Every finding on record at Aperion Care Westchester

Based on interview and record review, the facility failed to follow their change in condition policy but failing to notify one resident's (R25) representative of a new skin alteration requiring antibiotic therapy. This affect one of one (R25) resident reviewed for change in condition on the sample size of 48. Findings Include:R25 was admitted to facility on 06/15/2021 with a diagnosis of dementia, anemia, hypertension, osteoarthritis of knee, repeated falls and cerebral infarction.R25 brief interview for mental status score dated 7/14/26 documents a score of 1/15 which indicates severe cognitive impairment.R25's progress note dated 7/18/26 documents by V21 (Nurse): The resident appears to have an abscess on his left forearm. draining with pus, mild bleeding and painful to touch. MD notified. The writer received a new order for antibiotic (Bactrim DS).On 8/5/26 at 2:35PM, V21 (Nurse) said when there is a change in condition, they should call the doctor and family. V21 said she thinks she called R25's family but does not recall speaking directly to anyone.Review of R25's medical record did not document any attempt or notification to R25's family on 7/18/26.On 8/7/26 at 10:19AM, V41 (R25's POA/Family) said they were not contacted by facility staff related to any skin changes to R25's arm or new medications. V41 said she was informed by other family members while they were visiting R25 of the changes to R25's skin.On 8/6/26 at 2:33PM, V12 (ADON) said for any changes in medication or change in skin alteration the assigned nurse should notify the family and document the notification in the medical record. If the family representative does not answer they should attempt again or relay to the next shift.On 8/7/26 at 11:56AM, V2 (Director of Nursing, DON) said staff should notify the family for a change or start of new medication or any changes in condition. V2 said the notification should be documented in the electronic medical record.Facility change in condition policy revised 11/13/18 documents: To ensure that medical care problems are communicated to the attending physician or authorized designee and family 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 and if known notify the resident legal representative or an interested family member when there is: a decision to transfer ot discharge the resident from the facility.

Based on interview and record review, the facility failed to follow their abuse policy by not reporting an allegation of physical abuse to the Illinois Department of Public Health's Regional Office for one out of three residents reviewed for abuse in a total sample of nine. Findings Include: R4 is a [AGE] year old with the following diagnosis: spastic quadriplegic cerebral palsy, chronic kidney disease, heart failure, mild cognitive impairment, and contracture of the right hand and wrist. On 5/27/26 at 12:52PM, R4 was able to state name and birthdate correctly. R4 stated the date was 5/20/16 and R4 was in [NAME], IL. When asked if R4 has any issues or concerns in the facility, R4 stated no. When asked if R4 felt safe in the facility, R4 stated no. R4 reported a lady tried to drown R4 in the shower last week. R4 was unsure of the exact date and was unable to name the CNA. R4 described the CNA as a black female with long black hair. R4 reported the CNA sprayed R4 in the face with the water hose. R4 stated R4 was able to breath while being sprayed but did have some coughing throughout the day. R4 was unable to state how long the CNA sprayed the water in R4's face. R4 denied telling the CNA to stop spraying R4 in the face or telling the CNA that it was too much water. R4 also denied telling any other staff about the incident in the shower. When asked why R4 didn't tell the CNA to stop spraying or why R4 didn't report the incident to management, R4 said, I forgot. R4 stated R4 knows to report all concerns to the administrator and was able to state the administrator's name. R4 reported this is the only time this CNA has ever been rude to R4. When asked if the CNA said anything to R4 during the shower, R4 stated the CNA told R4 that since the CNA had gotten into it with R4's mom the CNA was going to hurt R4 and didn't like R4. When asked what R4 meant by gotten into it, R4 reported the CNA and R4's mom had a fight about what took place in the shower. When asked if there was any other incident that took place before the shower, R4 said, no. R4 was unaware of R4 and R4's mom had any altercations before the shower incident. R4 denied working with the CNA since the shower incident. R4 denied being aware if the facility reported the incident to Illinois Department of Public Health. On 5/26/26 at 2:24PM, V9 (CNA) stated R4's family member began having issues with V9 when V9 told the family member to get out from behind the nurse's station because private information from for residents was behind the nurse's station. V9 reported V9 and V2 gave R4 a shower without any issues. V9 stated R4's family member came into the facility that same evening about 8 PM and immediately called the police after finding out V9 worked with R4. V9 stated R4's family member reported to the police that V9 tried to drown R4 by spraying water in R4's face. V9 denied ever being suspended pending an investigation. On 5/27/26 at 1:05PM, V18 (DON) stated the facility did an internal investigation on the allegations R4's family member reported against V9. V18 reported R4 was unable to verbalize the same story the family member was reporting to staff. V18 stated R4 did not have any breathing or choking issues so they did not send in an official report to IDPH. On 5/27/26 at 1:31PM, V19 (Administrator) stated the facility has a long history of R4's family member's behavior. V19 reported V9 gave R4 a shower with another CNA present due to past allegations. V19 stated R4's family member saw V9 when visiting that evening and fabricated the story to get V9 terminated. V9 stated R4's family member called the police and spoke with the police about the allegation, but R4 denied any issues during the shower. V19 reported there was no indication that any abuse occurred. V19 stated V19 did an internal investigation for this incident. V1 denied sending in the incident report to Illinois Department of Public Health's Regional Office because R4 was able to verbalize that R4 was fine and the police did not do anything when they were called. A Behavior note dated 4/21/26 documents R4's family member was being verbally aggressive by the nurse's station and started shouting at a particular CNA. The nurse was able to redirect the family member. The nurse stated R4 was OK and had no concerns. R4 had a shower and no unusual behaviors were noted during the shower. The family member called police because the family member did not like the CNA. The family member was redirected and R4 remains at baseline.The Facility Reported Incident with the date of the occurrence being 4/21/26 documents the incident category as resident abuse. The incident description reports that R4's family member alleged that V9 put water on R4's face. R4's family member reported the incident to the police. V9 was not assigned to R4. R4 was interviewed and stated V9 did not attempt to drown R4 but had just washed R4's face. R4 is at baseline and had no concerns. V9 was interviewed and stated V9 showered R4 around 7:00 AM with assistance of another CNA. V9 denied any incidents occurred and once R4 was bathed, R4 was dressed and stayed in the dining room. Another staff member was near the area during the shower and did not hear R4 scream out or see any incidents during the shower. There is a care plan for R4 in regards to R4's family members who has poor boundaries. Social services checked on R4 to monitor psychosocial and emotional well-being. R4 remained at baseline for mood and behavior and feel safe in the facility. This report was not sent to Illinois Department of Public Health's Regional Office. This was documented as an internal investigation.The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score as 6 (severe cognitive impairment). The policy titled, Abuse and Retaliation Prevention and Reporting- Illinois, dated 1/8/26 documents, . Abuse means any physical or mental injury; retaliation; or sexual assault inflicted upon a resident other than by accidental means. Internal Reporting Requirements and Identification of Allegations - Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, exploitation, retaliation, mistreatment, or appropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or a compliance officer. Reports will be documented, and a record will be kept of the documentation. Any allegation of abuse, retaliation, or any incident that results in serious bodily injury will be reported to the Illinois Department of Public Health immediately, but not more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours.

Based on interviews and record review, the facility failed to follow policy procedures, failed to clarify physician orders, failed to ensure that the required rate for IV (Intravenous) infusion was ordered (prior to administration) and failed to document the rate of IV infusion for one of four residents (R2) reviewed for change in condition. Findings include:R2's care plan (revised 1/29/26) states the resident requires use of IV (Intravenous) fluids/medications related to hydration therapy. Interventions: Provide IV fluids as ordered. R2's (1/1/26) Physician Orders include Dextrose Intravenous Solution 5%. Use 2 liter intravenously one time only for dehydration for 2 days [infusion rate was excluded].R2's (January 2026) MAR (Medication Administration Record) includes Dextrose Intravenous Solution 5%. Use 2 liter intravenously one time only for dehydration for 2 days, which was documented as administered at 6:32pm, however the infusion rate was excluded.R2's (1/2/26) progress notes state, iv fluids d5 ns (normal saline) infusing and IV fluids continuous running however the infusion rate was excluded from both entries. On 3/4/26 at 9:32am, surveyor inquired why R2 was receiving IV fluids. V8 (Registered Nurse) responded, I (V8) follow the order. Surveyor inquired about R1's (1/2/26) IV fluid rate of infusion (prior to hospital transfer). V8 responded, Normally we (staff) run it 75 per hour at the facility. Surveyor inquired how much IV fluid R2 received V8 replied I cannot remember. On 3/4/26 at 10:20am, surveyor inquired why R2's IV fluids were administered on 1/1/26 without a prescribed rate of infusion. V2 (Director of Nursing) responded, That isn't possible. Surveyor requested evidence that orders (including rate of infusion) were received for R2's (1/1/26) IV fluids - prior to administration.On 3/4/26 at 10:54am, V2 affirmed that she spoke to the Pharmacist regarding IV fluid orders and stated It's based on the weight of the patient however provided no documentation at this time.R2's MAR affirms that V9 (LPN/Licensed Practical Nurse) administered the D5 IV fluid on 1/1/26. On 3/4/26 at 12:23pm, surveyor inquired about R2's (1/1/26) IV fluid rate of infusion when V9 (LPN) administered the D5. V9 stated, To be honest, I'm (V9) not sure of this exact order. Surveyor read R2's (1/1/26) D5 IV fluid orders aloud (via phone) and inquired again about the rate of infusion. V9 responded, You're (surveyor) asking me (V9) about a rate that the doctor gave me (V9)? I'm not sure of the order given by the doctor at that time. Surveyor inquired if V9 clarified R2's (1/1/26) IV fluid order (which excludes rate of infusion) prior to administration. V9 replied, Again, I (V9) don't remember anything from that date, it was a while ago. Surveyor inquired if a Physician order needs to be clarified, how is that carried out? V9 stated, I would have called the doctor if I had a question about an order that was given to make sure the order was correct. Surveyor inquired if V9 contacted the Physician to clarify R2's (1/1/26) IV fluid orders. V9 responded, I don't recall being in a situation to call the Physician when an order was wrong. Surveyor inquired if the facility has standing orders for administering IV fluids V9 replied No, I'm not aware of standing orders for IV.The physician orders policy and procedure (revised 1/31/18) states when receiving physician's orders by telephone: enter the order into the resident's chart under order tab and according to the instructions for the type of order received. Medication orders should include route, dose, time, frequency. Notify the resident's physician, (if not the prescribing physician) for verification if applicable. Verbal and telephone orders will be documented as such in the electronic medical record.

Based on observation, interview, and record review the facility failed to ensure that call lights were placed/secured within reach, failed to ensure that essential equipment was functioning, and failed to supervise an at risk for falls resident while outside smoking, This failure affects three of three residents (R1, R3, R4) reviewed for falls on the sample of four. Findings include:1.The (2/23/24-2/1/26) fall report affirms R1 fell on 3/18/24, 10/1/24, 12/8/24, 3/23/25, 8/12/25, 1/2/26, and 1/13/26 therefore seven (7) times within the last 24 months. R1's (3/18/24) fall occurrence note was requested, however was not received during the survey, on 3/5/26 at 1:40pm, V1 (Administrator) affirmed that the facility doesn't have it.R1's diagnoses include but not limited to dementia, bipolar disorder, end stage renal disease, dependence on renal dialysis, difficulty walking and unspecified fall. R1's (1/9/26) BIMS (Brief Interview Mental Status) determined a score of 7 (severe impairment). R1's (1/9/26) functional assessment affirms R1 requires substantial/maximal assistance with chair/bed to chair transfers. Walking was not attempted. R1's (9/28/21) care plan states the resident is at (high) risk for falls related to dementia, osteoarthritis of knee, poor safety awareness, impulsive behavior, and incontinence. Interventions: (1/7/22) Anticipate and meet the residents' needs. (1/7/22) Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. R1's (2/12/26) fall risk assessment determined a score of 22 (high risk).On 3/5/26 at 9:48am, R1 was lying in bed on a (bordered) mattress, the call light was on the floor (out of reach) and R1 was alone in the room.On 3/5/26 at 9:50am, V10 (CNA/Certified Nursing Assistant) affirmed that she (V10) is currently assigned to R1. Surveyor inquired about R1's fall prevention interventions V10 stated The floor mats then proceeded to enter the room and picked up R1's call light. Surveyor inquired about the location of R1's call light prior to entering room V10 responded, It was on the floor but to be honest when I (V10) was in here earlier it was on here (referring to the bed). Surveyor inquired if there was a clip on R1's call light to secure it to the bed V10 replied No. Surveyor inquired if R1 has any other fall prevention interventions V10 stated She's (R1) not left in the room by herself if she's up in the wheelchair. Normally she's up but she didn't feel good today and doesn't sleep at night. Surveyor inquired if R1 can transfer herself V10 responded Oh, no. 2. R3's diagnoses include hemiplegia and hemiparesis affecting the right side. R3's (1/9/26) functional assessment affirms resident requires partial/moderate assistance with chair/bed to chair transfer. R3's (2/19/25) fall risk assessment determined a score of 10 (at risk). R3's (2/19/25) care plan states the resident is moderate risk for falls related to gait imbalance problems and incontinence, interventions: (2/19/25) Be sure resident's call light is within reach. Bed height to be placed in low position when resident is in bed. On 2/24/26 at 11:35am, surveyor inquired about R3's (1/29/26) fall V3 (Restorative Nurse) stated He (R3) has intermittent confusion and needs assist during transfer, but he doesn't ask for assistance all the time. He thinks he can transfer by himself, but he can't. R3's (1/9/26) BIMS determined a score of 11 (moderate impairment). On 3/5/26 at 9:56am, R3 was lying in bed the call light was tied to the side rail however the button was dangling below the bed - out of sight. R3's bed was not in the lowest position; it was knee high.On 3/5/26 at 10:25am, V11 (CNA) affirmed that she's (V11) assigned to R3. Surveyor inquired about R3's fall prevention interventions V11 stated The floor mats, call light, lower the bed to the floor and bed rails. Surveyor inquired about the location of R3's call light V11 entered the room and responded, 'It's hanging on the bed. Surveyor inquired if R3's bed was in low position V11 replied It's not all the way to the floor. Surveyor inquired how high R3's bed is V11 stated To your (surveyor) knee. V11 then attempted to lower R3's bed, however, was unable to do so. V11 inspected R3's bed and stated, The bed is unplugged. V11 then plugged R3's bed into the outlet and attempted to lower the bed again, however, was still unable to. Surveyor inquired if R3's bed was broken V11 responded It's not working, the bed not working.3. R4's diagnoses include dementia, neuralgia, neuritis, osteoarthritis (left hip) and weakness. R4's (12/6/25) functional assessment affirms resident requires partial/moderate assistance with chair/bed to chair transfer. R4's (1/20/25) fall risk assessment determined a score of 11 (at risk).R4's (1/20/25) care plan states resident is moderate risk for falls related to confusion, gait/balance problems, and poor safety awareness, interventions be sure the resident's call light is within reach and encourage resident to use it.R4's (1/23/26) fall occurrence note states (unwitnessed) fall. CNA reported that the resident had fallen while on smoke break - on patio. Resident stated I fell while turning. I lost my balance and fell in the bushes. I didn't hit my head or anything. My left hand broke my fall. I'm in no real pain. No injuries observed. On 2/24/26 at 11:47am, surveyor inquired about R4's (1/23/26) fall V3 (Restorative Nurse) stated She's (R4) alert, ambulatory, and uses a walker but has a gait imbalance. She requires supervision. She fell while turning and lost her balance in the bushes on the patio. Surveyor inquired if R4's fall was witnessed by staff V3 affirmed that it was not. R4's (12/6/25) BIMS determined a score of 14 (cognition intact). On 3/5/26 at 10:01am, R4 was sitting on the bed however the call light was tied to the side rail and dangling near the floor. On 3/5/26 at 10:32pm, V11 (CNA) affirmed that she's (V11) assigned to R4. Surveyor inquired about R4's fall prevention interventions V11 stated Her (R4) walker and the call light. Surveyor inquired about the location of R4's call light V11 entered the room and responded, Wrapped around on the bed rail, hanging down. Surveyor inquired where resident call lights should be located, V11 replied Across the bed in reach. Surveyor inquired if R4's call light has a clip to secure it within reach V11 stated No. Surveyor inquired if the facility call lights have clips V11 responded Some of them. The (11/28/12) fall prevention program states a fall risk assessment will be performed at least quarterly and after any fall incident. Safety interventions will be implemented for each resident identified at risk. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. Direct care staff will be oriented and trained in the fall prevention program. Malfunctioning equipment will be immediately reported to maintenance for repair or removed from service. The residents will be checked every two hours, or as according to the care plan, to assure they are in a safe position. The frequency of safety monitoring will be determined by the resident's risk factors and the plan of care.

