 is not getting properly cared for and would have less of a chance of aspirating if she would have been assisted to her chair to eat. V12 said she is upset that this happened around lunch time and that it took her to call up to the facility at 7:00 PM to figure out something was wrong with her mother. R1's nursing progress note entered by V5 (RN) on [DATE] at 12:30 PM showed, At 12:30 resident was observed to be coughing by the CNA (Certified Nursing Assistant), CNA informed the writer, and immediately assessed the patient, resident aspirated with a portion of her food and coughing continuously. Patient was repositioned, and immediately given nebulization treatment, after the treatment, the coughing episode stops, and the patient's breathing improved with O2 (oxygen) saturation of ,d+[DATE]% at 4LPM (liters per minute) of oxygen inhalation. DON informed. POA informed. R1's nursing progress note entered by V5 on [DATE] at 1:03 PM showed, [V12] notified in regards to the resident having an episode of choking, we also informed her about the management done and the current condition of the patient. We will update her if there would be any changes in the patient's condition, currently the coughing stops, difficulty breathing was lessen, oxygen saturation at 95% on 4 liter of oxygen . R1's nursing progress note entered by V2 (DON) on [DATE] at 1:30 PM showed, Call received from resident's POA in regard to resident aspirating on her lunch. POA does not want her mother sent out to ER (emergency room ) at this time, however, she wants her mother up for all meals and no trays served in bed. POA agreeable to having a sign posted at bedside stating resident is to be out of bed for meals. R1's nursing progress note entered by V3 (RN) on [DATE] at 9:36 PM showed, Received a phone call from resident's daughter and asked the writer if resident got up for her supper. Writer told the daughter that resident stayed in her bed during her meal. Daughter then asked to speak with the resident. Daughter also spoke with [Manager on Duty] and was requesting to send the resident to the hospital . R1's nursing progress note entered by V13 (RN - Nurse Consultant) on [DATE] at 7:47 AM showed, Investigated why resident was not up out of bed during meals. Staff explained that when attempted resident refused and started swearing at them and told them to get out of her room. Staff and resident have been educated recently on the importance for [R1] to be up in chair during meals. Upon return will continue to educate and reinforce compliance. R1's acute care hospital documentation dated [DATE] showed, . The patient was noted to have a coughing fit for 10 minutes while eating dinner. She was thought to have aspirated. The patient's family requested that she be sent to the emergency department for further evaluation . The patient was not answering questions well and just said that she did not feel well . CT found evidence of aspiration pneumonia and [CONDITION(S)]. The patient appeared to have [CONDITION(S)] making administration of oral antibiotics difficult. The patient received (intravenous antibiotics) . On [DATE] at 12:49 PM, V5 RN said when asked about R1 on [DATE], That day a CNA was in her room. As far as I know the CNA was feeding her. There were times she needed to be fed and times she fed herself. Most of the time she fed herself. The CNA approached me and said [R1] was continuously coughing. I immediately repositioned her and removed food from her mouth. There was bacon in her mouth. (This event occurred at approximately 12:30 PM, the menu for [DATE] showed bacon was served at breakfast.) When I went in, she was in bed at a 45 degree angle, I turned her on her side and patted her on the back to help her get it out. After that I gave her a nebulizer treatment and her oxygen level increased. I let the DON (V2) know and let the POA know what happened. The POA said during feeding time [R1] should be up to a chair. I talked about sending her to the hospital with the DON but then the DON and the POA discussed her going to the hospital. I did not send her to the hospital because she was stabilized at that time. My shift ended at 3:00 PM so I let the oncoming shift know [R1] was at risk for aspiration now. I did not call the physician, I updated him through fax. On [DATE] at 11:28 AM, V3 RN said, [R1] had an aspiration episode per the day shift nurse. I checked on her. She was the same as she had been before. The dinner time came and after dinner her daughter called the facility and requested to talk with her mom. [V12] said she heard something in her mom's voice and requested I send her to the hospital. She was not coughing then. I contacted the hospital for transport . The facility's fax communication sheet initiated by V5 with R1's physician dated [DATE] and faxed at 2:35 PM showed, Just to inform that the resident has episode of aspiration this afternoon while taking her lunch around 12:30 PM. Nebulization (breathing treatment) done, coughing with difficulty of breathing stabilized. Recent oxygen saturation at 95% on 3/lpm of oxygen . The facility's fax communication sheet dated [DATE] and transmitted at 8:50 PM showed, This is to inform you that the resident above (R1) has been sent to the hospital as per daughter's request. She has aspirated this day during lunch and family wants her to be sent to the hospital to make sure she is okay. On [DATE] at 12:29 PM, V11 CNA said, I only served her breakfast because I had been assigned room trays that morning. She was really sleepy. She was right across the hall from the nurse's station so I could see her pretty well because the door was open. I had her up at a 90 degree angle. She did not want to wake up. I had to try and wake her up to get her to eat. She ate very little. She was in bed for breakfast . On [DATE] at 1:28 PM, V10 CNA said, [R1] is not normally my resident and I don't normally go in her room. I went in her room ([DATE]) and she was coughing. It looked like something was wrong. I told [V5]. I had went in to pick up the room trays and it looked like she was sleeping. She had not even touched her lunch tray. When I woke her up, she started coughing but it was different than her cough before. I told the nurse right away because I knew her, and she looked terrible. She had her eyes shut and was not coughing but was doing like a short, half cough like you are trying to get something up. There was a CNA that said she had taken bacon out of her mouth at breakfast. She said she picked up her breakfast tray and she pulled bacon out of her mouth . I stopped in before I left at 7:00 PM and asked how she was doing, and she said the right side of her head hurt. She said, 'I don't know what happened but my head hurts.' On [DATE] at 1:50 PM, V7 CNA said, [R1] usually does not eat everything. She does sometimes choke. She eats by herself. We keep an eye on her while she eats . We watch her the entire time if we are on room trays. She will start coughing while she is eating, and it sounds like [MEDICATION(S)] in her system. She wants to get up so we get her up and before she can even get her meal, she wants to lay back down, so we have to lay her back in bed because that is what she wants. We thought it would be okay for her to be in the bed while she eats. Before she never choked so bad that we had to intervene. We could go in if she calls or chokes. We would go in there. On [DATE] at 2:05 PM, V6 CNA said, I only assist her if she is very sleepy and looks like she needs help. I usually do keep an eye on her when she is in the bed because I'm scared something is going to happen. She feeds herself most days . We would sometimes try and get her up but very rare, always see her in the bed. I feel like the only time she wakes up is to eat. It started a few months ago where she just became a lot sleepier. She will wake up if you tell her that her breakfast is here. If I walk by and she hasn't eaten I'll help her, for instance, if we are 30 minutes into the mealtime and she is not waking up to eat, I'll help her. She is pretty good at chewing and swallowing as long as you go at a good pace and give her drinks as well . On [DATE] at 3:22 PM, V14 (Nurse Practitioner) said, We would expect the staff to call us and alert us of something like an aspiration incident. I was not notified of this incident at all. I would be concerned for aspiration pneumonia. It would be to the emergency room she would go because the nursing home is not able to make things happen quick enough like a hospital can. Timeliness of notification is important. She is able bodied to feed herself. They put the tray in front of her, but she might not be sitting up properly, and she is unable to reposition herself. She is often times lying in bed and she isn't adjusted in a proper way. I've seen it before when I'm there. On [DATE] at 11:15 AM, V2 (DON) said, I'm sure you are here about [R1]. She had a coughing episode at lunch. The daughter was informed and didn't want to send her out to the hospital. Then she stayed in bed for supper. There was no incident that occurred during supper, but the daughter called and found out she had stayed in bed again to eat and requested her to be sent to the hospital. At 3:06 PM, V2 said, I think [V5] said he called the physician to let him know right after the incident. I would expect them to contact the physician for any new orders . I would say they would need to call and get the information to the physician; faxes should be used for something more of an FYI (for your information), not something you need immediate attention to. I did do in servicing on contacting the physician via phone for something like this after this happened. The facility's policy and procedure with revision date of [DATE] title Physician-Family Notification of Change in Condition showed, Purpose: To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner . The facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner . (A) An accident involving the resident which results in injury and has the potential for requiring physical intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) .