Based on observation, interview, and record review, the facility failed to follow its Medication Administration Policy by failing to administer medications in a timely manner. This applies to four of 15 residents (R2, R7, R4 and R5) reviewed for medication administration in a sample of 15.The Findings include:On 9/23/25 at 10:12 AM, V6 (Licensed Practical Nurse/LPN) was passing medication and stated, I have 10 more residents (R2, R3, R4, R7, R8, R9, R10, R11, R14, and R15) to pass the morning medications, which were supposed to be administered at 8:00 AM. We are supposed to administer medications within 2-hour window (one hour before and one hour after) around the scheduled time. I would be able to finish by 10:45 AM.R2 is an [AGE] year-old female with moderate cognitive impairment as per MDS dated [DATE]. On 9/24/25 at 12:30 PM, R2 stated (with Spanish interpreter V8/Housekeeping), I don't know what time I received my medications today. I would like to get my medications on time.A review of the R2's POS and MAR indicates that R2 was scheduled to get the prescribed medications at 8:00 AM including Amlodipine 10 milligram (mg) daily, Aspirin 81 mg daily, Losartan Potassium 25 mg daily, Eliquis 5 mg twice per day (BID), Metoprolol 100 mg daily, Lasix 80 mg BID, and Gabapentin 300 mg three times a day (TID).R7 is a [AGE] year-old male with intact cognition, as per the MDS dated [DATE]. On 9/23/25 at 12:40 PM, R7 stated, The morning medication should come around 8:00 AM, and I got it around 10:30 AM today. I would like to get my medications on time. Today it was late by two and a half hours.A review of the R7's POS and MAR indicates that R7 was scheduled to get the prescribed medications at 8:00 AM, including Amlodipine 10 mg daily, Hydrochlorothiazide 12.5 mg daily, Lisinopril 40 mg daily, and Gabapentin 300 mg three times a day (TID).R4 is an [AGE] year-old male having intact cognition as per the MDS dated [DATE]. On 9/23/25 at 12:45 PM, R4 stated, The morning medications were delayed today, not all the time. I prefer to get my medication on time.A review of the R4's POS and MAR indicates that R4 was scheduled to get the prescribed medications at 8:00 AM, including Amlodipine 7.5 mg daily.On 9/23/25 at 10:20 AM, V7 (Registered Nurse/RN) was passing morning medications and stated, I have three more residents (R5, R12, and R13) to pass 8:00 AM medications. I am sorry, I am late today, because one of my residents was getting shortness of breath and stomachache.R5 is a [AGE] year-old male admitted with mild cognitive impairment as per the MDS dated [DATE]. On 9/23/25 at 12:50 PM, R5 stated, I would prefer to get my medications on time. It was delayed today.A review of the R5's POS and MAR indicates that R5 was scheduled to get the prescribed medications at 8:00 AM, including Ferrous Sulfate Elixir 220 mg (Fe 44)/5milliliter(ml) (Give 7.5 ml) daily, Potassium Chloride 20 milliequivalent (mEq) daily, and Terazosin 2mg daily.On 9/23/25 at 10:25 AM, V5 (LPN) was passing morning medications and stated, I have one more resident (R6) to give 8:00 AM medications. I have residents going out for appointments, and I must prepare them. That's the way I got delayed.A review of the facility's Medication Administration policy, dated September 2018, reveals that, at a minimum, the 5 rights - right patient, right drug, right dose, right route, and right time - should be applied to all medication administration.On 9/24/25 at 9:39 AM, V2 (Director of Nursing) stated, Our staff supposed to follow the five rights of medication administration, including right patient, right drug, right dose, right route, and right time. On 9/23/25 at 11:00 AM, V2 added, Our staff is supposed to pass medications within a two-hour window around the scheduled time (one hour before and one hour after the scheduled time). We will in-service all our nurses and change the administration time from 8:00 AM to 9:00 AM.

Based on observations, interviews, and record reviews, the facility failed to wear gloves while touching food while taking food temperatures before lunch was served, failed to wear beard nets and properly wear hair nets while in the kitchen area. This failure has the potential to affect all residents receiving meals in this facility. Findings include:The census on 7/22/25 was 114 residents. V12 DON (director of nursing) stated that there are four residents that are strict nothing by mouth.On 7/22/25 at 9:55 AM, V14 (cook), V15 (dietary aide), and V16 (dietary aide) were observed to have facial hair. V14, V15, and V16 were not wearing beard nets. V15 and V16 were observed with a hair net on head with hair extending below the hair net.On 7/22/25 at 10:40 AM, this surveyor observed a bag of hair nets and a bag of beard nets attached to door to the kitchen. V13 (dietary supervisor) arrived at the kitchen and placed a hair net on head with hair extending below the hair net.On 7/22/25 at 11:00 AM, V14 was observed preparing the gravy for the lunch meal service. V13 was not wearing gloves.On 7/22/25 at 11:05 AM, when questioned if any staff should be wearing beard nets, V13 responded he didn't know. When questioned if all of a staff member's hair should be in a hair net, V13 responded yes and put his long hair in his hair net.On 7/23/25 at 10:30 AM V6 ADON/IP nurse (assistant director of nursing/infection prevention nurse) stated that gloves are worn to prevent cross contamination.On 7/22/25 at 11:45 AM, V14 was observed checking food temperatures prior to serving meal. V14 wore a glove on his left hand while using his ungloved right hand to check the temperatures. The back of V14's right hand was observed touching the food while checking temperatures.Per the FDA (Food and Drug Administration) food code, dated 2022, notes food service employees shall wear hair restraints and beard restraints that are designed and worn to effectively keep their hair from contacting exposed foods.

Based on observations, interviews, and record reviews, the facility failed to have an effective pest control program and ensure the kitchen area was free from flying insects. This failure affects all residents that receive meals in this facility. Findings include:On 7/22/25 at 10:40 AM, this surveyor toured the facility's kitchen with V13 (dietary supervisor). In the pantry where canned goods are stored, there were several, too active to count, fruit flies present.On 7/22/25 at 10:50 AM, V13 stated that there is no food stored in the pantry. V13 stated they are just fruit flies. V13 stated that the outside pest control company came to facility yesterday and provided treatment in the kitchen.On 7/23/25 at 12:15 PM, V7 (maintenance director) stated that the outside pest control company are here today placing extra traps for fruit flies throughout facility, mostly in the kitchen. V7 stated that some fruit flies were observed under the dishwasher. V7 stated that V13 informed him yesterday afternoon of fruit flies in the kitchen.The outside pest control company's service inspection report, dated 7/7/25, notes preventative treatment was performed, no activity seen.The outside pest control company's service inspection report, dated 7/23/25, notes treatment for fruit flies performed. Deep cleaning is necessary in all dish room areas, mainly under the dishwasher machine, the food extractor, and all corners. All broken tiles, missing grout, need to be fixed to eliminate accumulation and stagnant water and prevent breeding for fruit flies, and cut their cycles of live.

Based on observations, interviews, and record reviews, this facility failed to follow its policies and procedure to ensure resident received incontinence care at least every two hours or as needed, and failed to ensure a resident was positioned per physician order for feeding. This affected four residents (R103, R48, R61, and R113) reviewed for activities of daily living assisted by staff on the sample of 45.Findings include:On 7/22/25 at 12:25 PM, R48 was observed in reclining chair in dining room; head was raised 30 degrees. R48 was brought lunch tray. R48 was not repositioned, the chair back was not raised to the upright position. R48 was observed coughing after each bite taken.On 7/23/25 at 8:50 AM, R48 was observed in bed with head of bed raised 30 degrees. R48's breakfast tray was positioned in front of R48. V10 CNA (certified nurse aide) was observed in R48's room. R48 asked V10 to have the head of bed raised so R48 could eat breakfast. V10 stated that R48 can raise the head of bed herself and exited room.On 7/23/25 at 9:00 AM, V12 DON (director of nursing) stated that R48 is alert and oriented x 3. V12 stated that R48 keeps scooting self-down in bed. V12 stated that R48 is finished with breakfast. This surveyor and V12 entered R48's room. R48 had only consumed two bites of breakfast. When questioned if R48 is positioned correctly in bed to eat meal, V12 responded R48 can raise the head of bed herself. V12 asked staff to reposition R48.On 7/23/25 at 9:30 AM, R48 was observed to be in the same upright position. Throughout this survey, R48 was not observed scooting self-down in bed or chair.On 7/25/25 at 10:10 AM, V28 NP (nurse practitioner) stated that a resident on aspiration precautions should be sitting in an upright position for all meals. V28 stated that V28 expects staff to carry out physician orders. On 7/25/25 at 10:50 AM, V12 DON and V6 ADON (assistant director of nursing) presented R48's care plan for problematic behavior in which R48 acts characterized by inappropriate behavior related to dementia, anxiety disorder, major depressive disorder, and stroke. R48 slides self in bed. It was initiated on 7/17/25. When questioned what interventions have been put in place to prevent R48 from sliding self-down in bed or chair during and after meals, V12 and V6 did not respond. When questioned if R48's physician has been notified of this behavior, V12 and V6 did not respond. V12 and V6 were informed that during this survey, this surveyor did not observe R48 exhibiting this behavior.R48's modified barium swallow study, dated 5/14/25, notes study was completed to rule out aspiration, assess extent of oropharyngeal dysphagia, change in oral function. Speech pathologist impressions: suspect at least moderate oropharyngeal dysphagia secondary to reduced bolus control and formation, decreased labial strength, decreased lingual coordination/strength, delayed initiation of pharyngeal swallow response, and reduced base of tongue strength. Observed at least mild post swallow residuals within superior hypopharynx. Suspect reduced swallow safety with possible aspiration as evidenced by immediate and delayed cough response with cyanosis after mechanical soft and larger cup sip with thin trials. Recommend puree diet with teaspoon sips of thin liquids via slow 1:1 supportive feeding assistance, in upright/midline position. Strict adherence to swallow precautions by staff for safe oral intake. Detailed diet recommendations include but not limited to: small bites, monitor rate, aspiration precaution, protective cough/throat clear, small sips by teaspoon, upright 90 degrees, no straws, monitor pulmonary status, and resident to be fed.R48's POS (physician order sheet), dated 5/16/25, notes an order for puree solids and nectar thick liquids, upright for all oral intake, slow rate, small bites/sips, alternate solids/liquids, no straws, aspiration precautions.R48's speech therapy's Discharge summary, dated [DATE], notes puree diet with nectar thick liquids. Recommendations include but not limited to upright posture during meals and upright posture for more than 30 minutes after meals. Prognosis to maintain function good with staff follow-through. R48 discharged from therapy due to exhaustion of benefits.The facility's physician orders policy, revised 1/31/18, notes when receiving physician orders by telephone, enter the order in the resident's chart. Be sure to include a diagnosis or indication for use. Verbal and telephone orders will be documented as such in the electronic medical record.On 7/23/25 at 11:25am, R103 was observed with a large bulging adult brief. V29 (nurse) checked R103 incontinence brief. R103 was observed with an adult brief and a urine soiled and saturated incontinence insert. V29 said, R103's insert was soaked with urine. V29 said, he doesn't no know why R103 had an insert inside of the incontinence brief. V29 said, he is not sure when the last time R103 was provided incontinence care. V29 said, it took over two hours for R103 to be soaked and saturated with urine.On 7/23/25 at 11:40am, V12 (don) said, residents should be provided incontinence care every two hours and as needed. On 7/22/25 at 3:20 PM, R48 was observed sitting in the dining room. R48 stated that R48 was wet and staff won't change R48's brief.On 7/22/25 at 3:40 PM, V18 CNA (certified nurse aide) was observed providing incontinence care for R48. R48 was observed to have a saturated panty liner (13 inches x 28 inches) in a saturated brief.On 7/22/25 at 3:40 PM, V18 CNA stated that V18 provides incontinence care to assigned residents twice, once at the beginning of shift and once at end of shift.On 7/23/25 at 12:50 PM, R113's call light was observed to be activated. At 1:00 PM, when questioned if R113 needed staff assistance, R113 removed blanket and pointed to incontinence brief. When questioned if R113 needed to have brief changed, R113 nodded head 'yes'. At 1:14 PM, V21 CNA was observed entering R113's room, turned off R113's call light and exited room. At 1:16 PM, V21 informed V11 CNA that R113 needed to have brief changed. At 1:25 PM, V11 entered R113's room to provide incontinence care.On 7/24/25 at 1:15 PM, when R61 was questioned if R61 needed brief changed, R61 stated that R61 needed to use the bathroom as R61 had been holding her urine waiting for staff to assist R61. V20 CNA was informed that R61 needed to use the bathroom. V20 transported R61 via wheelchair to R61's room. V20 checked the front of R61's brief and stated that the brief was dry. V20 was asked to check the backside of the brief; it was saturated with urine.On 7/24/25 at 1:20 PM, V20 CNA stated that V20 provides incontinence care for assigned residents at the beginning of the shift and right before shift ends.On 7/25/25 at 9:50 AM, V6 ADON (assistant director of nursing) stated that incontinent residents should be checked and changed every 2-3 hours, more often if heavy wetter.R48's MDS (minimum data set), dated 6/8/25, notes R48 is dependent on staff for toileting assistance. R48 is always incontinent of bowel and bladder.R61's MDS, dated [DATE], notes R61 requires substantial assistance from staff for toileting. R61 is always incontinent of bowel and bladder.R113's MDS, dated [DATE], notes R113 is dependent on staff for toileting assistance. R48 is always incontinent of bowel and bladder.R103's minimal data set (MDS) dated [DATE] brief interview for mental status documents a score of twelve which indicated moderate cognitive impairment. Section H (bladder and bowel) documents: urinary continence-frequently incontinence (seven or more episode of urinary incontinence). R103's care plan initiated on 9/18/24 documents: R103 have bowel incontinence related cognitive impairment. Interventions: Provide peri-care after each incontinent episode.The facility's incontinence care policy, revised 1/16/18, notes incontinent residents will be checked periodically in accordance with the assessed incontinent episodes or every two hours.

Based on observation, interview and record review, the facility failed to follow the medication storage policy by having opened undated medication and expired medication of the medication cart. This affected four of four residents (R3, R74, R113 and R95) reviewed for labelling and storage in the sample of 45. Findings Include:R3 was diagnosis with Dementia Mellitus. R3's physician order dated [DATE] documents: Insulin lispro solution - Inject as per sliding scale (start date [DATE]). R74's physician order dated [DATE] documents: Brimonidine Tartrate Ophthalmic Solution 0.2 % (Brimonidine Tartrate) Instill 1 drop in right eye eve (start date [DATE])On [DATE] at 12:18pm, during medication cart inspection with V31 (nurse), R3 was observed with lispro insulin dispensed date [DATE] open and not dated. V31 said, R3's insulin was used, open and not dated. V31 said, R3's insulin should have been dated when it was initially opened. R74 was observed with Brimonidine eye drop dated [DATE]. V31 said, R74's eye drops are dated [DATE]. V31 said, R74's eye drops are expired and they were good for twenty-eight days. V31 said, expired medication should not be on the cart. R113's physician orders dated [DATE] documents: Fiasp FlexTouch 100 UNIT/ML Solution pen-injector- Inject as per sliding scale (start date [DATE]). R95's physician orders dated [DATE] documents: Lyumjev KwikPen 100 UNIT/ML Solution pen-injector- Inject as per sliding scale (start date [DATE])On [DATE] at 12:35pm, during medication cart inspection with V32 (nurse), R113 was observed with Fiasp FlexTouch Solution pen-injector (insulin) dated [DATE]. R95 was observed with Lyumjev KwikPen 100 UNIT/ML Solution pen-injector (insulin) dated [DATE]. V32 said, insulin is good for thirty days. V32 said, both R113 and R95's insulin is expired. V32 said, expired medication should not be on the cart. On [DATE] at 12:50pm, V12 (don) said, not expired medication should be on the medication cart. V12 said, insulin is good for twenty- eight to thirty days after opening. V12 said, eye drops are good for thirty days. V12 said, insulin and eye drops are opened, the date they are open should be written on the package. Storage of Medication Policy no date documents: Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedure for medication disposal and reordered from the pharmacy, if a current order exists. Certain medications or packages types, such as ophthalmics, once open, requires an expiration dated shorter than the manufacturer's expiration date to insure medication purity and potency. When the original seal of a manufacture's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened. If a vial or container is found without a date opened, the date open will automatically default to the date dispensed and the expiration date will be calculated accordingly. All expired medication will be removed from the active supply and destroyed in the facility, regardless of amount remaining.

Based on observations, interviews, and records reviewed the facility failed to ensure staff wear gloves when handling soiled laundry and failed to follow the facility failed to follow its glucose testing policy by not placing a barrier between a used glucometer and the medication cart, and failed to perform hand hygiene and clean the glucometer while taking blood glucose levels. This affected two of two residents ( R7, R3) reviewed for infection control practices and residents residing on the 200 hall. Findings Include: The findings include: On 07/23/2025 at 11:00 AM V4, Laundry Aide, observed in the 200 hall removing laundry from 1st soiled bin. V4 wearing no gloves. V4 then pushed her laundry cart to a 2nd bin wearing no gloves and adjusted the bag inside, closed the bin and then went to 3rd laundry bin. V4 wore no gloves when removing or adjusting bags on the soiled laundry bins. At 11:04 AM V4 said they tell us not to wear gloves when collecting laundry in the hall way. On 07/23/2025 at 11:52 AM V6, Infection Preventionist, said gloves should be worn when handling gloves with soiled items, yes laundry. V6 said gloves should be worn when removing laundry from the bin. V6 said gloves should be worn because the item is soiled and incase the bag tears. V4's orientation checklist dated 9/26/24 states she trained on linen handling, Infection Control procedures, and use of personal protective equipment. The facility Infection Prevention and Control Program policy dated 11/28/17 states the purpose includes all facility personnel are required to routinely wash hands and use appropriate barrier precautions to prevent transmission of infections. CDC.gov guidance accessed on 7/25/25 states Best practices for linen (and laundry) handling. Always wear reusable rubber gloves before handling soiled linen. R7 was diagnosed with type two Diabetes Mellitus. On 7/23/25 at 10:49am, during medication pass, V29 (nurse) was observed donning gloves, taking R7 blood glucose level, V29 took R7's blood glucose level, walked back to the medication cart, placed the blood glucose monitoring machine directly on the medication cart without any type of barrier, cleaning the machine or washing hands/using hand sanitizer after removing his gloves. R3 was diagnosed with type two Diabetes Mellitus On 7/23/25 at 10:51am, during medication pass, V29 took the same glucose machine he used on R7, donned new gloves, took R3's blood glucose level which resulted 147mg/DL without cleaning the machine or washing hands/using hand sanitizer after removing his gloves R3's blood glucose level on 7/23/25 at 10:54 documents: 147mg/dL On 7/23/25 at 11:08am, V29 said, he was supposed to wash/sanitize his hands before and after putting on gloves/removing gloves and in between each resident. V29 said, he was also supposed to clean the blood glucose machine between each resident with bleach wipes. On 7/25/25 at 12:50pm, V12 (don) said, she expects nursing staff to follow the glucometer policy, staff should put down a barrier, clean hands before and after donning/doffing gloves and clean the glucometer machine. Glucose Testing-Glucometer dated 11/28/12 documents: Place clean paper towel or clean barrier on surface and places supplies in surface. Remove gloves and perform hand hygiene. Hand Hygiene/Handwashing policy dated 11/29/12 documents: Hand hygiene means clean you hand by using either handwashing (washing hands with soap and water) antiseptic hand wash or antiseptic hand rub (i.e alcohol-based hand sanitizer including foam or gel.) Examples of when to perform hand hygiene: at room entry, before performing an aseptic task, before exiting room, before and after having direct contact with a patient's intact skin (taking a pulse or blood pressure, performing physical examinations, after contact with blood, body fluids or excretions and after glove removal.

Based on interviews and records reviewed the facility failed to follow orders and obtain a urine analysis ordered on 4/6/25 for a resident with a history of urinary tract infections This affected one resident (R22) reviewed for physician orders on the sample of 45.The findings include:R22 has impaired cognition and diagnosis include, but are not limited to Alzheimer's Disease, Major Depressive Disorder, and Dementia. R22's Functional Abilities dated 6/3/25 identifies dependent on staff for toileting hygiene and always incontinent of urine.On 07/22/2025 at 10:36 AM R22 sitting in a wheel chair in the dining room. R22 alert, confused not talking or verbally responding, just looks at the surveyor.On 07/22/2025 at 3:45PM V24, R22's daughter, said on 4/6/25 I came to visit my mother and she was rambling. V24 said when she does that, I know that is a sign she is developing a UTI. I notified the nurse. We asked what happened, was anything going on with her and telling them she is not herself. V24 said then on 4/24/25 my sister came to see mom and had her sent to the ER. V24 said at the emergency department R22 was found to have a UTI. V24 said I talked to V12, DON, about this, the nurse not acting on R22's reported symptoms until my sister came in to report her concerns. V24 said talking to V12 got me no where.On 7/25/25 at 9:24AM V23, CNA, said I have been taking care of R22 for the last 3 months. R22 does not speak or communicate her needs. She comes in and out of it, sometimes more alert. V23 said R22 is always incontinent, she does not use the toilet and is not able to say when she needs to be changed. V23 said I don't know if she has a history of Urinary Tract Infections. On 7/23/25 at 2:10PM V6, Infection Preventionist, said R22 does not meet the criteria for antibiotic use, but she had the prescription for the antibiotic from the hospital. On 7/24/25 at 6:25pm V25, LPN, said I work both day and evening shifts and I float around the building. V25 said I know who R22 is. I don't know her to have a history of UTIs. I have seen R22's family visiting her while I am working. V25 said I can't remember if R22's family reported anything to me about her needing to get a Urine Analysis (UA), there's so much going on in that building. V25 said I must have gotten the order if I put it in the chart. V25 said if a change in resident condition is report, I asses the patient, report to the doctor, and document. V25 said in a situation when urine is needed to be collected and we don't get it on our shift we pass it on to the next shift. V25 said lab results are found in the resident computer chart. R22's Order Detail report dated 4/6/25 includes an order UA, reflex to culture. The order was written by V25.On 7/25/25 at 9:48AM V6, Infection Preventionist, said risk factors for UTI include sitting in urine, poor hydration, poor peri care or incontinent care. V6 said residents that are incontinent are at risk for UTI. At 11:07AM V6 said R22 has a history of UTI, in the past.On 7/24/25 at 2:03PM V6 said R22's family did not speak to me specifically about UTI or UA. V6 said I found out that R22 had a UTI after she returned from the hospital on 4/24/25. At 2:17PM V6 said if a UA is ordered we expect the staff to get it done right away.On 7/24/25 at 1:08PM V12, DON, was asked if she was aware of R22's family reporting signs that they know are symptoms of R22 developing a UTI? V12 said I was on vacation. V12 was asked for the dates she was on vacation and did not give them or say how many days she was on vacation. V12 was asked about R22's symptoms being reported on 4/6/25. V12 said I don't know what happened, I wasn't here. V12 handed the surveyor labs for R22 dated March 2025 and said the doctor saw R22 on 4/17/25.On 7/24/25 at 1:46PM V26, Acting Administrator, said if a family reports a concern I would expect it be documented on a concern form and the appropriate department follow up. At 2:14PM V26 said V6 was off from 4/11/25- 4/14/25. (5 days after R22's family reported symptoms.) V26 said we do not have results for R22's UA ordered on 4/6/25.7/25/25 9:07AM V12, DON, said the NP saw R22 on 4/7/25 for the symptoms of UTI and said she was fine. V12 presented a progress note for R22.On 7/25/25 at 9:48AM V6, Infection Preventionist, said risk factors for UTI include sitting in urine, poor hydration, poor peri care or incontinent care. V6 said residents that are incontinent are at risk for UTI. At 11:07AM V6 said R22 has a history of UTI, in the past. On 7/25/25 at 9:54AM V28, Nurse Practitioner, said I saw R22 on 4/7/25, just routinely. V28 said I see all the patients weekly. V28 said R22 is alert and oriented times 1 or 2. V28 said you can speak to R22, but it doesn't make sense to her. R22 can physically respond, but she does not respond verbally. V28 said I assessed R22 for abdominal tenderness on 4/7/25 and she displayed no signs. V28 said abdominal tenderness is not always present for a UTI. V28 said I don't recall speaking to R22's family about a UTI. V28 said if the staff or family reported a concern I would have documented what they reported to me. V28 said I am in the facility Monday thru Friday. V28 said I am not on call on the weekends. V28 said if I had written an order, I would have written a progress note. V28 said I expect the staff to carry out physician orders given. V28 said I didn't know R22 had an order for a urine analysis written on 4/6/25. V28 said it is important to treat a UTI, she could have gone septic if not treated. A review of R22's Progress Notes dated 4/6/25-4/25/24 was completed. Physician saw R22 on 4/17/25 and he reviewed labs from 3/24/25, no mention of the UA ordered 4/6/25.Review of R22's Progress Notes dated 4/8/25 written by V28 states is seen today for Chronic Care Management.Progress Notes dated 4/24/25 at 9:57AM states R22's family reporting to V12 that R22 is not at baseline. Physician offered labs and UA with C&S and fluids. Family requested R22 be sent for evaluation. At 10:24AM R22 transported to hospital for evaluation via 911.Order Summary Report dated 4/25/25 includes Cefuroxime 500mg tablet for 7 days.Facility provided hospital record dated 4/24/25 identifies R22 urinary tract infection she was given a dose of Rocephin and is given a prescription at discharge. Diagnosis is Acute cystitis. Urine analysis collection date 4/24/25 includes criteria of urinary infection.Review of the facility McGreer Criteria for Infection Surveillance Checklist for R22 includes her name, room number, and date of infection 4/25/25. Nothing is filled out past that information on the form.Review of R22's history includes history of UTI.No Concern/Grievance form was found In April from R22's family.

Based on observations, interviews, and record reviews, the facility failed to ensure residents were treated in a dignified manner by providing timely toileting assistance. This failure affected three residents (R48, R61, and R113) reviewed for resident rights on the sample of 45. Findings include:On 7/22/25 at 3:20 PM, R48 was observed sitting in the dining room. R48 stated that R48 was wet and staff won't change R48's brief. R48 stated that staff had not changed her brief since she got in reclining chair for breakfast.On 7/22/25 at 3:40 PM, V18 CNA (certified nurse aide) was observed providing incontinence care for R48. R48 was observed to have a saturated panty liner (13 inches x 28 inches) in a saturated brief.On 7/22/25 at 3:40 PM, V18 CNA stated that V18 provides incontinence care to assigned residents twice, once at the beginning of shift and once at end of shift.On 7/23/25 at 12:50 PM, R113's call light was observed to be activated. At 1:00 PM, when questioned if R113 needed staff assistance, R113 removed blanket and pointed to incontinence brief. When questioned if R113 needed to have brief changed, R113 nodded head 'yes'. At 1:14 PM, V21 CNA was observed entering R113's room, turned off R113's call light and exited room. At 1:16 PM, V21 informed V11 CNA that R113 needed to have brief changed. At 1:25 PM, V11 entered R113's room to provide incontinence care.On 7/24/25 at 1:15 PM, when R61 was questioned if R61 needed brief changed, R61 stated that R61 needed to use the bathroom as R61 had been holding her urine waiting for staff to assist R61. V20 CNA was informed that R61 needed to use the bathroom. V20 transported R61 via wheelchair to R61's room. V20 checked the front of R61's brief and stated that the brief was dry. V20 was asked to check the backside of the brief; it was saturated with urine.On 7/24/25 at 1:20 PM, V20 CNA stated that V20 provides incontinence care for assigned residents at the beginning of the shift and right before shift ends.On 7/25/25 at 9:50 AM, V6 ADON (assistant director of nursing) stated that incontinent residents should be checked and changed every 2-3 hours, more often if heavy wetter.The facility's incontinence care policy, revised 1/16/18, notes incontinent residents will be checked periodically in accordance with the assessed incontinent episodes or every two hours.