Based on observation, interview and record review the facility failed to identify areas of pressure, assess areas of pressure and implement interventions for pressure prevention. These failures resulted in deterioration of the pressure area for R22. These failures resulted in R43's pressure deteriorating into an unstageable pressure injury. These failures resulted in R178 developing a deep tissue injury. This applies to 3 of 8 residents (R22, R43, R178) in the sample of 19 reviewed for pressure. The findings include: 1. The facility face sheet for R22 shows diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R22's facility assessment dated [DATE] shows R22 has severe cognitive impairment and requires extensive assistance of 2 for bed mobility and is always incontinent of urine. The facility wound report printed on 8/3/2022 shows R22 had a stage 4 pressure injury to her coccyx on 3/23/2022. The initial wound report dated 3/23/2022 by the facility shows a stage 4 facility acquired pressure injury measuring 1.8 x 1.5 x .6 centimeters with no tunneling. The wound report for R22 on 7/26/2022 shows the coccyx pressure injury is measuring 2.3 x 1.5 x .30 centimeters with tunneling of 4 centimeters present. The facility skin checks dated 4/5/2022 to 5/22/2022 shows no mention of a pressure injury to R22's coccyx. Starting 6/22/2022 the weekly skin observation sheets show a pressure injury to R22's coccyx. On 8/03/22 at 3:25 PM, V3 Assistant Director of Nursing (ADON) and wound nurse said R22 was admitted to hospice in February and the hospice nurse said they were doing the weekly skin assessments. V3 said the hospice staff did not let the facility know she had a pressure wound to her coccyx. On 8/04/22 at 8:30 AM, V7 Hospice Registered Nurse (RN) said the pressure injury was first observed to R22's coccyx on 3/1/22. V7 said an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V7 said when new orders are written at the facility, the facility nurses are always informed of changes. 8/04/22 at 9:00 AM, V8 Hospice Certified Nursing Assistant (CNA) said she cares for R22 2-3 times a week and she first noticed a black looking area to R22's coccyx the beginning of March. V8 said she informed the hospice staff as well as the facility staff. The hospice caring for R22 was notified and sent this surveyor copies of their wound assessments for the month of March 2022. The records were not available at the facility. The hospice first wound assessment shows on 3/1/2022 a 1x1 centimeter unstageable pressure injury with hard black/brown scab to R22's coccyx. The hospice wound assessment dated [DATE] for R22 shows the wound is now a stage 3 pressure injury and R22 is grimacing and moaning while wound care is provided. The facility Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The treatment Administration record for the Month of March for R22 shows a treatment in place for the wound to the coccyx and was being completed by the facility staff. The facility care plan for R22 shows new interventions were not put into place until 3/24/2022 (24 days after initially being found by the hospice staff). On 8/04/22 at 10:15 AM, V2 Director of Nursing (DON) said the nursing staff should be assessing the wound weekly for sure and doing measurements even though hospice is involved. If the treatment was started by hospice, we should still be assessing the wound. The facility should have had better communication with hospice and obtained the records from them and put interventions in place sooner. The facility policy with a revision date of 1/17/2018 for pressure injury and skin condition assessment shows to establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented. Pressure and other ulcers will be assessed and measured at least every 7 days by a licensed nurse and documented in the resident's clinical record. 2. R43's Admission Record, provided by the facility on 8/4/22, showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R43's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders showed cleanse right great toe with wound cleanser, paint area with [MEDICATION(S)] and leave open to air daily. R43' Wound Assessment Details Report dated 6/27/22 showed, on that date, a facility-acquired, unstageable pressure injury was identified on R43's right big toe measuring 1.10 cm (centimeter) x 1.20 cm. R43's Braden assessment (a tool used to determine a resident's risk for pressure injury) dated 11/5/21 showed R43 was a high risk for the development of pressure injuries. The facility assessment dated [DATE] showed R43 had moderately impaired cognitive skills and required extensive assist of two staff members for bed mobility. R43's Pressure Ulcer care plan, initiated on 1/5/22, with a revision date of 1/7/22, showed at that time she had a pressure ulcer to her right lateral ankle, right lateral heel, and gluteal (area located below the pelvic girdle that extends into the upper leg) related to immobility. The care plan was not updated to show the pressure area to R43's right great toe. The care plan showed interventions in place were to follow facility's policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R43's potential for skin impairment care plan initiated on 1/5/22, showed interventions in place were to assess and record changes in skin status and to minimize pressure over bony prominences. R43's Progress Note dated 6/25/22 showed a 1 centimeter pressure area was identified on R43's right big toe. The note showed it seemed to be caused by a constrictive sock worn consistently by R43. The Progress Note dated 6/27/22 at 10:00 AM, showed Resident was found to have a 1 cm dark spot on right great toe post shower. Resident has been wearing compression type stockings, noted this has put increased pressure on (the) tip of (her) toes. Stockings left off post shower. Will monitor DTI (deep tissue injury). The progress note dated 6/27/22 at 1:21 PM, showed V3 (Assistant Director of Nursing) assessed the pressure injury to R43's right great toe. V3 noted a deep maroon area to R43's right great toe measuring 1.10 cm x 1.20 cm. On 8/3/22 at 1:06 PM, V3 (Assistant Director of Nursing) went into R43's room with this surveyor to look at the pressure area on R43's right great toe. R43 had a dark scab on the tip of her right great toe. V3 said R43 had recently had a pressure area to her right heel that has healed. At 1:32 PM, V3 said she would expect staff to identify areas of pressure prior to them becoming unstageable. V3 said the facility was using agency nurses at the time. V3 said a lot of things did not get done and it was hard to keep track of things. V3 said now the facility has more nurses hired and are training them. On 8/3/22 at 2:03 PM, and again at 3:15 PM, R43 was lying in bed with nothing under her heels. R43's heels were directly flat on the bed. On 8/04/22 at 12:05 PM, V2 (Director of Nursing- DON) said R43 needs staff assist for dressing. Staff should perform skin checks and look for any changes off of R43's baseline. V2 said staff should report any changes to the nurse on duty, so they can assess the area. V2 said the facility may have been able to identify any subtle skin changes and put something in place before it got to that point with R43's great toe. V2 said staff should follow the interventions in place and offload R43's heels to prevent a reoccurrence of pressure areas. R43's Wound Assessment Details Report dated 8/1/22, showed R43 recently had a deep tissue injury to her right heel, that was identified on 7/22/22. A Wound Assessment Details report dated 3/31/22 showed R43 had previously had an unstageable pressure injury to her right heel that was identified on 10/15/21. A Wound Assessment Details Report dated 3/4/22 showed R43 had a previous deep tissue injury to her right lateral heel that had been present on admission. The facility's policy and procedure titled Pressure Injury and Skin Condition Assessment, with a revision date of 1/17/18, showed the purpose of the policy was to establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented. The policy showed 1. A skin condition assessment and pressure ulcer risk assessment (Braden) will be completed at the time of admission/readmission. The pressure ulcer risk assessment will be updated quarterly and as necessary. 2. Residents identified will have a weekly skin assessment by a licensed nurse .4. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment .6. Care givers are responsible for promptly notifying the charge nurse of skin breakdown .17. The resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches and goals for care. 3. On 8/2/22 at 1:00 PM, R178 was lying in bed. R178 was not wearing any heel protectors and his heels were not being floated. On 8/2/22 at 1:31 PM, R178 was observed on the floor, face down on a fall matt. R178 was not wearing a sock on his left foot. R178 had a purplish-black, egg size area to his left heel. On 8/3/22 at 1:38 PM, V3 (WCN-Wound Care Nurse) stated she was not following or treating R178 for any skin issues. V3 said she was unaware of any skin problems with R178. V3 said R178's heels should be offloaded when he is in bed to prevent any break down. On 8/3/22 at 4:19 PM, R178's was lying in bed and his heels were directly on the mattress. R178's heels were observed with V3 present. V3 stated she did not know anything about the dark area on his left heel. V3 said, That is new to me. I was not aware of this until now. V3 said that looks like a pressure issue to me. It could be a DTI (deep tissue injury). His heels should be offloaded to take off the pressure. V3 said the aides should be inspecting resident skin daily during all cares. Any changes should be reported to the nurse right away. V3 said the nurses also do weekly skin assessments and should be inspecting the skin from head to toe. V3 said this should have been reported immediately. It is important to treat pressure ulcers right away to prevent worsening of the issue. R178's progress note dated 7/28/2022 (last weekly skin assessment) showed no skin concerns and FOOT OBSERVATIONS/CARE: No foot concerns noted. R178's wound round documentation dated 8/2/22 at 12:40 PM by V3 (WCN) showed no wound or skin concerns. R178's wound round documentation dated 8/3/22 at 5:36 PM (after the observation with surveyor) by V3 (WCN) showed a facility-acquired left heel deep tissue pressure injury. The measurements were 6.00 cm long by 5.00 cm wide by 0.01 cm deep. On 8/4/22 at 9:40 AM, V2 (Director of Nurses) stated skin checks should be done daily by the aides with all ADLs (activities of daily living) and cares. Any changes should be reported immediately. Resident's skin is checked weekly by the floor nurses too and special attention is needed for high pressure areas like the backside and heels. It is important to catch changes right away to stop rapid deterioration. It is important to start interventions right away to prevent further breakdown. Staff should be finding skin changes before reaching a DTI level. Finding pressure problems at an advanced level takes it longer to heal. The facility Pressure Injury and Skin Condition Assessment policy revision dated 1/17/18 states: 4. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. 6. Care givers are responsible for promptly notifying the charge nurse of skin breakdown.

Based on interview and record review the facility failed to prevent a resident's mental health from declining and failed to implement interventions to keep a resident's behavior from escalating for 1 of 3 residents (R3) reviewed for behavioral health services in the sample of 10. This failure resulted in R3's psychiatric behaviors escalating requiring hospitalization . The findings include: R3's Face Sheet dated 5/24/22 shows she was admitted to the facility on [DATE] and her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Minimum Data Set (MDS) dated [DATE] shows she has severe cognitive impairment. R3's Progress Notes include a Psychiatry Note signed at 2:26 PM on 3/23/22 from V16, Psychiatric Physician Assistant (PA). The note includes the following: Plan- Med Changes: No medication changes recommended at this time. Continue current treatment plan. Medication List: [MEDICATION(S)] [antipsychotic], [MEDICATION(S)] [antidepressant], [MEDICATION(S)] [anticonvulsant], [MEDICATION(S)] [sedative], [MEDICATION(S)] [anxiolytic (anti-anxiety)], [MEDICATION(S)] [antidepressant], [MEDICATION(S)] [anticonvulsant and is also used to treat [CONDITION(S)] disorder], [MEDICATION(S)] [sedative], [MEDICATION(S)] [antipsychotic], [MEDICATION(S)] [antihistamine], and [MEDICATION(S)] [[MEDICATION(S)] agonist]. Gradual Dose Reduction: Medication does, and duration are appropriate and not duplicitous .Medications prescribed are medically necessary for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Gradual Dose Reduction (GDR) is clinically contraindicated at this juncture due to attempted dose reduction likely impairing resident's function and causing psychiatric instability by exacerbating an underlying psychiatric disorder. R3's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/23/22 at 10:00 AM, V2, Director of Nursing (DON), said R3 has a long psychiatric history. V2 said Hospice stopped R3's medications without family agreement. V2 said she noticed R3's behaviors had increased, and she witnessed R3's poor impulse control after her psych meds had been discontinued. V2 said R3 was hearing voices and throwing objects. V2 said there should have been a GDR, it is not an acceptable practice to just discontinue psych meds. V2 said R3 had been taking her medications regularly before they were discontinued. V2 said R3 ended up in the hospital due to her behaviors as a result of her medications being discontinued. On 5/23/22 at 11:15 AM, V11, R3's daughter, said she received a call from the facility about a month and a half ago informing her R3 was acting out and requiring more supervision. V11 said she was told hospice discontinued all of R3's psych medications all at once without her (V11) consent. V11 said she was told the facility did not have enough staff to provide one to one monitoring of R3. On 5/24/22 at 9:39 AM, V2 said she feels R3's worsening behavior was a direct result of her psych medications being abruptly stopped. V2 said V11, R3's daughter, was not aware everything was going to be discontinued. On 5/24/22 at 10:46 AM, V12, Physician/Medical Director of Hospice, said [CONDITION(S)] medications are never abruptly discontinued. V12 said we go by symptoms and behaviors and try to optimize [CONDITION(S)] medications [for patients]. V12 said if psychiatric medications are abruptly discontinued, it can lead to [CONDITION(S)] and exacerbate symptoms such as aggression, hallucinations, and paranoia with a worsening of psychiatric problems. On 5/24/22 at 11:46 AM, V1, Administrator, said R3 was sent to the hospital for medication management and stabilization. V1 said it was an emergency as R3 had been sitting on her bed and punched the window. V1 said they had been trying to manage R3's medications in house and it did not go well. V1 said it is not the facility practice to abruptly discontinue a resident's psych medications. R3's Nurses Note dated 3/25/22 at 3:33 PM shows an order was given to discontinue most of R3's medications except for comfort medications and V11 was notified and not in agreement. R3's Progress Notes show many examples of worsening psychiatric symptoms. On 3/31/22 at 5:45 AM resident reported feeling lost, scared, and indicated she was hearing voices. On 4/1/22 at 6:41 AM resident continues to exhibit fear, anxiousness, and paranoia, on 4/12/22 at 10:28 PM resident's thinking is scattered and unfocused. She is argumentative with staff and verbally aggressive and mean. On 4/13/22 at 10:24 AM the resident threw the tray on the floor and yelled at her roommate. On 4/19/22 at 2:04 PM, Psychiatry note shows R3 was placed on hospice and some of her medications were stopped. Since that time, it appears her mood has been worsened .she has had some behaviors where she would get upset and throw herself on the floor, and reports being frustrated and feels helpless and hopeless. R3's progress notes show she (R3) was found on the floor on 4/12/22 at 11:30 AM. The Interdisciplinary Team (IDT) met and per their documentation on 4/10/22 at 2:06 PM in R3's progress notes, determined the following: Root cause of fall: Resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Progress Notes show behaviors continued throughout April 2022; on 4/21/22 at 9:23 PM Nurses Note show she was attempting to get out of bed all day, attempting to bribe staff to leave the building so she can go gamble, on 4/23/22 at 1:43 AM, R3 requesting to call her family, on 4/26/22 at 4:50 PM R3 was on the floor mat next to her bed, on 4/30/22 at 11:30 AM, R3 was found on the floor mat next to her bed. On 5/2/22 at 5:48 AM Behavior/Mood charting shows R3 was attempting to put herself on the floor. Resident verbally aggressive with staff, yelling out, attempting to hit at staff. On 5/4/22 at 3:03 AM Nurses Note documents R3 increasingly agitated hitting staff, yelling at staff and trying to get out of bed, at 3:27 AM resident yelling to staff that I'm going to kill you along with other threats and profanities, and at 3:33 AM, R3 accused staff of hitting her and stealing her candy and spit at staff. The Fall-Initial Occurrence Note of 5/4/22 at 10:30 AM shows R3 was again found on the floor mat next to her bed. On 5/4/22 at 3:06 PM, Nurses Note shows R3 hit the window with a boot and destroyed the blinds. R3 was sent to the hospital for evaluation. R3's Care Plan shows a focus initiated on 11/16/21 as follows: I have the potential to be physically aggressive. I will throw items at others, hit, kick and bite. No new interventions were implemented after 11/16/21. R3's Care Plan shows a focus initiated on 11/16/21 as follows: I am/had potential to be verbally aggressive. I yell/scream at others and use abusive language .No new interventions were initiated after 11/13/21.

I. Based on observation, interview, and record review the facility failed to have a policy following the Centers for Disease Control (CDC) recommendations for Personal Protective Equipment (PPE) for new admissions, the facility failed to follow recommendations from the CDC by not wearing N-95 masks or eye protection when caring for a newly admitted resident (R272) on contact/droplet precautions being monitored for COVID-19, and the facility failed to have appropriate signage up for a resident on contact/droplet precautions. These failures have the potential to affect 13 residents (R11, R16, R19, R21, R26, R29, R32, R34, R46, R52, R65, R69, R73) who are not fully vaccinated and have no history of COVID-19 within the past 90 days. The Immediate Jeopardy began on May 18, 2021 when the facility failed to implement the appropriate isolation precautions for a new resident admitted to the facility that was not fully vaccinated against COVID-19. The Immediate Jeopardy was identified on May 18, 2021. V2 (Director of Nursing) was notified of the Immediate Jeopardy on May 20, 2021 at 9:00 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on May 21, 2021, but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R272's electronic face sheet printed on 5/18/21 showed R272 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/18/21 at 9:32 AM, R272's room was observed with isolation bins outside of her door. There were no signs outside of R272's door as to what type of isolation was being utilized. The only sign posted showed, Attention: isolation room please do not enter without personal protective equipment on. Don (apply) gown, N95 or facemask, gloves. Doff (remove) gloves, gown, facemask. On 5/18/21 at 9:37 AM, V3 (Registered Nurse-RN) stated, (R272) is on isolation for 14 days due to a recent hospital stay. We know what personal protective equipment to put on because the sign on the door shows us how to put our PPE (personal protective equipment) on and take it off. In (R272's) room we wear a gown, gloves, and a surgical mask. We don't need to wear an N-95 mask in her room. (R272) has not received her COVID-19 vaccination. On 5/18/21 at 10:30 AM, V4 (Certified Nursing Assistant-CNA) applied her gown, surgical mask, and gloves. (V4 did not have an N95 or eye protection on). Upon exiting the room, V4 removed her gown & gloves but kept her surgical mask on. On 5/18/21 at 10:33 AM, V5 (Advanced Practice Nurse) applied her gown, surgical mask, and gloves and entered R272's room. (V5 did not have an N95 or eye protection on). At 10:44 AM, V5 left R272's room without changing her surgical mask. The resident roster provided by the facility on 5/18/21 showed V5 visited 11 residents throughout the facility on 5/18/21. On 5/18/21 at 10:43 AM, V4 (CNA) stated, (R272) is on isolation because she was in the hospital. She's been here about a week. In her room we have to wear a gown, gloves, and a surgical mask. We do not need to wear eye protection. I'm sure it would be different if she was COVID positive. Technically I have eye protection on because I wear glasses, right? On 5/18/21 at 11:43 AM, V4 stated, I am covering all of the north side residents today which is all of 200 hall. The resident roster provided by the facility on 5/18/21 showed 18 residents residing on the 200 hall. (R272 resides on this hall) On 5/18/21 at 12:12 PM, V4 delivered R272's room tray. V4 applied her isolation gown, gloves, surgical mask, and goggles and entered R272's room. Upon exiting the room, V4 left her surgical mask and goggles on. V4 did not disinfect her goggles or replace her surgical mask upon leaving R272's room. V6 (Certified Nursing Assistant) was observed on 3 separate occasions from 5/18/21 thru 5/20/21 not wearing a face covering while in resident care areas. On 5/18/21 at 2:10 PM, V2 (Director of Nursing) stated, There should be a sign on (R272's) door indicating what type of isolation precautions she is on, but for some reason there isn't. She is only on contact isolation as a person under investigation due to a recent hospitalization . We are just