Based on interviews and record reviews, the facility failed to accurately incorporate a resident's directive for life sustaining treatment into the medical record. This failure affected one resident (R9) reviewed for advance directives in the sample of 45.Findings include:On [DATE] at 1:30 PM, V8 SSD (social services director) stated that R9 is a full code. This surveyor and V8 reviewed the completed POLST (practitioner order for life-sustaining treatment) form, dated [DATE], in R9's medical record, acknowledged that R9 has signed DNR (do not resuscitate) form. V8 stated that the R9's family revoked the DNR status. When questioned for documentation of revocation, stated it is in her progress notes. This surveyor reviewed V8's progress notes with her, V8 stated that there is no documentation that DNR was revoked. V8 stated that neither R9's care plan nor the face sheet were not updated to note change in R9's code status.R9's face sheet, care plan, and POS (physician order sheet) note R9 is a full code.The facility's advance directives policy, revised [DATE], notes if a resident or health care representative indicates an advanced directive regarding CPR (cardiopulmonary resuscitation) or scope of treatment (POLST form), the appropriate forms will be completed. Advanced directives shall be included in the resident's plan of care and will be reviewed during the care plan meeting with the resident and/or the resident's legal representative when present. A resident, their legal representative or authorized health care representative may rescind their advance directive(s) at any time. An oral revocation will be documented in the resident's health records indicating the time, date, and place of verbal expression.

Based on observations and interviews, the facility failed to provide privacy while providing a bed bath. This affected one resident (R48) reviewed for privacy while receiving direct care on the sample of 45. Findings include:On 7/23/25 at 9:35 AM, V11 CNA (certified nurse aide) and V6 ADON (assistant director of nursing) were observed entering R48's room. V11 closed the door behind them. R48's roommate was observed sitting in wheelchair facing R48's bed. V11 gathered supplies to provide R48 a bath. R48's privacy curtain was not closed around R48's bed. R48's right arm was removed from gown exposing right breast. At 9:41 AM, R48's left arm was removed from gown exposing both breasts and abdomen. At 9:44 AM, another staff member entered R48's room to speak with V6. Afterwards, V11 pulled the privacy curtain to finish bathing R48.On 7/25/25 at 9:50 AM, V6 ADON stated that the resident's door should be closed and privacy curtain pulled around resident's bed to provide privacy prior to providing resident care.

Based on observation and interview the facility failed to ensure the resident room was clean and sanitary for one of 8 residents (R59) in total sample of 45 reviewed for clean homelike environment. Findings include:On 7/22/25 at 1:10pm R59 said the floor in his room is dirty and sticky. Surveyor shoes was sticking to the floor when taking steps.Facility policy titled housekeeping, no date noted denotes in-part to provide guidelines to maintain a safe and sanitary environment for residents, facility staff and visitors.

Based on observations, interviews, and record reviews, the facility failed to ensure oxygen tubing changed and dated weekly. This failure affected two residents (21 and R48) reviewed for respiratory care on the sample of 45. Findings include:On 7/22/25 at 10:05 AM, R21 was observed in room with oxygen tubing placed behind R21. R21's oxygen tubing was undated.On 7/22/25 at 10:30 AM, R48 was observed in dining room. R48's oxygen tubing was dated 7/14/25. On 7/23/25 at 9:35 AM, R48's oxygen tubing was dated 7/23/25.On 7/25/25 at 9:50 AM, V6 ADON (assistant director of nursing) stated that oxygen tubing is changed weekly and as needed. V6 stated that the oxygen tubing should be dated when changed. V6 stated that the date noted on the oxygen tubing should match the date documented in the resident's MAR (medication administration record). R21's POS (physician order sheet), dated 9/18/22, notes an order to change out, date, and label oxygen tubing every night shift every Sunday.R48's POS, dated 3/27/24, notes an order to change out, date, and label oxygen humidifier 500ml (milliliters) and oxygen tubing every night shift every Sunday.R48's MAR, dated July 2025, the nurse noted R48's oxygen tubing was changed 7/13 and 7/20.

Based on observation, interview and record review the facility failed to ensure the call light was functioning for a dependent resident R2 reviewed for functioning call light system in total sample of 45 residents.Findings include: R2 face sheet shows diagnosis of unspecified osteoarthritis, lack of coordination, need for assistance for personal care.On 7/22/25 at 2:37pm R2 said the call light for her bathroom shower is not working. R2 said the light should be working so that she can pull the string if she needs help from the staff. R2 did not give a situation/ time/ episode of an event that she pulled the shower call light and staff did not respond and she had to wait. R2 said she told maintenance about the call light last week.Surveyor pulled the cord to the call light for the shower (in R2 bathroom) , and the light did not illuminate at the call light box, or above the entry door to the room, the string did not pull.7/22/25 V30 (RN) was made aware immediately upon exit of R2 room that R2 call light for the shower is not working in R2's room.On 7/24/25 with assist from V7 (Maintenance staff) to check R2 call light for the shower, R2 call light for the shower was not working, it did not illuminate at the call box, above the door, and it did not activate at the nurse's station. V7 said the call lights should be functioning by activating and lighting up above the door and registering at the Nurses station call light system. V7 said he was made aware of the call light in R2 bathroom not working for the shower. V7 said he don't recall who informed him of the call light not working. V7 said she don't recall when he was informed that R2 call light for the shower was not working. V7 said the plan is for the company to fix the call light.Facility policy titled Call light last revision date 2/2/2018 denotes in-part call bell system defects will be reported promptly to the maintenance department for servicing. Check room frequently until system is repaired.Facility failed to present policy for functioning call light system upon exit of this survey.

Based on observations, interviews, and record reviews, the facility failed to ensure enteral feeding and tubing is properly labeled and dated before administration, failed to ensure tubing was in correct position in the feeding pump for one resident (R113) reviewed for enteral feedings on the sample of 45. Findings include:On 7/22/25 at 3:30 PM, R113 motioned for this surveyor to enter his room. When questioned what the matter was, R113 pointed to his gastrostomy feeding that was hanging on the intravenous pole next to his bed. R113's gastrostomy feeding tubing was observed not connected to the feeding pump and the clamps on the tubing were open. The feeding container was not labeled with R113's name or date and time hung.On 7/22/25 at 3:35 PM, V12 DON (director of nursing) came to R113's room. V12 stated that the feeding should not be running like that. V12 stated that the tubing should be connected to the pump. V12 stated that the day shift nurse didn't know how to connect the tubing to the feeding pump. When questioned what is the expectation for the nurses if they do not know how to use the equipment, V12 responded the nurses should ask V12 for assistance.On 7/22/25 at 3:40 PM, V9 RN (registered nurse) came into R113's room. V9 stated that the feeding container should be labeled with the R113's name and the date and time feeding started. V9 stated that the tubing should be connected to the feeding pump to ensure the correct amount of feeding per hour is administered.The facility's gastrostomy tube feeding and care policy, revised 8/3/20, notes cyclic feedings are prescribed amount of formula volume is given over a specific period of time and given by an enteral feeding pump. The feeding container should be labeled with resident's name, flow rate, date and time hung.

Based on interviews and record reviews, the facility failed to have an appropriate diagnosis for the use of antipsychotic medications, failed to identify a specific behavior for the use of an antipsychotic medication. This failure affected two residents (R8 and R9) reviewed for unnecessary medications on the sample of 45.Findings include: 1.R9's medical record notes R9 with diagnoses including but not limited to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. On 7/23/25 at 3:45 PM, V12 DON (director of nursing) provided this surveyor with signed psychotropic consents for gabapentin (for treatment of nerve pain) and mirtazapine (appetite stimulant). When questioned if this was all of R9's signed consents for psychotropic medications, V12 responded yes. On 7/24/25 at 11:50 AM, V6 ADON (assistant director of nursing) reviewed R9's current medication orders. V6 stated that R9 is receiving olanzapine for a psychotic disorder. V6 reviewed R9's medical diagnoses and stated that R9 has dementia. V6 reviewed R9's psychotropic consent forms and was unable to find a consent form for olanzapine in R9's electronic medical record. When questioned if olanzapine was appropriate for a resident with a diagnosis of dementia, V6 did not respond. On 7/24/25 at 1:30 PM, V6 presented a signed consent for R9's olanzapine. V6 stated that she found the consent form in the medical record office. When questioned if this consent should be in R9's electronic medical record, V6 responded yes. When questioned why the consent dated 4/10/24 was not uploaded prior to this surveyor asking about it today, V6 responded I don't know. V6 unable to articulate how V6 was able to find a one page document not in a binder and placed in the medical records office more than a year ago so quickly. R9's care plan, initiated 10/10/24, notes R9 uses psychotropic medications olanzapine related to disease process mood disorder. R9's POS (physician order sheet), dated 8/12/24, notes an order for olanzapine 2.5mg (milligrams) oral at bedtime for antipsychotic. R9's psychotropic medication intervention review, dated 5/5/25, notes targeted behaviors include anxiety and agitation. Prior to 4/9/24, V33's NP (psychiatry nurse practitioner) documentation notes R9 with dementia without behaviors. On 4/9/24, R9 expressed desire to discharge home with family. V33 noted R9's judgement to be fair, short term memory fair, long term memory adequate. R9 obeys commands. V33 started R9 on olanzapine 2.5mg oral at bedtime. Prior to R9 starting any antipsychotic medication, V33 documented with each visit GDR (gradual dose reduction contraindicated due to potential worsening. After olanzapine started, V33 continued to document GDR contraindicated. Per the FDA (food and Drug Administration), olanzapine is approved for the treatment of schizophrenia. Elderly residents with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Olanzapine (zyprexa) is not approved for the treatment of residents with dementia-related psychosis. 2.R8's diagnosis include but are not limited to Unspecified Dementia, unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbances, Mood disturbance, and Anxiety, Unspecified Dementia, Severe, with Mood Disturbances, Depression, and Anxiety Disorder. Cognitive score of 15, intact. 07/22/2025 10:30 AM R8 in her room in bed. R8 alert and oriented. No restlessness or inappropriate responses during conversations. After reviewing R8's records and comparing to her statements R8 presents with mild confusion to some circumstances, including indication for her most recent hospitalization. Hospital Record admission 7/14/25, readmission 7/17/25, states chief complain abdominal pain and later determined related to hernia. On 7/24/25 at 12:28PM V6, Infection Preventionist, said she is also the psychotropic nurse. V6 reviewed R8's medications with the surveyor. V6 said R8 receives Olanzapine for psychotic disorder. V6 read off R8's diagnosis from R8's diagnosis list including Unspecified Dementia with Mood and Severe Disorder, Adjustment Disorder with Anxiety, Anxiety Disorder and Depression. V6 was asked what specific R8's displays that she requires Olanzapine. V6 said R8 has anxiety, she gets overwhelmed. V6 said the nurses check off on the Medication Administration Record (MAR) if the resident is having any behaviors. V6 was asked to review the MAR with the surveyor to show the target behaviors. V6 said it has not been entered into the system since her recent readmission. The surveyor reviewed the entire month of July 2025 MAR with V6. V6 said it's not there. V6 presented psyche therapy notes from 7/18/25 for R8's behaviors. V6 said this is what they talk about and she is treated. Only diagnosis are listed and conversations but no displayed behaviors were addressed related to use of Olanzapine. V6 was asked to present documentation she can find of R8 displaying behaviors that may require treatment with Olanzapine. On 7/25/25 no documentation was provided. Review of R8's Order Summary Report includes Olanzapine Tablet 7.5mg two times a day for psychotic behavior. Review of R8's care plan includes I use psychotropic medication Olanzapine. No specific behavior related to medication use is documented. Review of R8's Active Diagnosis MDS dated [DATE] includes Non-Alzheimer's Dementia, Anxiety, and Depression. No other Psychiatric/Mood disorder. Additional diagnosis includes Unspecified Dementia with severe mood disturbances. Review of R8's MDS dated [DATE] for Behavioral Symptoms indicates none displayed. The facility policy for Psychotropic Medication – Gradual Dose Reduction dated 2/1/18 states the purpose is to ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition.

Based on observation, interview and record review the facility failed to ensure that the state inspections are available for the residents to read without having to ask the staff for them. This affects 4 of 4 residents (R91, R40, R111, R23) in the sample of 45 resident reviewed for residents' rights for state inspection. Findings include: On 7/23/25 at 11:10am R98 (president of resident council) said the survey binder/ state inspections was at the front desk. R23 and R111said they don't know what the survey binder are with the state survey results.On 7/25/25 at 8:48am during tour, there was no survey binder observed out in view at the front desk. Request was made to review the survey binder with previous state inspections, V5 (receptionist) looked at the binders that was located in the back of the receptionist desk and stated that the binder is not there. V34 (Regional Nurse Consultant) said the survey binder should be at the front desk. V34 and V12 looked for the survey binder in the administrator's office, and around the front desk area, foyer near the smoke patio.7/25/25 8:57am V12 (DON) presented the survey binder and stated that V5 did not know what the survey binder was. V12 was asked should V5 know what the survey binder is, just in case the resident request to see the binder. V12 declined to answer. V12 was asked should the binder be available for the resident to review without asking, V12 declined to answer.

Based on interview and record review the facility failed to develop an effective plan to prevent and/or reduce the risk of falling for a resident identified to at high risk for falls, and failed to follow their fall prevention protocol to complete fall risk assessments quarterly and accurately assess and document fall risk factors. This affected 6 of 6 residents (R1, R2, R4, R5, R6 and R7) reviewed for falls and fall risk assessments. This failure resulted in R1 having multiple falls R1 had a fall in his room on 8/27/24 at 7:45AM, and then another fall same day at 1:47PM in the dining room that resulted laceration in left side eye brow forehead requiring sutures on 8/27/24 and third fall on 9/12/24 in the dining room that resulted in left eyebrow laceration re-opening. Findings Include: R1 is [AGE] year old resident and still currently in the facility. BIMs score of 2 (severe cognitive impairment). Fall risk assessment dated [DATE] scored 13, and on 9/13/24 scored 14. On 10/24/24 at 9:30AM, V12 (Restorative Nurse/Fall Coordinator) stated that a resident is consider high risk for fall if they scored 10 or higher on the fall risk assessment. V12 stated that residents with a history of falls and impulsive behaviors would have someone close to resident to monitor for any behavior. R1 has a careplan for actual fall with major injury related to: nasal bone fractures, Parkinson's disease, left hip replacement, bipolar disease, developmental delay, ESBL (extended spectrum beta-lactamase -- bacteria) in the urine and acute kidney failure, poor balance, poor communication/comprehension, unsteady gait, impulsive behavior dated 9/19/24. Behavior Note documented on 8/27/24 at 7:45AM, reads in part: R1 was observed sitting on the safety mat next to the bed, with the bed in lowest position. On 10/23/24 at 2PM, V3 (LPN) stated that the incident was unwitnessed, V3 saw R1 lying on the floor mat next to his bed, bed was in low position. I do not know how R1 got himself to the floor mat. R1 was not able to explain how it happened. I asked V2 DON (director of nursing) if I should document it as a fall, but V2 said to document it as a behavior because no one saw him fall off the bed. On 10/24/24 at 9:30AM, V12 (Restorative Nurse/Fall Coordinator) stated that a fall incident is a change of plane. If fall unwitnessed and if the resident is not able to explain what happened, it is considered a fall incident. V12 stated that the fall incident should be documented and a fall risk assessment should be completed. On 10/24/24 at 11AM, V2 (DON) stated that the incident happened early morning and that it was not a fall, because it was not a change of plane. V2 stated that R1's floor mat is the same height as his bed. R1 rolls off the bed, and the floor mat is the same height as his bed. Bed in low position. Floor mat is in place when R1 is in bed and when R1 is out of bed, we take the mat up and put it against the wall of R1's room, it does not leave R1's room. On 10/24/24 at 11:15AM, the distance from the floor to the top of R1's mattress/bed was observed to be about 15 inches. The height of the floor mat was observed to about one inch. R1 was not observed to be present in R1's room. R1's floor mat was positioned on floor next to R1's bed. On 10/24/24 at 11:16AM, V4 CNA (certified nurse aide) stated that R1's bed and floor mat is what R1 has always had since admission to this facility. V4 acknowledged that R1's top of floor mat is not at the same height as the top of his bed. On 10/24/24 at 2:10PM, V4 CNA stated that R1 is usually awake when she arrives at 6:00AM. V4 stated that R1 should be on the get up early list. stated that R1 will activate his call light when he wakes up in the morning for toileting assistance. R1 needs prompt staff response to his call light. V4 stated that she did not see R1 sit himself on the floor on 8/27/24, when she arrived he was on the floor. Facility reported incident with date of occurrence of 8/27/24, reads in part: Thorough investigation completed. Medical record review and interviews of witnesses reveals on 8/27/24, R1 sustained a witnessed fall. Prior to the fall, R1 was notes sitting in the dining room. R1 did not request for assistance, but quickly got up to grab a cup of water, then stumbled on the table resulting in a fall. R1 sustained an opened area on the left eyebrow. Medical records review indicates that prior to admission, R1 has a history of acute comminuted mildly depressed bilateral nasal bones fractures with slight rightward deviation of the nose, acute nasal bone fracture which is superimposed upon an old chronic nasal bone fracture. R1 was transferred to the hospital for further evaluation and was diagnosed with closed fracture of nasal bone age indeterminate and laceration of the left eyebrow with 7 stiches. On 10/23/24 at 11:15AM, V3 (LPN) stated that on 8/27/24, around after lunch, staff alerted V3. V3 come here we need you. Few steps away from walking in the hallway. I just passed by the dining room V3 stated that V3 saw R1 on the floor. R1 lying on the side, with active bleeding under eye and wheelchair right next to R1. Wound care came after me and attended to the wound. R1 is extensive assist and able to self-propel, propels with his feet Does not use footrest. R1 needs assistance with standing due to cognition and poor safety awareness with impulsive behavior. R1 is high risk for fall. Staff are already on alert for fall, staff keep extra eye on R1 to prevent from falling. On 10/23/24 at 11:40AM, V4 (CNA), stated that on 8/27/24, V4 just changed R1's clothes after lunch meal, pushed R1 into the dining room. V4 stated that V4 heard an emergency bathroom call light alarming and she did not put any resident in the bathroom so V4 left the dining room to attend to call light. V4 stated I am not sure if any other staff member was in there. Waiting for activity staff to come around. When I returned they are picking R1 up already from the floor. R1's gait is very unsteady. R1 has a behavior of trying to get up and reaching for whatever is in front of him. R1 is a reacher. R1 is going to get whatever is in front of him, especially food and drink. R1 is a busy resident, would try to get everything and would reach anything in front of him. On 10/23/24 at 1:35PM, V10 (Restorative Aide) stated that R1 was sitting in the chair and R1 reached for some water. R1 was in the long table in the dining room. R1 stood up and fell forward. R1 hit the ground. V10 stated V10 was sitting in the alternate side of the table. There were 5 or 6 residents in the dining room. V10 stated that this was the first time watching R1 in the dining room, V10 was not aware of any impulsive behavior of R1. V10 stated V10 got up but was not able to stop the fall. We try to prevent falls. I do not know if he is high risk for fall. R1's hospital record dated 8/27/24, reads in part: 2.5 cm laceration located to the left forehead eyebrow. 2 deep sutures to close soft tissue and 6 superficial sutures to close the skin. CT (computerized tomography) scan of R1's head/brain with an impression of mild left forehead soft tissue swelling and age indeterminate mildly depressed nasal bone fracture. IDT FALL COMMITTEE NOTE dated 8/30/24, reads in part: Contributing factors: impaired memory, confused, anti-hypertensive user, antipsychotic use, gait imbalance, incontinent, weakness and narcotic use. Prior interventions and support provided: bed in lowest position, behavior monitoring, non-skid socks/footwear in place, call light in reach, and R1 was brought close to the dining room/nurses station. Root cause of the fall determined by IDT: R1 was impulsive behavior attempted to grab a cup of water from the table in the dining room and stumble on the table. R1 requires 1 person assist with ADL and transfer. New intervention put at the time of the fall, bed moved against the wall to prevent from sliding out. Anti-slip mat and anti-rollback were added to R1's wheelchair. Floor mat added to the side of R1's bed. Fall initial occurrence note dated 9/12/24, reads in part: R1 had an un-witnessed fall 09/12/2024 4:45 PM Location of Fall: Unit 1 Dining room, Nurse was told by RCS (Resident Aide) that R1 fell , when the writer went to Unit 1 dining room, RCS already put R1 back on his wheelchair. Noted small blood on the floor and left upper eyebrow. Sent to local hospital for evaluation. Nurses Note dated 9/12/2024 at 21:42, reads in part: Back from local hospital and after being evaluated with diagnosis .of fall initial encounter, Injury of Head, initial encounter, Acute Cystitis without hematuria. Sutures from left eyebrow off, steri- strips intact and covered with band aid. No discoloration noted at this time. On 10/23/24 at 3pm, V11 (RN) stated that a resident aide informed V11 about R1 fall. Dining room R1 blood on the floor, and noted R1 already on the wheelchair. Blood on the left eye brow. Sutures still present on the laceration, and noted blood coming out from that area, small amount. Dry dressing and bleeding stop. Sent out for further evaluation. R1 returned and hospital removed sutures and placed steri strips. R1 usually bend forward and reach for something, and that probably what happened. Last seen resident in the dining room and the aide was there, female RCS. On 10/24/24 at 11AM, V2 (DON) stated that the fall incident on 8/27/24, witnesses interviewed, they bring R1 in the dining room. Restorative was there, she was sitting around the corner not close to R1, She was not able to catch the fall. R1 was trying to grab a cup of water. Reached and fell forward from sitting in the wheelchair. R1 has history of multiple falls when he was at the group home. R1 has multiple falls prior to coming in the facility. High risk for fall that's the reason we bring him in the dining room, R1 is very impulsive, no sense of safety awareness. Supervision in the dining room. Stated that the fall incident on 9/12/24, R1 was in dining room and they are people supervising. CNA was in the dining room. CNA observed R1 dropped the spoon on the floor and R1 bent down and fell of the wheelchair. R1 is quick, and people were watching R1. Facility does not do one on one supervising. There are other people also in the dining room that they have to watch. Staff are monitoring other high risk for fall residents and the facility do not do one on one. IDT FALL COMMITTEE MEETING NOTE dated 9/13/24, reads in part: Contributing factors: Impaired memory. Situational factor: behavior symptoms. Root Cause: impulsive behavior attempted to pick spoon from the floor in the dining room when he slid and fell . On 10/23/24 at 1:35PM, V10 (Restorative Aide) stated that if any residents with such behavior and history of fall. Staff keep eyes on them and monitoring. Staff should be sitting close enough to be able to redirect the resident. Close enough to stop the reaching behavior of R1 for safety and prevent fall incident. Fall Prevention Program with a revision date of 11/21/2017, reads in part: 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. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. The fall Prevention Program includes the following components: Methods to identify risk factor, methods to identify residents at risk, use and implementation of professional standards of practice, immediate change in interventions that were successful, communication with direct care staff members. Care plan incorporated: identification of all risk/issue, address each fall, interventions are changed with each fall as appropriate, preventative measure. Safety interventions will be implemented for each resident identified at risk. Nursing personnel will be informed of residents who are at risk of falling. The fall risk interventions will be identified on the care plan. 34072 R2's medical record notes R2 was admitted with diagnoses including, but not limited to, high blood pressure, hypertensive urgency (occurs when blood pressure readings are 180/110 or higher but there is no organ damage or symptoms), history of falls, and primary osteoarthritis of ankle and foot. R2's POS (physician order sheet) notes an order, dated 5/14/24, for amlodipine besylate (medication to treat high blood pressure) 10mg (milligrams) oral daily. On 5/15/24, there is an order for hydralazine (medication to treat high blood pressure) 50mg oral every 8 hours. On 6/25/24, there is an order for olanzapine 2.5mg oral for mood/agitation. On 8/13, there are orders for furosemide (medication to treat fluid retention) 20mg oral daily. On 8/22/24, there is an order for lisinopril (medication to treat high blood pressure) 10mg oral daily. R2's admission fall risk assessment, dated 5/14/24, notes R2 does not take any high risk medications. R2 was receiving amlodipine besylate. It also notes R2 does not have any predisposing diseases, such as arthritis. R2 was admitted with a diagnosis of primary osteoarthritis of ankle and foot. It notes R2 is not at risk for falls. R2's fall risk assessment, dated 7/10/24 at 5:45PM, notes no falls in the past three months. This assessment was completed after R2 fell at 5:00PM. It notes R2 is not at risk for falls. R2's fall risk assessment, dated 9/11/24, notes R2 takes 1-2 high risk medications currently or within last 7 days. R2 was receiving amlodipine besylate, hydralazine, and olanzapine. It also notes no falls within the past three months. R2 fell on [DATE]. It also notes no predisposing diseases, such as arthritis. R2 was admitted with a diagnosis of primary osteoarthritis of ankle and foot. R2's gait/balance was not assessed. R2 was hospitalized ,d+[DATE]-[DATE] with medication changes. This was not identified on R2's assessment. It notes R2 is not at risk for falls. R4's medical record notes R4 with diagnoses including, but not limited to, stroke with paralysis affecting left dominant side (primary diagnosis on 8/3/2023) and history of falling. R4's fall risk assessment, dated 8/7/24, notes no falls within the past three months. This assessment was completed post fall. It also noted R4 does not have any predisposing diseases, such as stroke. It notes R4 is not at risk for falls. R4's fall risk assessment, dated 8/21/24, notes R4's gait/balance was not assessed. It also notes R4 does not have any predisposing diseases, such as stroke. It notes R4 is not at risk for falls. R4's fall risk assessment completed prior to 8/7/24 was done on 10/18/23. On 10/24/24 at 9:40AM, V12 (restorative nurse/falls coordinator) stated that V12 has been the falls coordinator at this facility for the past two years. V12 stated that a fall risk assessment is completed on all residents on admission, re-admission, status post fall, and quarterly. V12 stated that a resident is identified as a high risk for fall if the fall risk assessment score is 10 or higher. V12 stated that the resident's care plan would note resident is at risk for falls not at high risk for falls. V12 stated that nurses are expected to complete the fall risk assessments. V12 stated that the IDT (interdisciplinary team) will assess each resident and determine if the resident is at risk for falls. When questioned where is the IDT's assessment documented in the resident's electronic medical record, V12 did not respond. V12 stated that R2 had an unsteady gait and was on this facility's falling list. When questioned reason why R2 would be on the facility's falling list if all of R2 fall risk assessments, dated 5/14, 7/10, and 9/11, note R2 is not at risk for falls, V12 responded that the fall risk assessment is done at the discretion of the nurse. When questioned if V12 reviews the resident's fall risk assessment for accuracy, V12 responded 'no'. R4's fall risk assessments were reviewed with V12; R4 is identified as not at risk for falls. When questioned why R4 does not have any fall risk assessments done from 10/8/2023 until R4 fell on [DATE], V12 responded she does not know. V12 stated that R4 is unable to stand. When questioned if the nurse is expected to check all that apply for the R4's gait/balance, V12 did not respond. When questioned if R4's fall risk assessments were accurate, V12 responded she does not know. R5's medical record notes R5 with admitting diagnoses including, but not limited to, multiple fractures - skull, ribs, cervical spine, history of falling, and high blood pressure. R5's only fall risk assessment was completed on admission on 3/6/2024. R6's medical record notes R6 with diagnoses including, but not limited to, high blood pressure, difficulty in walking, abnormal posture, and lack of coordination. R6's fall risk assessment, dated 10/8/24, notes no falls within the past three months. This assessment was completed post fall. It also notes R6 is not at risk for falls. R7's medical record notes R7 with diagnoses including, but not limited to, stroke with paralysis affecting right dominant side (primary diagnosis on 12/16/2021), seizure disorder, high blood pressure, Parkinson's disease, and history of falling. R7's only fall risk assessment since admission on 12/16/2021 was completed on 2/24/2022. This assessment notes R7 does not have any predisposing diseases, such as high blood pressure, stoke, seizures, or Parkinson's disease. A review of the facilities fall prevention program, revised 11/21/2027, notes a fall risk assessment will be performed by a licensed nurse at the time of admission. A fall risk assessment will be performed at least quarterly and after any fall.