monitoring her. She was admitted to our facility from the hospital on 5/13/21 and has not had her COVID vaccine yet, nor has she had COVID-19. When entering her room, staff should be wearing gloves, gown, surgical mask, and eye protection. Staff are to take PPE off prior to leaving the room and they should take off everything including their mask. I suppose eye protection could be wiped down and reused but it's not required. Our last in-service was done about 3-4 weeks ago and included close monitoring of residents and keeping COVID out of your facility. We discussed how to monitor for signs and symptoms of COVID, how to don (put on) and doff (take off) PPE. We have plenty of N95's in the building and we continue to keep track of our burn rate for our PPE. Staff do not need to wear an N-95 mask in (R272's) room because she doesn't have any symptoms. If she did, we would wear an N95 mask. The facility roster provided on 5/19/21 showed 7 residents (R19, R21, R26, R34, R46, R65, R272) that are unvaccinated for health conditions, physician refusal or family refusal. The same roster showed 7 residents (R11, R16, R29, R32, R52, R69, R73) who are not fully vaccinated until 5/26/21. The facility's policy titled, COVID-19 Personal Protective Equipment Policy showed, Personal protective equipment for a person under investigation with- surgical mask, gown, gloves, eye protection (N-95 mask instead of surgical mask for aerosol generating procedures). Eye protection- acceptable eye protection: a surgical mask with an attached face shield, a full-face shield, or goggles. Special droplet and contact precautions. The CDC website pertaining to unvaccinated residents without a personal history of COVID-19 within the past 90 days updated on March 29, 2021 showed, Nursing homes must sustain core infection control practices and remain vigilant for COVID-19 infection among resident and healthcare providers in order to prevent spread and protect residents and healthcare providers from severe infections, hospitalization s, and death .healthcare providers should wear well-fitting source control at all times while they are in the healthcare facility .any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses .eye protection should be worn during patient care encounters to ensure the eyes are also protected from exposure to respiratory secretions .healthcare providers should wear an N95 or higher level respirator, eye protection, gloves, and gown when caring for residents in quarantine .In general, all other new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. The Immediate Jeopardy that began on May 18, 2021 was removed on May 21, 2021 at 11:30AM when the facility took the following actions to remove the immediacy: Facility has updated its policy on 5-20-21 to require 14-day quarantine and contact and droplet precautions for all new admissions that have not been fully vaccinated for COVID-19. Policy includes the requirement to wear gowns, gloves, eye protection, and N95 masks. Signage on resident room has been updated on 5-20-21 to reflect specific requirement of contact and droplet precautions which includes, but is not limited to, the wearing of gown, gloves, N95 masks and face shield or eye goggles. All facility employees in the building on 5-20-21 have been in-serviced by a member of the management staff on the updated policies and procedures for proper quarantine and isolation precautions for newly admitted residents that have not been vaccinated for COVID-19. All employees working on the PM and night shift on 5-20-21 will be in-serviced before they start their respective shifts by the Director of Nursing (DON) or a member of the management staff on the new policies and procedures. All employees will be in-serviced by 5-20-21. Temporary and PRN employees will be contacted and informed on 5-20-21 that they must be in-serviced on the updated policies and procedures before they can work their shift. This training will be done by either the DON or a member of the management staff. Temporary and PRN employees will be required to come in person for their in-service education no later than Thursday, May 27, 2021. If they are not able to come in person, educational material on the updated policies will be emailed to them and an email response will be required acknowledging receipt and review of the educational materials. A Quality Assurance (QA) tool will be implemented on 5-20-21 to monitor staff personal protective equipment (PPE) usage and compliance of PPE in new resident rooms under contact/droplet precautions. QA tool will be used to audit and ensure the use of N95 masks, face shield, gloves and gowns in contact/droplet precaution rooms. This audit will be done daily for the next 4 weeks by a nurse manager or his/her designee. Director of Nursing will review and monitor for compliance on a daily basis for 4 weeks. After 4 weeks, audits will be conducted twice weekly by a nurse manager and his/her designee for the next 2 months. Director of Nursing will review and monitor for compliance twice weekly for the next 2 months. After 2 months, audits will be conducted weekly for 4 months by a nurse manager and his/her designee. Director of Nursing will review and monitor for compliance weekly for 4 months. QAPI review will be conducted to review infection control concerns, root cause and plan of action. QAPI meetings to review action plan will take place monthly. On 5/21/21 at 9:00 AM, In-service records were reviewed and 63% of facility staff have received education related to new admissions being monitored for COVID-19, proper PPE to be worn in contact/droplet isolation rooms, and proper signage to post for residents on isolation related to COVID-19. Staff that are not able to attend an in-service prior to May 27, 2021 are being sent an electronic version of the training and must respond with acknowledgement that they received and read the education. V1 Administrator confirmed that all staff will have the training completed prior to working their next shift. II. Based on observation, interview and record review the facility failed to provide incontinence care in a manner to prevent cross contamination for one of one residents (R26) reviewed for infection control in the sample of 18. The findings include: R26's Face Sheet printed 5/20/21 showed she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R26's facility assessment dated [DATE] showed she had severely impaired cognitive skills and was dependent on two staff for bed mobility, dressing, toileting, and personal hygiene. On 5/19/21 at 3:35 PM, V9 and V11 Certified Nursing Assistants-CNAs were providing incontinence care for R26. V9 used one wipe and in one continuous motion, wiped under R26's abdominal fold, down across her pubic area and then down her vaginal/labial area. V8 did not use a clean wipe for different areas or fold wipe between areas. On 5/19/21 at 3:48 PM, V8 said for infection control reasons, he should have used a clean wipe for each area, so he does not introduce bacteria into the body. On 5/19/21 at 4:03 PM, V2 Director of Nursing-DON said it is unacceptable to wipe under a resident's abdominal fold, then across their pubic area and then their vaginal area in one motion. V2 said you can introduce bacteria into the body and cause an infection by doing it that way. On 5/20/21 at 1:19 PM, V16 CNA said it is not acceptable to clean under a resident's abdominal folds, then pubic area, then vaginal area in one swipe. V16 said staff should use a new wipe for each area to prevent contamination and infection. The facility's policy and procedure titled Incontinence (Peri-care) Care with a revision date of 8/19/16 showed the purpose of the policy is to decrease the risk of skin problems due to incontinence such as breakdown and infection through proper care. The policy showed 5. Care is given with a cloth, water, soap and/or peri wash using a front to back stroke in peri area. The facility's 4/20/17 document titled Peri Care Return Demonstration showed Used clean section for each wipe/wash cloth or used a new wipe/wash cloth each time.

Based on interview and record review the facility failed to supervise a resident in bed while providing personal care. This failure resulted in R1 falling off of the bed and sustaining 2 cervical fractures (neck fractures). This applies to 1 of 3 residents (R1) reviewed for safety/supervision in the sample of 3. The findings include: R1's electronic medical record lists [DIAGNOSES REDACTED]. The facility's resident occurrence/incident report dated (MONTH) 17, (YEAR) for R1 shows, called to room by CNA (Certified Nursing Assistant). Resident noted laying face down on left side of bed on floor mat between bed and dressers . noted with swell/purple discoloration to left forehead, also noted with 11.5 x 5.5 cm (centimeters) purple discoloration to right forearm containing 1.5 cm, 1.0 cm, 1.5 cm & 4.5 x 3.0 cm skin tears also noted with purple discolorations and skin tears to right hand . The same assessment shows, Cause/Probable cause: CNA stepped away from resident. Statement (V3 CNA): Resident was laying in bed slightly on left side. Resident had lifted legs off bed. Pulled down brief found BM (bowel movement) turned around to get wash clothes ready. Resident rolled off bed. Found on floor face down on bed mat. On (MONTH) 20, (YEAR) at 10:28 AM, V3 CNA stated, I walked into the room and put the bed up to about my shins. I checked her brief. She had a BM. She was lifting her legs off the bed. I turned my back to get washcloths ready and heard a noise, she fell from the bed and was on the floor. She stated, she was the only CNA in the room at the time. It's supposed to be 2 (2 CNAs). On (MONTH) 20, (YEAR) at 9:50 AM, V4 MDS coordinator stated, V9 Licensed Practical Nurse (LPN) and I were at the desk. V3 CNA said she needed us in R1's room. R1 was on the left side of the bed (on the floor). R1 was rolled over on her side, almost on her stomach. V3 told us that she opened her brief to see if R1 was dirty. She saw she was dirty, turned to get washcloths and heard R1 fall. V4 stated, R1 is supposed to have 2 people while doing cares and V3 was the only CNA in there at the time. On (MONTH) 20, (YEAR) at 9:30 AM, V8 CNA stated, R1's care plan says 2 people assist at all times. The Minimum Data Set, dated dated dated (MONTH) 11, (YEAR) shows, R1 requires two person physical extensive assist with bed mobility. The facility's bedside care plan for R1 shows, MUST HAVE 2 CNAS AT ALL TIMES! The bedside care plan is located in every resident's room above their bed, on the bulletin board. The local hospital's cat scan of the cervical spine for R1 dated (MONTH) 17, (YEAR) shows, Impression: [MEDICAL CONDITION] anterior arch of C1. Type II odontoid fracture of C2. Neurosurgical consultation recommended.