Based on observation, interview and record review the facility failed to perform pressure ulcer dressing changes as ordered by the physician for 2 of 3 residents (R1 and R2) reviewed for pressure ulcers in the sample of 9. This failure resulted in R1 developing an infected right heel pressure wound. The findings include: 1. R1's Wound Assessment Report dated 2/4/24 shows that she admitted to the facility with an unstageable pressure ulcer on her right heel measuring 5.5 cm (centimeters) x 6.8 cm x 0.1 cm with light serosanguineous (pink thin fluid secreted from wounds in the healing process) drainage present. R1's Wound Physician note dated 4/17/24 shows that R1's right heel pressure ulcer was now a stage 4 pressure ulcer measuring 8.5 cm x 5 cm x 1.9 cm. R1's right heel pressure ulcer had heavy purulent (thick pus like drainage from an infection) drainage and the wound progress was not at goal. That same report shows that Metronidazole (antibiotic) 250 mg crushed and sprinkled on wound daily for odor was ordered on 4/3/24 for 30 days. R1's Right Heel Wound Culture Report collected 4/19/24 shows moderate growth of escherichia coli, proteus mirabilis and enterococcus faecalis. R1's Treatment Administration Record (TAR) for April shows an order dated 4/3/24-4/14/24 for: Right heel-Dakins 0.125%-cleanse area with NSS (normal saline), pat dry, pack with Dakins wet to moist gauze, cover with ABD pad, and wrap with kerlix twice daily or as needed. Every day and evening shift for wound care. R1's TAR for April and May show an order dated 4/14/24-5/13/24 for: Right heel-Dakins 0.125%-Cleanse area with NSS, pat dry, pack with Dakins wet to moist gauze, cover with ABD pad, and wrap with kerlix twice daily or as needed. Every day and night shift for wound care. R1's April and May TAR shows that these dressings were not performed on 4/5 (Friday (Fri) evening), 4/9 (Tuesday (Tues) evening), 4/13 (Saturday (Sat) evening), 4/14 (Sunday (Sun) day), 4/15 (Monday (Mon) night), 4/17, 4/18, 4/19 (Wed, Thurs, Fri night), 4/20, 4/21 (Sat/Sun day), 4/22, 4/23, 4/24, 4/25 (Mon-Thurs night), 4/27 (Sat day and night), 4/28, 4/29 (Sun/Mon day), 5/2, 5/3 (Thurs/Fri day), 5/5 (Sun day), 5/6 (Mon night), 5/8 (Thurs night), 5/11 (Sat night) and 5/12 (Sun day and night). On 6/28/24 at 2:02 PM, V11 said that he does not know why so many dressing changes were not signed off on R1's April and May TAR. V11 said that anytime a dressing is changed, it should be documented on the TAR. V11 said that R1's Hospice nurse would perform dressing changes when she visited R1. R1's Hospice Communication Log shows that the Hospice Nurse did not see R1 on any of the above days besides 5/3/24. On 6/28/24 at 12:26 PM, V2 (Director of Nursing) said that all treatments should be documented in the TAR when done. V2 said, If it was not documented, it was not done. On 6/28/24 at 2:28 PM, V12 (R1's Wound Physician) said R1 was receiving treatment for a wound odor and increased drainage of her heel pressure ulcer. V12 said that they did a culture of the wound and it came back showing an infection. V12 said that it is important to do dressing changes as ordered. V12 said that if dressing changes are not done, the wound could become infected. V12 said that if the wound already had an infection and they were not done, that could keep the bacteria in the wound and limit healing. R1's Care Plan show that she was on antibiotic therapy, Bactrim DS related to an infection of her right heel wound initiated on 4/16/24 with intervention to include: Wound treatment applied as ordered. The facility's Pressure Injury and Skin Condition Assessment Policy revised on 1/17/18 shows, Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration . 2. R2's Wound Assessment Report dated 3/28/24 shows that she admitted to the facility with an unstageable left trochanter pressure ulcer measuring 6 cm x 5.5 cm x 0.1 cm. On 6/28/24 at 10:35 AM, V11 performed a dressing change to R1's right hip pressure wound. V11 removed the dressing and there was a small open area on her right hip present. R1's May TAR shows an order dated 5/3/24-5/28/24 for: Left hip-collagen with silver/acetic acid 0.25%-cleanse area with acetic acid, pat dry, apply silver collagen sheet and cover with dry dressing every two days or as needed. Every day shift every 2 days for wound care. R2 did not receive a dressing change for 8 out of the 13 ordered dressing changes. R2's May TAR shows an order dated 5/30/24-6/13/24 for: Left hip- Collagen with silver-Cleanse area with acetic acid, pat dry, apply silver collagen and cover with dry dressing daily or as needed. R2 did not receive a dressing change for 7 out of the 13 ordered dressing changes. R2's June MAR shows an order starting 6/14/24 for: Left hip-Collagen-Cleanse area with acetic acid, pat dry, apply collagen sheet and cover with dry dressing daily or as needed. Every day shift for wound care. R2 did not receive 9 out of 15 ordered dressing changes. On 6/28/24 at 2:02 PM, V11 said that he does not know why so many dressing changes were not signed off on R2's May and June TAR. V11 said that anytime a dressing is changed, it should be documented on the TAR. On 6/28/24 at 12:26 PM, V2 (Director of Nursing) said that all treatments should be documented in the TAR when done. V2 said, If it was not documented, it was not done. The facility's Pressure Injury and Skin Condition Assessment Policy revised on 1/17/18 shows, Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration .

Based on observations, interviews and record reviews, the facility failed to protect a confused and vulnerable resident (R1) from being physically abused by a staff member and failed to follow their abuse policy by not preventing staff to resident physical abuse. This failure resulted in R1 obtaining facial injuries with noted scratches with active bleeding, swelling, pain and bruising that required the resident to be transferred emergently to a local hospital for further evaluation. Findings include: R1's face sheet indicated that resident admitted to the facility from an acute care hospital on 11/10/2023 and has a past medical history not limited to: Alzheimer's Disease, Seizures, Vascular Dementia, Psychosis, Difficulty in Walking, Lack of Coordination, Weakness, Abnormalities of Gait and Mobility, Malignant Neoplasm of Brain, Atrial Flutter, Cerebral Infarction, and History of Falling. R1's Minimum Data Set Section C dated 11/13/2023 documented a score of BIMS (brief interview for mental status score) of 11 which indicates some cognitive impairment. R1's care plan last reviewed 11/13/2023 reads in part: use antidepressant medication (amitriptyline) related to Depression (11/20/2023); alteration in neurological status related to disease processes of Alzheimer's Disease and Vascular Dementia (11/20/2023); feelings of sadness, emptiness, anxiety, uneasiness, depression characterized by: ineffective coping, low self-esteem, tearfulness, motor agitation, withdrawal from care/activities related to brain deterioration, dependence, relocation, recent admission to long term care, decline in visits from family, decline in health (12/01/2023); given my poor and compromised health status, cognitive issues, physical decline and need for 24-hour care, the Inter-Disciplinary Team (IDT) recognizes that I am considered a vulnerable adult. Comprehensive assessment reveals a history of suspected abuse, neglect, exploitation and/or additional factors that may increase my susceptibility to abuse/neglect related to diagnosis of Dementia (12/01/2023). R1's active physician orders reads in part: Aripiprazole Oral Tablet 5 milligrams (mg) give 1 tablet by mouth one time a day for Anxiety; Amitriptyline HCl Tablet 75mg give 1 tablet by mouth at bedtime for depression; Apixaban Oral Tablet 2.5mg give 1 tablet by mouth two times a day for prevent blood clots. R1's behavior note dated 11/30/2023 04:43 documented verbal and physical aggression with no documentation of a physical altercation or of any noted injuries. R1's nursing progress note dated 11/30/2023 08:50 indicated resident was sent to local hospital for further evaluation and assessment. Reason for evaluation and assessment was not indicated, no documentation of a physical altercation, any noted injuries, or provided first aid was noted. R1's hospital records dated 11/30 2023 indicated resident was seen for contusion/abrasion of face and documented no fractures were found with hematoma (bruise) to left periorbital (eye) and left mandibular (jaw) soft tissues. R1's facility reported incident report dated 11/30/2023 indicated R1 stated that V5 (Certified Nursing Assistant) allegedly touched his face who was suspended pending investigation of physical abuse. Police report #23-02658. Fire department report #23-3147. On 12/01/2023, facility provided V5's statement dated 11/30/2023 that reads in part: while approaching R1's bed to try and calm him down, R1 kicked V5 in the stomach. V5 then said she grabbed R1's feet to help put the back into bed when R1 tried to hit her and had punched her breast. V5 added that she was trying to cover herself with her hands to keep space between her and R1 when another staff member came in between her and R1 and took V5 out of the room. Also provided was V7's (Licensed Practical Nurse) statement dated 11/30/2023 which indicated V7 was providing care to R1's roommate with the privacy curtain pulled when she heard R1 start yelling. V7 said she then went around the curtain and saw R1 kicking V5 (Certified Nursing Assistant) and proceeded to take her out of the room. On 12/01/2023 at 11:09 AM, observed three small scratches that were scabbed to the left side of R1's face, near the end of his corner eyebrow area, small light purple colored bruise below scabbed areas, and red scratch to R1's right cheek that was approximately three inches in length. When asked how the facial injuries occurred, R1 said I got the sh*t kicked out of me by a little girl. R1 continued to state that he didn't recall the date of the incident, but said it happened a few days ago. R1 then said on that night, he was lying in bed when she (V5) came over to me and smacked me on my head with her hand. R1 added that he was struck to the head and face a few times. R1 then showed surveyor purple colored bruising to his left side/rib area and to his left lower back/flank area but said he could not recall how these injuries had occurred. R1 informed surveyor that he has had a few falls while transferring himself since coming to this facility. R1's abuse/neglect screen dated 12/01/2023 12:02 documented a score of 7 which indicated resident is at a high risk for abuse (Time stamp indicates assessment was completed during and not prior to this complaint investigation). No other abuse/neglect screening was found in R1's electronic medical record. On 12/01/2023 at 12:05 PM and 12:13 PM, attempted to call V5 (Certified Nursing Assistant) with no answer at either attempt, message left. On 12/02/2023 at 12:43 PM, attempted to call V5 but was unsuccessful. On 12/01/2023 at 12:54 PM, V1 (Administrator) said R1 reported being smacked by a small lady then said the alleged incident occurred on third shift, so by the process of elimination from R1's description, V5 was identified as the alleged perpetrator and was suspended pending outcome of the facility's investigation. V1 also added that she has been trying to contact V5 but was unable to reach her, then said that she thinks V5 is scared. On 12/01/2023 at 1:56 PM V8 (Certified Nursing Assistant) said incident happened Wednesday night into Thursday morning (11/29-11/30/23) at approximately 2:30 AM. V8 then said that during rounds, V7 (LPN) asked her and V5 (CNA) for assistance with R1's roommate when R1, who was lying in bed, started to yell out is there a party in here. V7 added that V5 had left the room to get more supplies while she went to the other side of room with V7 with the privacy curtain pulled around resident's bed. V8 said she then heard R1 yelling out racial slurs that was coming from the other side of curtain, so she didn't know where V5 was in the room or what she was doing. V8 then said she started hearing a commotion that sounded like an altercation, so she came from behind the curtain and saw R1 sitting on the edge of the bed and V5 was standing in front of him. She added that she saw R1 kicking V5 to her stomach area while V5 was pushing R1's legs away from her with her hands trying to stop R1 from kicking her. V8 added that she saw bleeding to the top of R1's left face, by his eyebrow and a scratch to his cheek on the right side of his face. V8 continued saying that V8 then came around from behind the curtain and told V5 to get out of the room then V7 assessed R1. V8 added that a few minutes later, V7 left out of R1's room and told V5 she had to leave the facility and needed to call 911 and file an incident report. During review of V8's (CNA) statement, she recalled R1 yelling out stop multiple times and heard V5 (CNA) who sounded angered saying stop it, don't put your feet on me. V8 (Certified Nursing Assistant) also said that she did not know how R1 obtained the injuries to his face, doesn't recall if they were present upon entering the room but is certain that R1 was not bleeding when she entered the room, and the injuries were not self-inflicted. V8 added that she has worked with V5 frequently but had never seen anything like this before. On 12/01/2023 at 2:40 PM, V7 (Licensed Practical Nurse) said on Thursday (11/30/2023) between 3:00-3:30 AM, she went into R1's room to provide care to R1's roommate with the assistance of V8 (CNA) and the privacy curtain was pulled all the way around the bed. She added that V5 was not in the room initially, she came into the room later. V7 then said they started to hear R1 yelling out something about is this a party, then started yelling out profanities and racial slurs and when she came around the curtain, R1 was sitting on the edge of the bed facing the door and told V7 that he kicked and slapped her, then said that she slapped me back. V7 added that she saw some bleeding near the corner of R1's left eye above the eyebrow and a red mark on his right upper cheek so she started to assess R1 and tried to stop the bleeding but R1 was resistive. She said after a few minutes, she had stepped out of R1's room, headed down the hall and told V5 that she had to leave the building. V7 then said she informed the physician of R1's bleeding and wanted to send resident out to the hospital because he is on blood thinners, but he was refusing to go. During review of V7's (LPN) statement, she then said the bleeding was to the opposite eye, and the scratch was to the opposite side of R1's face then previously stated. V7 then said at no time did she see any physical contact (which is a contradiction of her previous statement made on 11/30/2023), and the bleeding looked like old blood because it was dark. On 12/02/2023 at 12:08 PM, V1 (Administrator) said she wasn't sure if abuse screens were to be completed upon admission, but she knows they are done quarterly. At 12:11 PM, V1 said she believes the abuse screens are done upon admission but will have to check with social services. At 12:28 PM, V1 said the screenings are done quarterly with no start date given and as needed with a new diagnosis or data. V1 then said the facility was not fully aware of R1's medial/behavioral/trauma history until recently being informed by resident's family. V1 provided pre-admission behavior notes dated 11/02 and 11/03/2023 for surveyor to review. On 12/02/2023 at 12:16 PM, R1 said regarding the incident with V5 that he was lying in bed when she came into his room, started saying nasty stuff and cursing to him, came to his bedside then smacked the left side of my face (R1 pointed to injuries to corner of left eye previously observed by surveyor). R1 said he then sat up on the side of the bed when V5 started to come near him again and stated that he had kicked V5 to her chest area. R1 said that V5 then hit him to his left jaw area (displayed facial grimacing while touching area of contact). R1 added that she got me good then said he had pain and swelling to the area after it happened. Mild swelling was observed to R1's left jaw area but unable to visualize any bruising due to the presence of a thick beard. On 12/02/2023 at 12:56 PM, V1 (Administrator) and V2 (Director of Nursing) were both present and stated that the nurse who assessed R1 post fall on 11/29 at 10:10 did not fully assess or document post fall injuries/findings then said R1 was sent to the emergency room for further evaluation of the bruising he sustained from the fall. V2 then said injuries could appear on a resident days later after falling. R1's physician note created by V9 (Medical Doctor) on 12/2/2023 14:11:45 that was time stamped for 11/30/2023 14:11 reads in part, I was contacted by [registered nurse] overnight about [patient] having skin lesion to side of eye, and patient was refusing to go to [emergency room ] for eval. Etiology of injury was vague. This AM, I came to eval [patient], he has mild skin abrasions on right and left side of eye, and upon further inspection with [registered nurse] at bedside, he has bruising on his wrist and torso. Per [registered nurse] management, [patient] had a fall overnight. [Patient] also did report he had some sort of altercation with a staff member, although recollection is vague given his sundowning. I instructed [registered nurse] management to send [patient] to [emergency room ] for further evaluation and investigate the patient's claims. Facility provided fall documentation dated 11/29/2023 which indicated no injuries. Facility provided conflicting witness statements dated 11/29/2023 from three staff members with two statements indicating noted bruising post fall to R1's back, and one statement that indicated scratches to R1's face. No other documentation from direct care staff indicating R1 sustained any injuries, no documentation noted indicating staff were monitoring R1's bruising and/or facial injuries until 48 status post fall. Abuse Prevention and Reporting policy last revised 10/24/2022 reads in part: Guidelines: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment (page 1). Definitions: Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment (page 2). Resident Assessment: As part of the resident's life history on the admission statement, comprehensive care plans, and Material Data Set (MDS) assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have needs, triggers, and behaviors that might lead to conflict (page 7).

Based on interview and record review, the facility failed to immediately inform a physician of abnormal labs prior to a resident's change of condition of 4/03/2023 for one of thirty residents (R3) in the sample. This failure resulted in R3 having to be hospitalized due to acute hypoxemic respiratory failure, seizures, and hypernatremia. Findings Include: R3 is a [AGE] year old female who was originally admitted to the building on 7/26/2012 and still currently resides in the facility. R3 has multiple diagnoses including but not limited to the following: epilepsy, vitamin D deficiency, multiple sclerosis, severe protein calorie malnutrition, dementia, hypernatremia, hypokalemia, pressure inducted deep tissue damage, and gastrostomy. Facility lab report dated 4/3/23 shows in part but not limited to the following: blood urea nitrogen (BUN): 30 (High) and Sodium (Na): 157 mEq/L (Critically High). Facility progress note dated 4/5/23 states in part but not limited to the following: R3 was observed during rounds with twitching of the face. R3 was not responding, skin was clammy, and face was twitching. Resident was placed on a non-rebreather, 911 was called, and R3 was taken to the emergency room . Per hospital records dated 4/11/23 show in part but not limited to the following: Principal problem: acute hypoxemic respiratory failure; active problems: altered mental status, seizures, AFib, hypernatremia, and lactic acidosis. New onset seizure activity, fever, currently AFib, sepsis due to bacteremia, acute hypoxic respiratory failure 2/2 seizures, hypernatremia was 163 mEq/L upon admit. On 6/13/23 at 12:15PM, V17 (Licensed Practical Nurse) was interviewed regarding R3's incident on 4/5/23 and care. V17 said on 4/5/23, I was doing medication pass and the wound team were doing rounds. They went into R3's room and they called me into the room. I observed R3's face twitching, her skin was clammy, and she was not responding to any stimuli. We sent her out via 911. I was working the day before and nothing out of the ordinary was noted, she was fine. The labs taken on 4/3/23 may have been routine labs, I do not remember anything out of the ordinary happening with R3 prior to 4/5/23. Per facility progress note dated 4/3/23 states in part but not limited to the following: labs relayed to V16 (Nurse Practitioner), awaiting orders. On 6/13/23 at 1:46PM, V16 was interviewed regarding R3's care and recent hospitalization . V16 said right now I cover majority of the residents in the building if they are having any acute changes, however I only work on Tuesday's and Friday's. I was made aware of R3's incident after she was sent to the hospital. I looked back at my phone today and it does look as if V17 messaged me regarding R3's lab results but I do not remember. I was not working on 4/3/23 so I do not remember seeing this message. However, I definitely would have ordered something if I was made aware. I typically always provide treatment when a resident's sodium is over 150 mEq/L. I would have increased her free water flushes since she is on a gastric tube and do labs the next day. If the lab was still high the following day, I would send the resident out. High sodium levels can be an indicator of dehydration and can also cause seizures. It is to be noted that R3's physician order sheet shows no new orders put in place between 4/3/23 and on 4/5/23 when R3 was sent to the hospital. On 6/14/23 at 2:05PM, V1 (Administrator) was interviewed regarding nursing expectations for residents who are experiencing a change of condition. V1 said it is expected that the nurse reach out to the resident's primary physician, nurse practitioner, or medical director. If they do not hear back from anyone, they are to report it to the oncoming nurse before leaving their shift. They should be continually following up to ensure the appropriate parties are aware. Per facility policy titled Assessment of Resident with revision date of 4/18/22 states in part but not limited to the following: Purpose: To gather comprehensive information as a basis for identifying resident problems/needs and developing or revising an individual plan of care. Guidelines: 8. If reassessing resident, review progress notes, physician's orders and progress notes, weights, intake/output records, laboratory test results, resident's response to current treatments. 10. Notify the attending physician or significant findings and request necessary change in orders. Accordint to the National Institutes of Health: The most serious complication of hypernatremia is subarachnoid or subdural hemorrhage due to the rupture of bridging veins and [NAME] sinus thrombosis. It can lead to permanent brain damage or death. Rapid correction of chronic hypernatremia causes cerebral edema, seizure, and permanent brain damage. Sonani B, Naganathan S, Al-Dhahir MA. Hypernatremia. [Updated 2023 May 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441960/

Based on observation, interview, and record review, the facility failed to prevent residents from developing facility acquired pressure ulcers who were admitted with no previous skin alterations and are totally dependent on staff for care and repositioning. This failure applied to two (R17 and R27) of three residents reviewed for pressure ulcers and resulted in R17 developing an infected wound to her right second toe that required treatment with oral and topical antibiotics, as well as a Stage 2 pressure ulcer to her coccyx and an unstageable pressure ulcer to right ischial tuberosity; R27 developed a Stage 3 pressure ulcer on the coccyx. Findings include: R17 is a [AGE] year-old female who has resided at the facility since 12/26/2021 with past medical history including, but not limited to Dementia, major depressive disorder, weakness, other abnormalities of gait and balance, altered mental status, etc. 8/01/2022 at 11:05 AM, R17 was observed in her room sleeping and unable to wake or respond to her name. At 2:15PM, R17 was still in her bed in the same position, a floor mat was noted at the bedside, room unorganized with some garbage noted on the floor, resident was not wearing any heel protectors and no wedges were noted on the bed. 8/2/2022 at 9:52AM, R17 was observed lying-in bed, still not able to respond to any questions or open her eyes or answer any questions, again no heel protectors or wedges noted. Progress note documented by V19 (RN/wound care) reads as follows: 08/02/22 1:33 PM Wound Care: Weekly wound rounds performed by writer. During wound rounds, resident noted with open area to R (right) 2nd toe. Area cleansed w/normal saline and protective dressing applied. Area appears reddened with small amount of purulent drainage coming from wound noted. Wound MD at bedside. Resident seen and treated by Wound Care MD. Wound care orders obtained from Wound MD. Oral and topical antibiotic ordered to treat infection to R 2nd toe. Resident to start 14-day course of [MEDICATION(S)] 100mg bid and [MEDICATION(S)] topical to be applied to area bid x 14 days. Labs ordered with (company name). Protective and preventive measures to be put in place including, but not limited to, air mattress, frequent repositioning, and incontinence program, offloading, and nutritional supplements. Progress note documented on 7/08/2022 by V19 reads; Weekly wound rounds performed by writer. During wound rounds, resident noted with pressure area to Right Ischium. Area cleansed w/normal saline and protective dressing applied. Spoke with daughter, (Legal Guardian) to make aware. Unit nurse made aware. Wound Care consult in place. Wound Care Md in facility during wound rounds and consult performed. Wound care orders obtained from Wound MD. Labs and supplements ordered. Protective and preventive measures to be put in place including, but not limited to, air mattress, frequent repositioning, and incontinence program, offloading, and nutritional supplements. Review of wound list provided by V3 (DON) showed that R17 has a stage 2 pressure ulcer to her coccyx and an unstageable pressure ulcer to right ischial tuberosity (the lowest of the three major bones that make up each half of the pelvis) both wounds are facility acquired. Braden observation dated 5/13/2022 scored R17 as 13 (moderate risk) for skin breakdown. Admission charting dated 4/22/2022 indicated that R17 has no skin or wound concerns. Care plan initiated 12/23/2018 and revised 8/03/2022 stated that resident has potential impairment to skin integrity due to incontinence, fragile skin, and impaired mobility. Interventions include, but not limited to encourage and assist with offloading pressure from bilateral heels while in bed, encourage and assist with turning and repositioning at regular intervals every shift. Wound care assessment detail report dated 7/8/2022 indicated that R17 has an unstageable pressure ulceration to her ischial tuberosity identified on 7/8/2022, measuring 3.70 x 2.30 x unknown (L x W x D), area 8.51cm and unknown volume. R27 is a [AGE] year-old female who has resided at the facility since 04/2021, with medical history including, but not limited to [CONDITION(S)], hypertensive chronic disease, dementia, abnormal posture, weakness, contracture of left knee and right wrist, etc. 8/01/2022 at 11:48AM, R27 was observed in her bed, awake but non-verbal and could not answer any interview questions. At 2:10PM, resident was observed lying in the same position as earlier and still non -verbal, no heel boot or wedges noted on the bed. 8/2/2022 at 10:30AM, resident was observed during wound care, awake and alert but did not respond to any questions. 8/02/22 at 10:30AM observed wound care for R27 with V19 (RN) who stated that resident has a stage 3 pressure ulcer that is facility acquired. Observed a large area of healed area in the resident's bottom (coccyx) and an area of fresh wounds that is about a quarter size. V19 said that the wound was facility acquired. Per record review, R27 was readmitted to the facility on ,d+[DATE], Braden score assessment dated [DATE] scored resident with a score of 9, very high risk for alteration in skin integrity. Admission assessment dated [DATE] did not document any skin concerns. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Care plan initiated 11/18/2021 states to assess and record changes in skin status. Facility Minimum Data Assessment (M D S) dated 5/5/2022 coded R27 in section C Cognition) with a BIMS score of 3, section G (Functional) coded R27 as dependent on staff for all ADL activities, and total dependence with 2 staff physical assist for toileting. Resident developed a stage 3 facility acquired pressure ulcer identified as documented in wound note dated 7/20/2022, measuring 1.70x 2.00x 0.50 (LxWxD), area of 3.40cm and volume of 1.70cm. Wound care note dated 8/2/2022 shows a Braden score of 10 (High risk), clinical stage of wound still a stage 3, measuring 2.80 X 2.00 X 0.30 (LxWxD). Area of 5.60cm and volume of 1.68cm. 8/3/2022 at 2:13PM, V3 (DON) said that the admitting nurses do the initial skin assessment to see if residents have any wound or skin issues, Braden score is part of the admission assessment to determine if residents are prone to skin breakdown, those identified at risk have care plan in place, with interventions like air loss mattress, offloading and turning and repositioning. Skin conditions should be identified during ADL care or weekly skin checks and any type of impairment like redness should be reported to the nurse or the wound team. A facility policy presented by V3 (DON) titled pressure ulcer prevention, with a revision date of 1/15/18, states as its purpose; to prevent and treat pressure sores/pressure injury. Under guidelines, the document states in part; to maintain clean/dry skin during daily hygiene, inspect the skin several times daily during bathing, hygiene, and repositioning measures, may use lotion on dry skin. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protecting bony prominences as indicated.

Based on observation, interviews and record reviews, the facility failed to prevent further decline of a contracture in the hand related to the use of splint and therpy carrot for one resident (R7) of one resident reviewed for restorative program. This deficiency resulted in R7's contracture of the left hand deteriorating from moderate to a severe contracture. Findings include: R7 is a [AGE] year-old male, originally admitted in the facility on 10/02/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/01/2022 at 11:30 AM, R7 was observed in bed, awake, has trouble speaking and unable to verbalize needs. His left elbow was observed stiff and flexed. His left hand/wrist was also stiff, clenched into a fist and the fingers were curled inward. No splint or therapy carrot was in his left hand were observed. V28 (Family Member) came for a visit and stated, He's (R7) been a resident here since October 2018. He had a severe stroke on his left side. The only concern is his left hand, it is clenched, unable to open it. I want to ask for any orders to treat his left hand. R7's POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Splints: Left hand in orange carrot for four to six hours daily as tolerated. Left hand and elbow extension splint for four to five hours as tolerated. Watch for redness, skin breakdown or pain, discontinue use and notify nursing and therapy. On 08/02/22 at 10:00 AM, R7 was observed in bed. No splint or therapy carrot were observed on his hand. On 08/02/22 at 10:15 AM, V4 (Restorative Nurse) was asked regarding R7's restorative program. V4 replied, He has a left hand contracture. He has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Instead, we are putting the carrot in his left hand. Several months ago, we used to put a splint, restorative does it but it was discontinued. He still uses the carrot. V5 (Restorative Certified Nurse Aide, CNA) is placing it every day. The carrot is stored in our office. There was no documentation in the medical record or physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V5 (Restorative CNA) was asked regarding application of the carrot in R7's left hand on 08/02/22 at 10:25 AM. V5 stated, The application of this carrot stick is still ongoing, we put it in the morning and sometimes in the afternoon and it stays for two to four hours. It was placed on his hand last Friday (07/29/2022). I am responsible for the application and removal of it when done. If I am not here, then he is not going to have the carrot placed in his hand. I did not place it last Saturday and Sunday because I was off and yesterday I worked on the floor. We're short of staff. There is a log that I have to sign with time duration in minutes that I put the carrot in his left hand. At 10:45 AM, surveyor asked V5 to show how the therapy carrot is placed in R7's left hand. V5 cleaned his left hand with wipes and carefully inserted the therapy carrot. It was observed that his hand and fingers were very stiff and difficult to stretch. Gradually, V5 was able to insert the carrot. V5 verbalized, It stays for two to four hours, most of the time, only two hours. R7's Care Plan, date initiated 10/25/21 regarding left hand and elbow splint/therapy carrot, documented in part: Interventions: Establish wearing schedule: four to six hours as tolerated. 08/02/22 at 11:35 AM, V4 (Restorative Nurse) was asked regarding R7's hand contracture. V4 verbalized, We used to have a Restorative Nurse but they left, don't know exactly the date. Since then, the facility doesn't have a Restorative Nurse. I started doing the Restorative notes last 04/20/22. His left hand and fingers could still be moved, the degree of contracture was moderate at 50% of normal. My assessment last month which I dated 08/02/2022, the left hand contracture was so severe, less than 50% of normal. He cannot open his fingers and move his wrist. It declined because the splint and the carrot was not continuously applied. He was referred for Occupational Therapy. R7's Restorative Observation Notes documented the following: 04/11/22: Splint program B. Contracture screen - left elbow: 3. Moderate 50% of normal; left hand/fingers: 3. moderate 50% of normal 07/29/22: Splint program B. Contracture screen - left elbow: 4. Severe <50% of normal; left hand/fingers: 4. severe <50% of normal OT daily treatment note dated 10/15/2021 reads: Elbow extension improved with elbow extension brace for LUE (left upper extremity). Patient displays increased active range of motion left hand. Continue with restorative nursing. R7's Restorative logs for the splint and therapy carrot administration indicated the following: May 2022: no documentation on 05/04; 05/05; 05/09; 05/10; 05/12; 05/13; 05/14; 05/15; 05/18; 05/20; 05/21; 05/26; 05/27 and 05/30. June 2022: no documentation on 06/01 to 06/10; 06/12 to 06/15; 06/17 to 06/20; 06/22; 06/25 to 06/29. July 2022: splint program for left hand and elbow as ordered for four to six hours for six to seven times per week as tolerated. Gentle ROM to BUE (bilateral upper extremity) and place orange carrot in left hand or elbow extension splint to LUE as tolerated. There was no documentation on 07/03; 07/07; 07/08; 07/11; 07/12; 07/13; 07/16; 07/17; 07/22; 07/23; 07/24; 07/26; 07/28; 07/29; 07/30 and 07/31. R7's restorative logs dated May to July 2022 indicated that splint and therapy carrot were not applied daily as ordered. 08/02/2022 at 3:46 PM, V20 (Occupational Therapist) was interviewed regarding R7's therapy evaluation. V20 stated, I did the evaluation on his left hand on 07/28/2022. He had a left hand contracture. He was not able to actively do it by himself with the whole upper left extremity. It had to be passive range of motion. The orange carrot helps to stretch the hand and that would hopefully reduce the contracture. The splint also reduces the contracture and prevent further decline or deformity of the hand. OT evaluation and plan of treatment dated 07/28/2022 reads: Musculoskeletal System Assessment LUE ROM (range of motion): elbow/forearm-impaired; wrist-impaired; hand-impaired; thumb-impaired; index finger-impaired; middle finger-impaired; ring finger-impaired; little finger-impaired AROM (Active Range of Motion) - Left wrist: flexion, severe LUE contractures, allows for minimal PROM (Passive Range of Motion); extension, severe LUE contractures, allows for minimal PROM 08/03/22 at 9:52 AM, V21 (Physician) was interviewed regarding R7 and contracture. V21 stated, He is my patient. I've been taking care of him for a long time. He has a history of stroke, had a right sided [CONDITION(S)] ([CONDITION(S)], stroke) and left [CONDITION(S)] (paralysis, weakness), and a contracted left hand. His fingers can't be moved and are always contracted. If I give an order, it should be followed. Splints and the carrot help prevent further decline in the contracture of the left hand. 08/03/22 at 11:51 AM, V3 (Director of Nursing) stated, Restorative Aides are the ones applying the splints or carrot sticks. If restorative nurse and aides are not here, the nurses on the floor are trained to apply the devices. The splints/braces should be kept at bedside. Splints/carrot prevents further contracture. In the log, if it is not documented, it is not done, maybe staff forgot about it but it should be documented. Facility's policy titled, Restorative Nursing Program, revision date 1-4-19 stated in part but not limited to the following: Purpose: To promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. Includes, but is not limited to, programs in walking/mobility, dressing and grooming, eating and swallowing, transferring, bed mobility, communication, splint or brace assistance, amputation care and continence programs.