Based on observation, interview, and record review the facility failed to ensure a resident requiring assistance was safely transferred from her wheelchair to her bed with the use of a gait belt to prevent resident injury. This failure resulted in R2 sustaining a large hematoma to her right chest, extensive bruising across her chest and both breasts on (MONTH) 1, (YEAR), and requiring hospitalization on (MONTH) 3, (YEAR). The facility also failed to ensure staff use the mechanical lift safely when transferring residents to prevent resident's from receiving bruises. This applies to 4 of 5 residents(R2, R3, R4, R5) reviewed for safety in the sample of 5. The findings include: 1. R2's Electronic Medical Record (EMR) accessed on (MONTH) 4, (YEAR) shows that R2 has [DIAGNOSES REDACTED]. The EMR also shows that R2 has severe cognitive impairment and requires extensive assist of two staff for transfers. R2's Progress Notes dated (MONTH) 3, (YEAR) state, During the nurse's assessment, purple bruising to right upper chest noted, traveling to left chest, raised area to right chest noted, 13cm long x 5cm raised, warm to touch. Swelling to right hand, swelling noted around digits 2 through 4. Resident stated she is unaware of how this occurred. Resident sent to the ER for further evaluation. The hospital consult note dated (MONTH) 4, (YEAR) written by V7(Nurse Practitioner) states, She has extensive bruising noted to her bilateral breasts, purplish in color to underneath her breast tissue, but yellowed in color to her right upper chest wall. These appear to be older bruising. She is with a cast/splint to her right arm and in a sling, due to a right distal radius fracture, and a closed non-displaced fracture of third metacarpal bone of right hand. On (MONTH) 4, (YEAR) V7 stated, {R2} had bruising to her right upper chest that was yellowed. The fractures are a concern also but I did not review the X-rays or the X-ray reports. Generally bruises are bright purple for many days before they turn yellow. She has no history of a blood coagulation problem. It looks like someone bear-hugged her. I heard that the facility had no idea how it happened. It was extensive enough that I felt social services should be involved. It looked like an elder abuse case. The hospital X-ray report of R2's Right hand dated (MONTH) 3, (YEAR) shows, Suspected age-indeterminate fractures versus areas of [MEDICAL CONDITION] change seen at the head of the third metacarpal and distal radius. On (MONTH) 4, (YEAR) at 9:15AM, V2(Director of Nursing) stated, On Monday(April 2, (YEAR)) I was asked to assess {R2} because she had a hard lump on her right side, kind of under her arm. It was a hard mass. There was slight bruising under the mass. We called the doctor and he ordered blood work STAT. We got the results and faxed them to him but he didn't really do anything. Then on Tuesday morning {R2} had bruising from one arm to the other (across chest). We called the doctor and he said to send her to the ER. They admitted her last night for pneumonia. We looked at the schedule and talked to the nurse from Sunday night. He worked a double shift and the mass wasn't there at the start of his shift but it was there on Monday morning. Since {R2} doesn't transfer out of her bed on night shift we narrowed it down to PM shift on Sunday night. We found that a new CNA transferred {R2} without a gait belt and her preceptor just watched her do it. {V3- Assistant Director of Nursing} is doing the investigation. On (MONTH) 4, (YEAR) at 9:45AM V3 stated, I called seven staff that worked 2nd shift on Sunday. {V8- CNA-Certified Nursing Assistant} was training {V9-CNA}. {V8} watched {V9} care for {R2}. {V8} said she didn 't think {V9} used a gait belt to transfer her. {R2} requires extensive assist of one staff and {V9) bear-hugged her and transferred her. I have not talked to {V9} yet. On (MONTH) 4, (YEAR) at 1:05PM V8 stated, I was orienting a new CNA, {V9}. I was standing in the room, {V9} transferred {R2} to the bed. {V9} was on her left side, she hooked her under one arm and grabbed the back of her pants. She did not use a gait belt. On (MONTH) 4, (YEAR) V3 provided surveyor with a written copy of her interview with V9. At 3:00PM V9 stated to V3, On (MONTH) 1, (YEAR) {V8} watched me transfer {R2}. I held on to her britches and under her arm to transfer her. R2's care plan dated (MONTH) 13. (YEAR) states, Provide extensive assist of one with FWW(Front Wheeled Walker) for transfers. Utilize gait belt at all times. The facility policy entitled Gait Belt Usage Policy dated 8/20/2016 states, Residents that require hands on and stand by assist with transfers and ambulation will have gait belts used as part of the process. Purpose: To provide safety and protection during the transfer process. 2. The incident report for R3 dated (MONTH) 20, (YEAR) states, Resident has a bruise to her right shoulder. This may have occurred when the staff (mechanically lifted) her into bed. The (mechanical lift) may have landed on her shoulder. The incident report for R4 dated (MONTH) 27, (YEAR) shows that R4 has a pink raised area on her right forehead. The incident report states, She may have hit her head on the (mechanical lift). The incident report for R5 dated (MONTH) 29, (YEAR) shows that R5 has 4 small bruises on her right lower arm and a bruise on the back of her left hand. The incident report states, She could have bumped arm in the wheelchair during a transfer or on the (mechanical lift). On (MONTH) 4, (YEAR) at 3:45PM V3(Assistant Director of Nursing) stated she was not sure why so many residents were developing bruises related to the mechanical lift. On (MONTH) 4, (YEAR) at 4:00PM, V2 and V3 (Director of Nursing and Assistant Director of Nursing) confirmed that they are aware that the facility has had some issues with transfers and they are in the process of setting up a skills training for the CNAs. The facility policy entitled Hoyer (mechanical lift) Transfer dated (MONTH) 24, (YEAR) states,Using a hydraulic lift to raise the immobile resident from the supine to the sitting position allows safe, comfortable transfer between bed and chair.

Based on observation, interview, and record review the facility failed to provide a safe transfer for a resident. This resulted in R1 sustaining a fracture to her left humerus and bruising to R1's left shoulder, arm, hand, and knee. This applies to 1 of 3 residents (R1) reviewed for transfers in the sample of 6. The findings include: R1's Admission Assessment Record dated (MONTH) 17, (YEAR) shows R1 is alert and oriented x 3, readily able to answer questions, and quick comprehension. The same assessment also shows R1 requires staff assistance of two with a walker for transfers. The assessment record shows [DIAGNOSES REDACTED]. R1's Incident Report dated (MONTH) 21, (YEAR) shows R1 sustained a fracture during a transfer. R1's radiology report dated (MONTH) 22, (YEAR) shows: There is an .displaced fracture involving the left humeral neck (upper left arm) . On (MONTH) 27, (YEAR) at 10:00 AM, V17 (CNA) transferred R1 into bed and provided her a bed pan. A purple-black grapefruit size bruise was observed on her lateral (outer edge) of her left knee. R1's left hand had dark purple bruising covering the top of it. R1's left arm was covered with a night gown and could not be viewed by this surveyor. V17 said she had no idea what the bruising was from and it's been there awhile I think. On (MONTH) 27, (YEAR) at 12:45 PM, V2 said R1 did not have any left knee bruising prior to the (MONTH) 21, (YEAR) incident. V2 said she did not realize R1 was experiencing arm and knee bruising. V2 said the bruising had not been reported by nursing staff. On (MONTH) 27, (YEAR) at 8:30 AM, V2 (DON-Director of Nurses) stated R1was transferred from her wheelchair to the bed on (MONTH) 21, (YEAR) by V4 and V16 (CNAs-Certified Nurse Aides). V2 said she did not witness the transfer but interviewed the CNAs days after the transfer. V2 stated both CNAs said R1 was pressing against them with her arms during the transfer and they heard a pop sound near R1's arms. At 12:45 PM, V2 said after interviewing V4 and V16 she determined that R1 sustained a left shoulder fracture on (MONTH) 21, (YEAR) because it was a bad transfer. On (MONTH) 27, (YEAR) at 9:25 AM, R1 stated she was lifted out of her wheelchair by two aides a few days ago. R1 was unable to recall who the aides were but said they used my arm to lift me when I was standing next to the bed. R1 said she heard a sound like fingers snapping. R1 said, They held me by my arm right here, and pointed to her left upper arm. On (MONTH) 27, (YEAR) at 10:00 AM, V17 and V18 (CNAs) said residents should never be held or grabbed by the arms. V17 said a gait belt should be used to stabilize residents during a transfer. V18 said residents should never be lifted by the arms or held by the arms. V18 stated that could cause a pulled muscle, bone dislocation, or bone fracture. On (MONTH) 27 (YEAR) at 11:05 AM, V4 (CNA) stated she did assist V16 when transferring R1 out of the wheelchair and into her bed on (MONTH) 21, (YEAR). V4 said R1 gets very nervous at every transfer and tends to push up against us with her arms. V4 said R1was pushing and resisting during the transfer when she heard a sound like a crack. V4 said it sounded like her arm had cracked, like knuckles cracking. On (MONTH) 27, (YEAR) the facility attempted to reach V16 (CNA) by telephone. This surveyor also telephoned V16 on (MONTH) 27 and left three call back messages at 11:00 AM, 1:30 PM, and 3:40 PM. V16 was scheduled to work the evening shift on (MONTH) 27. V16 did not show up for her shift or return phone messages during this survey. On (MONTH) 27, (YEAR) at 2:20 PM, V7 (Registered Nurse) said if a resident is resisting a transfer aides should stop and re-approach the resident later. At 2:40 PM, V3 (Assistant Director of Nurses) said aides should not force a transfer if the resident is pushing or resisting. Aides should find additional staff to re-approach the resident with a new face. R1's (MONTH) (YEAR) progress notes show entries pertaining to bruising on several entries beginning on (MONTH) 22nd (9:40 PM) -Call received from (R1's physician) inquiring on resident's incident of fractured humerus and bruise on the left knee measuring 10x6 centimeters. On (MONTH) 24th (1:39 PM)-left shoulder bruised, left hand is bruising now, anterior left knee bruised. On (MONTH) 24 (2:02 PM)-Dark purple bruising continues to left upper arm down through hand. On (MONTH) 25 (8:55 AM)-Bruising continues to left shoulder down to left hand. On (MONTH) 25 (2:07 PM) Bruising remains to left shoulder and left hand. Bruising to left knee remains. The facility's Restorative Nursing Transfer Program policy updated on (MONTH) 20, (YEAR) states under the education section: 3. If at any time during the transfer process a resident resists, is not participating safely, or unable to participate safely, the transfer is stopped and the resident is returned to a safe position then the nurse is notified.

Based on observation, interview and record review the facility failed to ensure a resident's safety after the resident left the facility without approval, with her husband for an overnight stay. This failure resulted in R1 returning to the facility with a fractured clavicle and skin tear to the arm. This applies to 1 of 3 residents (R1) reviewed for safety in a sample of 3. The findings include: The undated Resident Admission Record for R1 lists her [DIAGNOSES REDACTED]. The admission profile sheet shows R1 was a resident at the facility from July 2015 till December 2015. R1 was discharged to supportive living. On February 16, 2016, R1 was readmitted to the facility for long term care. R1 is [AGE] years old. The Minimum Data Set (MDS) of March 5, 2016 shows the Brief Interview for Mental Status (BIMS) score for R1 is 9. A score of 8 - 12 indicates a resident has moderate impairment in decision making in activities of daily living. The MDS shows R1 feels depressed, has trouble concentrating and is fidgety or restless nearly every day. R1 requires extensive assist of 2 persons for bed mobility and dressing, extensive assist of 1 person for transfer, walking, toilet use, hygiene and is totally dependent on staff for bathing. R1 is not steady with transfer and requires staff assistance to stabilize while moving from seated to standing position, walking, turning around, on and off the toilet and transfer from the bed to the chair. R1 is frequently incontinent of urine and bowel. R1's abuse/neglect risk assessment of February 15, 2016 (on admission) states, R1 has a history of being abused by her husband. The initial MDS assessment of February 15, 2016 shows R1 had history of fall in the last month prior to admission. The MDS show R1 had a fracture related to a fall in the 6 months prior to reentry to the facility. The physician order [REDACTED]. There is no order on April 26, 2016 that with the POA approval, R1 may leave the facility with the husband. On May 3, 2016 at 12:40 PM, E5 (Registered Nurse - RN) stated on April 26, 2016, he entered R1's room to administer her 5:00 PM scheduled medications. R1 told him she was going home to spend the night with her husband. R1's husband was with the resident helping her gather her belongings. E5 stated not knowing what to do, he called E3 (Director of Nurses - DON). E5 stated E3 advised him to call the physician to get his approval for her to leave with the husband and send her medications with her. E5 stated he was not aware of any restrictions regarding R1 leaving the facility with her husband, nor the husband's ability to provide care for R1. E5 stated while he was still trying to make contact with the physician, R1 left the facility with her husband. E5 stated he felt R1 was alert and orientated and able to make her own decisions. E5 stated he had seen R1's husband take her out the previous week. E5 stated (after R1 had left the facility) the physician office returned the call and stated he did not want R1 to leave with the husband unless it was approved by the POA (power of attorney). E5 stated he incorrectly read the resident profile information and saw that R1 was responsible for herself; he was not aware she had a POA for healthcare therefore he did not call the POA after R1 left. E5 stated he had not thought about R1 not having her medications. E5 stated Z1 (POA) called him later in the shift and was very angry that R1 left with her husband. Z1 told him R1 was not supposed to be out with him, the physician and she did not approve the leave. E5 stated he was not aware if R1 had prior physician approval to go on any outings or overnight stay with the husband. E5 stated he had heard there was gossip about R1's husband having abusive behaviors, but never in an official capacity. On May 3, 2016 at 2:55 PM, Z2 (physician) stated he was not aware that R1 had previously left the facility with the husband for a day pass. Z2 stated the family tells me he (husband) is hurting R1. I cannot let R1 go with him without the POA approval. On May 3, 2016 at 3:05 PM, Z1 (POA) stated R1 called her after 6 PM and told her she was at her home and would be staying there all night with her husband. R1 told her she did not have any medications. Z1 stated she called the facility and the nurse told her R1 had left, and the physician cleared the leave and everything was fine. Z1 stated E5 did not seem concerned about her safety and the husband's ability to provide care for R1. Z1 (POA) stated she has asked the facility to not let the husband take her out. Z1 was told by the facility there was nothing they could do, as R1 is able to make her own decisions, and they can't control her decisions. On the first day after she was readmitted , Z1 asked the facility is there was any way he could again be restricted in his visits and contact with R1, and she was told they were unable to do that. Z1 stated she did not feel the husband was able to lift her if she would fall; she was afraid she would be hurt and is not safe at home. Z1 stated if the facility had called her about leaving with the husband she would have told the nurse no, do not to let her go as she knew she would get hurt. On May 4, 2016 at 3:20 PM, E3 (Director of Nurses - DON) stated she told E5 (RN) to call the physician and get an order, and also get permission from the POA. E5 did not tell her that R1 left before he spoke to the physician. E5 should have absolutely notified herself or the administrator that R1 left without the POA's permission. E3 stated, If I had been notified, I would have called the POA myself to assure the resident safety. On May 4, 2016 at 8:50 AM, R1 was seated in a wheelchair in her room with a sling stabilizing her left arm. R1 pointed to her shoulder and stated it is all broke up here and it is painful. I fell and I guess I landed on that shoulder. I get dizzy and fell at home. On May 4, 2016 at 10:15 AM, E4 (Social Services) stated after R1 left the facility, E5 (RN) should have notified administration to ensure the resident was safe. If a resident wants to go home, therapy can provide caregiver training to safely meet the resident needs at home. E4 stated I would not have recommended an overnight stay because R1 needs more help than the husband can give her. On May 3, 2016 at 11:30 AM, E1 (Administrator) stated she and E2 (ADON) were not notified until the next morning (April 27, 2016) after R1 left the facility without approval. On May 4, 2015 at 10:50 AM, E1 (Administrator) stated if the POA did approve a home stay, R1 would have to have a home care aide to visit to help with hands on care. R1's husband would not be able to care for her. E1 stated there should also be a physician order [REDACTED]. E1 stated she expected someone from administration to be notified that R1 left the facility (without approval). E1 stated she would have went to the home and asked her to come back had she known. On May 3, 2016 at 10:30 AM, E8 (Licensed Practical Nurses - LPN) stated R1 left the facility the night before (April 26, 2016) with her husband without permission. R1 returned the next morning with a skin tear to the top of the left forearm and was complaining about shoulder pain. R1 had an x-ray that day that showed a left clavicle fracture. The undated facility policy titled out on pass with medications states, the nurse will obtain an order from the physician for a therapeutic pass for a resident leaving for a long period of time that requires medications to be sent. Notify the POA, if the responsible party is not the POA.

Based on observation, interview and record review the facility failed to perform daily skin checks and report skin condition to the nurse. The facility failed prevent the re-occurrence of a pressure sore on a previously healed area. The facility failed to identify a wound until it was unstageable. The facility failed to identify the risk factors for the development of pressure ulcers under a brace. These failures resulted in R21 developing multiple pressure sores ranging from Stage II to stage IV and one unstageable area. This applies to 1 of 4 residents (R21) reviewed for skin breakdown in the sample of 11. The findings include: The September, 2013 Physician order [REDACTED]. The Minimum Data Set (MDS) Assessment of 9/24/13 shows R21 is cognitively intact (BIMS of 15), is totally dependent and requires two staff for bed mobility and transfers. The same assessment shows R21 is at risk for developing pressure areas, and currently had "1 -Stage 2 pressure ulcer" and "1- Stage 3 pressure ulcer" which was acquired at the facility. The Braden Skin Risk assessment dated [DATE] shows that R21 has a score of 14 (where a Total score of 13-14 =MODERATE RISK for skin breakdown). On 10/18/13, R21's record showed the following 1. Right Buttock: R21's Plan of Care on 9/11/13 shows (R21) has pressure ulcer to right buttock and has had pressure ulcer prior to admission to area which was resolved. R21's Progress Note (dated 9/11/13) states, " Wound noted right buttock. 1cm x 1cm x 0.3 cm...". The facility Wound/skin healing records (updated 10/7/13) shows 1-Stage 3 to Right buttock/lower sacrum. The 10/17/2013 facility's "weekly pressure ulcer surveillance report" does not show R21 as having a pressure sore on her buttocks. Right Buttock: R21's nursing note dated 9/20/13 shows, "Left buttock has 1 x 0.5 cm pressure ulcer... 2. Left Buttock: R21's nursing note dated 9/20/13 shows, "Left buttock has 1 x 0.5 cm pressure ulcer... 3. Left Ankle (under brace): R21's Plan of Care on 9/20/13 shows (R21) has a pressure ulcer to left ankle D/T (do to) brace to leg". A Progress Note (dated 9/20/13) states, "wound noted to Left ankle 1cm x 0.5cm..". The facility Wound/skin healing records (updated 10/7/13) shows 1-Stage 2 to left ankle. 4. Left Plantar foot: The nursing note dated 10/01/13 shows, "New pressure area noted on (left) plantar foot under small toe, size 2x2 cm, opening 1x1cm, but surr.(surrounding) skin is white likely non-viable tissue, to measure the 2x2. Depth not able to measured since wound bed is necrotic mix of yellow and gray tissue...". R21's plan of care on 10/3/13 (R21) has a stage 4 pressure ulcer to left plantar foot D/T brace to left foot." The facility Wound/skin healing records (updated 10/7/13) documents the following wounds: One-Stage 4 to left plantar foot. On 10/17/13, Z2's (Wound Physician) wound care specialist evaluation shows R21 has a "Stage 4 pressure wound of the left, plantar foot of at least 14 days duration." The 10/17/2013 facility's "weekly pressure ulcer surveillance report" shows R21 has a stage 4 on her left plantar foot, which was first observed on 10/2/13. 5. Left Dorsal Foot: The 10/17/2013 facility's "weekly pressure ulcer surveillance report" shows R21 has unstageable (area) to the left dorsal foot, which was first observed on 9/11/13. R21's record does not have a skin risk assessment completed after the new pressure areas were observed. On 10/18/13 at 2:00 PM, R21 had an open pressure area to her buttock with no dressing applied. R21 had an open pressure area on the bottom of her foot. The wound on her foot had white/pink center and neurotic tissue was present. The wound to the left outside foot/ankle was healed. On 10/18/13 at 2:00 PM, R21 stated, "I told them (facility staff) to look at my foot. It hurt a little behind my toes; that's how they found it (pressure ulcer). R21 continued, "I've had braces over [AGE] years and never had problems (before now)." On 10/18/21 at 2:00PM, E4 (RN, Assistant Director of Nursing) stated the skin assessments are completed quarterly. The assessments are not updated when a resident develops a new pressure area. E4 stated, "As far as I know (R1's) wounds were acquired at the facility... The bath aides are expected to complete a head to toe (skin) assessment, document skin problems and report to a nurse... Whoever applies (the brace) should do a skin assessment, before putting on brace. I don't know who assesses the brace to ensure fitting properly." E4 confirmed, "wounds from the brace were preventable." E4 stated, "I don't see a facility policy on applying braces." On 10/18/13 at 1:30 PM, E21 (Licensed Practical Nurse) stated, R21 "first developed the pressure sore on the buttock. It was found at a stage 3. (R21) is totally dependent with transfers, bed mobility and max assist with all other ADLs (Activities of Daily Living), except eating. Skin checks should be completed at least twice a day by a CNA (Certified Nursing Assistant). Any redness or skin changes should be reported to the floor nurse. (R21) is non-compliant with laying down. She had braces which were taken off while (she) was in bed. Whoever is applying/removing brace should do a skin assessment. There is no documentation prior to 9/11/13 of a problem with (R21's) skin... It should have been documented on the skin-check sheet on 9/11/13. (R21's) wound is healing, and is definitely preventable in the future. Had staff known the brace was causing pressure the wound could have been prevented. (R21's) bottom is healing, she has a low-air-loss mattress. I know we can heal it. Had the mattress been in place and she been compliant (R21's) buttock (wound) could have been prevented." E21 continued, we first explained the implications of compliance (to her) when she first broke down. "She is receptive most of the time. Now that she understands, she has been compliant." The undated facility policy titled, Skin Care Program, states, "POLICY: To ensure that a resident who enters the facility without a pressure sore does not develop pressure sores unless the individuals clinical condition demonstrates that they were unavoidable; the facility will further ensure that a resident having a pressure sore receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing... Prevention Risk Assessments used at admission and ongoing: 2. Identified areas of risk from the Braden and other assessments will have interventions for prevention implemented and placed on their plan of care; 3. Daily with care given the CNAs monitor and report changes to nurse; 4. Weekly on shower/bath day the resident receives a skin audit and results are reported to the nurse..." (p. 1) The same policy shows, The "Braden Scale "is done on admission, quarterly, and with a significant change in a resident's condition." (p. 3)

Surveyor: HARRIS, STEPHEN Based on observation, interview, and record review the facility failed to prevent pressure ulcers for residents at risk for skin breakdown. The facility failed to ensure interventions were in place to prevent pressure ulcers from worsening. This failure resulted in R16 developing a stage III pressure ulcer. This applies to 3 of 4 residents (R6, R16, R57) reviewed for skin breakdown in the sample of 20. The findings include: 1. The August, 2013 Physician order [REDACTED]. The Minimum Data Set (MDS) Assessment of 6/28/13 shows R16 requires extensive assistance of one staff member for bed mobility and transfers. The same assessment documents R16 did not have a pressure area during the assessment period for the 6/28/13 MDS. The Braden Skin Risk assessment dated [DATE] shows that R16 has a score of 17 (where a Total score of 15-18 represents " MILD RISK " ) and is at mild risk for skin breakdown. The facility Wound/skin healing record dated 8/3/13, shows R16 developed a stage 2 pressure area (2.2 x 2.0 x 0.2 cm) and was initially noticed by the facility on 8/3/13. The wound care specialist evaluation (dated 8/8/13) shows R16 ' s pressure ulcer had worsened: R16 " has a stage 3 pressure wound of the left buttock of at least 1 day(s) duration. There is light serous exudate associated with this wound. " The same assessment shows, " Objective: Healing; Wound Size (L x W x D) 1.1 x 1.6 x 0.1 cm; Thick Adherent Devitalized Necrotic Tissue: 5%. " R16 ' s care plan for " stage 3 pressure ulcer to left buttock related to total dependence with bed mobility, transfers, and immobility " shows approaches were started on 8/8/13, showing a five day delay from when the facility identified R16 ' s new pressure ulcer. The approaches include the following: ensure that specialty cushions are on both wheelchair and electric scooter and overlay mattress on bed. The same plan of care has the goal of " will not increase in size and show signs of healing ... " The facility ' s clinically unavoidable pressure ulcer assessment shows R16 has a "history of healed skin problems." R16's previous pressure areas were healed with the necessary interventions, showing R16's pressure sores are preventable due to his medical comorbidities. On 8/14/13 at 8:55 AM, R16 was sitting in his wheelchair and he had a 1 inch foam pad in his wheelchair. R16 was not on a 4-inch foam or a gel cushion for pressure reduction. On 8/14/13 between 8:55 AM and 11:00 AM, E3 (RN, Case Manager) stated, R16 " is non-compliant; he doesn ' t like to lie down. No documentation related to facility staff (providing ongoing) education to (R16) on preventing pressure was located during the survey. E3 confirmed R16 did not have the correct pressure-relieving-cushion on his wheelchair. Z2 (Wound Physician) stated, "I discussed offloading and repositioning with (R16). E2 (Director of Nursing) did not provide any documentation showing the facility staff had reeducated R16 on the risk of pressure sore development when sitting up for extended periods of time and the consequences of poor compliance with physician recommendations. E2 did not provide any documentation showing the facility had evaluated R16's reasons for non-compliance or an attempt to resolve R16's concerns resulting in his non-compliance. On 8/14/13 at 10:30 AM, E2 explained, R16 " is independent when he is up in his wheelchair ... After (R16) developed a new pressure sore, we should have reeducated him (on the risk of sitting up in his wheelchair for long periods). " E2 continued, (R16) "should have a 4-inch-foam-pad in his wheelchair. I do not know where he got the one he has, ours are all 4 inches." On 8/15/13 at 10:30, R16 had a pressure area to his upper buttock near the sacrum. The wound measured 3.2 x 0.2 x 0.2 cm. On 8/15/13 at 10:30 AM, Z2 stated, " I hope to heal (R16 ' s pressure sore), we were able to heal his wounds before. (R16) has compliance issues and a lot of co-morbidities. " Z2 continued, " Gel (cushions) are a lot better (for relieving pressure) than foam. He (R16) should be on a gel cushion. " The undated facility policy titled, Pressure Ulcer Prevention, states, "POLICY: To ensure appropriate measure are taken to prevent pressure ulcers based on level of residents' risk according to the Braden Scale... 5. Basic elements of the plan of care for residents with any level of risk will consist of: Residents at mild risk: d) Gel cushion to wheelchair... 9. Residents with increased safety risks and pressure ulcer risks will be placed on the appropriate cushion according to the individual Braden scale score..." (pp. 1-2) 2. The Physician order [REDACTED]. The MDS of 6/7/13 shows R6 requires extensive assistance with transfers, ambulation, dressing, and hygiene/bathing. R6 has inattention and disorganized thinking, with verbal and physical behavior symptoms directed towards others. The facility admission assessment dated [DATE] documents R6 was admitted with "buttocks dark purple with two decubs mult bruises/scabs". The hospital transfer form and admission orders two stage III pressure ulcers". The Braden Scale for Predicting Pressure Sore Risk dated 12/11/12 shows R6 had a score of 15 (score of 10-12 is high risk, 13-14 moderate risk, 15-18 mild risk), identifying R6 was at mild risk for skin breakdown on admission to the facility. R6's Braden Scale assessment dated [DATE] does not identify him as being at risk for pressure sore with a score of 21. The 6/4/13 assessment does not identify R6 as being at risk for pressure sores with a score of 19. On 4/5/13 the facility "Nursing: doctororderfax" form states "may we have an order for [REDACTED]. On 8/15/13 at 1:30 PM, E2 (Director of Nursing) said there is no other documentation of an assessment of the "reddened buttocks" and the physician fax "reddened buttocks" is considered the wound assessment. E2 said if the nurses spend time writing out the fax they do not need to put it in the nurse notes too. E2 said the only other documentation of the wound is the facility treatment record to apply [MEDICATION NAME] twice a day, which does not document a description of the area. The Weekly Pressure Ulcer Healing Record dated 5/18/13 shows R6 had a 3.3 cm x 1 cm area to coccyx with no exudate, slough present on wound bed, pink surrounding skin color, and normal skin surrounding tissue wound edges. The Weekly Pressure Ulcer Healing Record dated 5/18/13 shows a 0.2cm x 0.2 cm area to left buttocks with no exudates, normal skin wound bed, pink surrounding skin, and maceration of the surrounding tissue/wound edges. The Weekly Pressure Ulcer Healing Record dated 5/18/13 shows a 1.5cm x .6cm area to right buttocks with no exudate, pink/beefy red wound bed, normal surrounding skin color, and normal surrounding tissue/wound edges. The Wound Care Specialist Evaluation Notes dated 5/23/13 documents that R6 had a "Stage 3 Pressure wound of the Right Buttock " measuring 0.6x1.5x 0.2cm with light serous exudate. On 8/15/13 at 1:30 PM, E2 (DON) stated, "He (R6) is not at high risk. His Braden Score is 18. He is not at high risk (for developing a pressure sore)." E2 was referencing the Braden Scale updated 1/11/13. E2 failed to identify that R6 was at high risk for pressure sores do to his history of two recent stage III pressure ulcers, age, and poor skin conditions. Z2's (Wound Care Physician) Progress Note (dated 8/15/13) documents "Pt (R6) due to his poor skin condition, is a higher risk and it only takes a short period of time of not repositioning to begin the breakdown process. Pt's poor skin is due to advanced age and history of [MEDICAL CONDITION] along with comorbid conditions". R6 did not have a plan of care in place to prevent skin breakdown until 3/15/13, three months after he was admitted to the facility with two stage III pressure ulcers. The interventions in his plan of care do not adress the use of a gel cushion, or specific times R6 should be repositioned (every two hours). On 8/15/13 E3 (RN Case Manager) said R6 was at high risk for pressure ulcers and should have had a plan of care in place since admission. On 8/15/13 at 8:00 AM, E26 (RN-Director of Monarch Unit) said R6 used to have a gel cushion that he sat on. E26 said R6 did not have any problems using it but they stopped it because he was spending more time sitting out in the living area by the nurse station. E26 said R6 should have had a plan of care in place for his risk for pressure ulcers on admission. On 8/14/13 at 8:35 AM, E29(Certified Nursing Assistant -CNA) said R6 does not have a gel cushion or any special cushion for his chair and the CNA's do not follow any special interventions for wound care. On 8/14/13 at 8:55 AM, E28 (CNA) said R6 used to have a cushion they put in his chair but they stopped doing it a couple months ago. E28 said the cushion did not seem to bother R6 and she is not sure why they stopped using it. The facility Pressure Ulcer Prevention Policy states "Residents with any level of risk will have a skin care plan in place...Residents at mild risk: Gel cushion to wheelchair...Residents with history of pressure ulcer regardless of current Braden scale score will always be at the moderate risk or higher level...Residents at moderate risk: place resident on turning schedule, post schedule inside closet door, Resident to be turned every 2 hours using 30-degree rule...4" foam cushion or 3" gel and foam combination in chair". 3. R57 has [DIAGNOSES REDACTED]. R57's Braden scale dated 8/2/13 identified her as being at high risk for skin breakdown. (R57's score = 14 with >12 being considered high risk.) A 10/30/12 Wound Care Specialist Initial Evaluation identified R57 had a diabetic wound of the right heel with moderate serous exudate associated with the wound. The physician's recommendation documents "Off-Load Wound, diabetic shoe fitting." A care plan dated 8/24/12 with a target date of 11/24/12 identified R57 as at risk for skin breakdown. The only interventions listed, dated 8/24/12, were as follows: "Avoid shearing resident's skin during positioning, transferring, and turning"; "offer snacks between meals"; "Provide incontinence care after each incontinent episode and apply barrier cream to peri area"; and "Report any signs of skin breakdown (sore, tender, red, or broken areas)." R57's Diabetic Right Heel wound was healed on 4/4/13, according to the Wound Care Specialist Evaluation of 4/4/13. A nursing note dated 5/19/13 identified R57 had developed an open area to her right heel. The Wound Care Specialist Evaluation of 5/23/13 documents R57 with a "Stage III pressure wound of the right, medial heel." Continued Wound Care Specialist Evaluation notes showed R57 had changes in treatments for the heel ulcer between the onset of 5/19/13, and the present 8/14/13, which included several sharp debridement procedures. No additions, changes or updates were made to R57's care plan. On 8/14/13 at 11:40 AM, E5 (Licensed Practical Nurse/Care Plan Coordinator) stated R57 had no care plan related to skin since the development of the pressure ulcer on 5/19/13. On 8/15/13 at 10:30 AM, E3 stated skin checks are done by the CNA's (Certified Nursing Assistant's) during each residents' shower. E3 stated it is the CNA's responsibility to report any findings or changes in skin condition at that time. R57's shower sheets were reviewed from 4/4/13 to 5/30/13. The shower sheets contained no documentation of the right medial heel area until 5/19/13 at which time it was identified as a Stage III Pressure Ulcer. On 8/19/13, the facility provided documentation that R57 lays "on side of sore" while in bed to watch Television. This issue/concern had not been identified by the facility during the previous 9 months of wound care provision for the right medial heel. The undated Facility Policy for Pressure Wound Assessment states a systemic, on-going wound assessment on all pressure ulcers will be done to determine the response to nursing care and treatment modalities. The undated Facility Policy for Skin Care Program documents under Policy #2 - "Identified areas of risk from the Braden and other assessments will have interventions for prevention implemented and placed on their plan of care." The undated Facility Policy Pressure Ulcer Prevention under #4 showed: "Residents with any level of risk will have a skin care plan in place." Under #10, "Residents with a history of Pressure ulcer regardless of current Braden scale score will always be at the moderate risk or higher level."