Based on observation, interview, and record review, the facility failed to carry out physician's orders related to the use of a hand splint and therapy carrot (Splints/carrot prevents further contracture) for one (R7) of one resident reviewed for restorative nursing. This failure resulted in R7's left hand contracture deteriorating from moderate to severe contracture. Findings include: R7 is a [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/01/2022 at 11:30 AM, R7 was observed in bed, awake, has trouble speaking and unable to verbalize needs. His left elbow was observed stiff and flexed. His left hand/wrist was also stiff, clenched into a fist and the fingers are curled inward. No splint or therapy carrot (positions the fingers away from the palm to protect the skin from excessive moisture, or further contracture) on his left hand was observed applied. V28 (Family Member) came for a visit and stated, He's (R7) been a resident here since October 2018. He had severe stroke on his left side. The only concern is his left hand, it is clenched, unable to open it. I want to ask for any orders to treat his left hand. R7's POS (Physician Order Sheet) dated 10/20/21 documented: Splints: Left hand in orange carrot for four to six hours daily as tolerated. Left hand and elbow extension splint for four to five hours as tolerated. Watch for redness, skin breakdown or pain, discontinue use and notify nursing and therapy. On 08/02/22 at 10:00 AM, R7 was observed in bed. No splint or therapy carrot were observed on his left hand. On 08/02/22 at 10:15 AM, V4 (Restorative Nurse) was asked regarding R7's restorative program. V4 replied, He has a left hand contracture. He has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Instead, we are putting the carrot in his left hand. Several months ago, we used to put a splint, restorative does it but it was discontinued. He still uses the therapy carrot. V5 (Restorative Certified Nurse Aide, CNA) is putting it every day. The carrot is stored in our office. There was no documentation in the medical record or physician orders confirming that splint for the left hand was discontinued. V5 (Restorative CNA) was asked regarding application of the carrot in R7's left hand on 08/02/22 at 10:25 AM. V5 stated, The application of the carrot stick is still ongoing, we put it in the morning and sometimes in the afternoon and it stays for two to four hours. It was placed in his hand last Friday (07/29/2022). I am responsible for the application and removal of it when done. If I am not here, then he is not going to have the carrot in his hand. I did not place it last Saturday and Sunday because I was off and yesterday I worked on the floor. We're short of staff. There is a log that I have to sign with time duration in minutes that I put the carrot in his left hand. In an interview conducted on 08/02/22 at 11:35 AM, V4 (Restorative Nurse) was asked regarding R7's left hand contracture. V4 verbalized, We used to have a Restorative Nurse but that person left, don't know exactly the date. Since then, the facility doesn't have any Restorative Nurse or Aide. I started doing the Restorative notes last 04/20/22. His left hand and fingers could still be moved, the degree of contracture was moderate at 50% normal. My assessment last month which I dated 08/02/2022, the left hand contracture was so severe, less than 50% of normal. He cannot open his fingers and move his wrist. It declined because the splint and the carrot were not continuously applied. R7's Restorative Observation Notes documented the following: 04/11/22: Splint program B. Contracture screen - left elbow: 3. Moderate 50% of normal; left hand/fingers: 3. moderate 50% of normal 07/29/22: Splint program B. Contracture screen - left elbow: 4. Severe <50% of normal; left hand/fingers: 4. severe <50% of normal OT daily treatment note dated 10/15/2021 reads: Elbow extension improved with elbow extension brace for LUE (left upper extremity). Patient displays increased active range of motion left hand. Continue with restorative nursing. OT evaluation and plan of treatment dated 07/28/2022 reads: Musculoskeletal System Assessment LUE ROM (range of motion): elbow/forearm-impaired; wrist-impaired; hand-impaired; thumb-impaired; index finger-impaired; middle finger-impaired; ring finger-impaired; little finger-impaired AROM (Active Range of Motion) - Left wrist: flexion, severe LUE contractures, allows for minimal PROM (Passive Range of Motion); extension, severe LUE contractures, allows for minimal PROM R7's Restorative logs for the splint and therapy carrot administration indicated the following: May 2022: no documentation on 05/04; 05/05; 05/09; 05/10; 05/12; 05/13; 05/14; 05/15; 05/18; 05/20; 05/21; 05/26; 05/27 and 05/30. June 2022: no documentation on 06/01 to 06/10; 06/12 to 06/15; 06/17 to 06/20; 06/22; 06/25 to 06/29. July 2022: splint program for left hand and elbow as ordered for four to six hours for six to seven times per week as tolerated. Gentle ROM to BUE (bilateral upper extremity) and place orange carrot in left hand or elbow extension splint to LUE as tolerated. No documentation on 07/03; 07/07; 07/08; 07/11; 07/12; 07/13; 07/16; 07/17; 07/22; 07/23; 07/24; 07/26; 07/28; 07/29; 07/30 and 07/31. R7's restorative logs dated May to July 2022 indicated that splint and therapy carrot were not applied daily as ordered. R7's Care Plan, date initiated 10/25/21 regarding the left hand and elbow splint/ therapy carrot, documented in part: Interventions: Establish wearing schedule: four to six hours as tolerated. On 08/03/22 at 09:52 AM, V21 (Physician) was interviewed regarding R7 and contracture. V21 stated, He is my patient. I've been taking care of R7 for a long time. R7 has a history of stroke, R7 had a right sided [CONDITION(S)] ([CONDITION(S)], stroke) and has left [CONDITION(S)] (left sided weakness, paralysis), and a contracted left hand. His fingers can't be moved and are always contracted. If I give an order, it should be followed. Splints and the carrot help in preventing further decline in the contracture of the left hand. 08/03/22 at 11:51 AM, V3 (Director of Nursing) stated, If there is an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Doctors' orders should be followed per the resident's plan of care. Splints/carrot prevents further contracture. In the log, if it is not documented, it is not done, maybe staff forgot about it but it should be documented. Facility presented policy titled Physician Orders - Entering and Processing revision date 1-31-18 when requested. The policy does not specifically address guidelines in following doctors' orders for restorative program.

Based on observation, interview and record review the facility failed follow their policy and monitor for abnormal lab levels, failed to notify physician of unresolved changes in condition and failed to administer medication as ordered for 2 of 3 (R3, R50) residents reviewed for physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Findings Included: 1. On 3/17/22 at 9:22am V26 (R3 POA) said R3 was not given her [MEDICATION(S)] medication and R3's ammonia levels (indicator of liver function) were not monitored at the facility. V26 said she called the facility to enquire about R3's general health and was told by V20 (Nurse) that R3 was lethargic and needed to be sent to the hospital for further care. V26 told V20 that R3 would respond like that if R3's ammonia levels were high. V26 said she asked V20, if R3 was given her [MEDICATION(S)] medication and V20 responded in a manner as if she was not aware that R3 was taking [MEDICATION(S)]. V26 asked V20 if the facility checked R3's ammonia levels and V20 replied no. V26 said R3 had to be intubated at the hospital due being unresponsive because of the ammonia levels was so high. V26 said R3 has since recovered, but she has concerns about the care that R3 received at the nursing home. On 3/17/22 at 9:30AM R3 said she was sent to the nursing home for rehab and because she was having issues with her liver. R3 said her memory has not been the best since the hospital stay, and she cannot say for sure if she was getting all her medications at the nursing home. R3's progress notes dated 2/2/22 shows in part resident unresponsive to pain, sternal rub done. bp (blood pressure) 135/74; hr (heart rate) 81; rr (respirations) 21; temp 97.8, o2 sat 95 at room air. rbs (random blood sugar) 300; MD informed. ordered to send to hospital and start IVF therapy; called 911. IV started 0.9 NaCl @ 100ml/hr. On 3/17/22 at 11:04am V20 (Nurse) said she was the nurse that originally contacted V20 when R1 was not herself on 1/30/22, R3 was lethargic, staff had to feed R3 and R3 was a resident that would eat independently. V20 said the physician gave orders for labs to be drawn, she remembers following up with the physician after the labs, but she is not sure if there were orders. V20 said R3 continued to be lethargic for 3 to 4 more days, and then R3 became unresponsive. V20 said on the days that R3 remained lethargic she did not contact the physician and she didn't have a reason as to why. V20 said she remembers doing a sternal rub but R3 would not respond. V20 said she did call the physician when R3 was unresponsive on 2/2/22, and orders were given to send R3 out to local hospital. V20 said she should have contacted the doctor when R3 continued to be lethargic. V20 said she did not review R3's clinical background or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V20 said she was not aware of R3's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V20 said she did not review R3's clinical records before she contacted the physician. On 3/17/22 at 12:00pm V27 (Physician) said he was notified of R3's change in mental status on 1/30/22 and he ordered CMP, CBC, and urine analysis to rule out a urinary tract infection and R3's urine looked dark. V27 said after receiving the lab report back he ordered intravenous fluids for R3 for hydration. V27 said his partner saw R3 on 1/31/22 for follow up. V27 said he did not receive any follow up calls from the facility on 2/1/22 when R3 continued to experience lethargy. V27 said if he would have been made aware, he would have sent R3 to local hospital for further care on 2/1/22. V27 said R3 has complex medical conditions, and when the ammonia levels are high the resident's condition can change quickly. V27 said he should have been made aware if R3 continued to experience a change in mental status. R3's hospital records dated 2/2/22 shows in-part patient presents with altered mental status, patient is 67y/o female with PMH (past medical history) of [CONDITION(S)] (hypertension), DM (Diabetes) and [CONDITION(S)] presented to the ED via EMS from the nursing home with worsening AMS (altered mental status). On arrival to Ed pt. (patient) was intubated. Ammonia level 198 mcmol\L, CXR (chest Xray) no acute process patient admitted to ICU for further evaluation. Facility policy Titled Physician -Family Notification- change in condition dated 10/1/2015 with revision date of 11/13/18 shows in-part to ensure that the medical care problems are communicated to the attending physician or authorized designee and family/ responsible party in timely, efficient, and effective manner. The facility will inform the resident, consult with the resident physician or authorized designee such as Nurse Practitioner, and if known, notify the resident legal representative or an interested family member when there is a significant change in the resident physical, mental, or psychosocial, status (deterioration in health, mental, or psychological status in either life threatening conditions or clinical complications), condition. On 3/18/22 at 2:56pm V2 (Director of Nursing) said the physician should be notified when the resident is experiencing a change in condition and when the change in condition does not resolve with treatment. V2 said the nurse should complete an assessment and review the resident history, and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. R5's face sheet shows R5 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/18/22 at 10:00am V2 said [MEDICATION(S)] is not a [CONDITION(S)], the medication is used for [CONDITION(S)]. R5's MAR-(Medication Administration record) dated January 2022 shows on March 12, 2022 an empty box, no initials showing that the medication was administered. February 2022 shows on February 23, 2022 an empty box, no initials showing that the medication was administered. On 3/18/22 at 2:56pm V2 DON (Director of Nursing) said when the nurse administers a medication the nurse should document on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 said if it's not documented then it was not given. Facility policy Titled Medication Administration general guidelines no date noted shows in part medication are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medication do so only after they have been properly orientated to the facility medication distribution system (procurement, storage, handling and administration). The individual who administers the medication dose records the administration on the resident MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time the space provided on the front of the MAR for that dosage administration is initialed and circled. Review of R5's progress notes and MAR, there is no documentation that R5 refused the medication [MEDICATION(S)]. On 3/18/22 at 8:45am V3 (Nurse) was observed to administer medication and V3 signed off on the administration of that medication after giving it. V3 said when the nurse gives medication the medication should be signed off after administration, this shows that that the medication was given.

Based on observation, interviews and records reviewed the facility failed to provide a safe environment to to include monitoring/supervision and effective fall prevention interventions to prevent or reduce the risk of falling for 3 of 3 residents reviewed for fall and fall prevention interventions. This failure resulted in R4 falling from in an unsafe enviroment sustaining a fractured pelvis and R1 falling while wandering into another residents room falling and sustaining an aterior inferior dislocation of the humeral head. Findings include: a. R4 has diagnosis of unspecified cerebral infraction, chronic embolism and [CONDITION(S)] of deep vein of lower extremity, presence of other vascular implants and grafts, [CONDITION(S)] and [CONDITION(S)] following cerebral infraction affecting left dominate side, [CONDITION(S)], history of falling, need for assistance with personal care, muscle weakness, lack of coordination, difficulty walking, abnormalities of gait and mobility, cognitive communication deficit, chronic pain, contractures of left hand, multiple fractures of ribs left side, fracture of left pubis. R4 MDS dated [DATE] shows R4 requires one-person physical assist with transfers. Section E for overall presence of behaviors is documented no, put resident at risk for physical illness or injury - question is not answered, impart on care- is not answered. Rejection of care- no is documented. On 3/16/22 at 11:30a.m R4 said he did not fall from reaching for candy on 1/17/22, R4 said he fell on [DATE] when he got up from bed to adjust the heat. R4 said he did not have on shoes, he had his socks on only, and the floor is slippery with he has his socks on only. R4 said he had on regular socks like the ones he had on today (3/16/22), R4 observed to have on regular socks. R4 said he did not call for assistant because the staff will not answer the call light any. R4 said he fell , and it resulted in small fracture, the doctor told him that he does not need surgery. R4 said when he put the call light on the staff will not answer it, R4 said it take an hour sometimes for staff to answer the call light. R4 said he would be waiting forever. R4 said the facility has a rule that everyone should answer call lights and they won't. R4 said when he needs something, he uses the phone and call the nurse station that's how bad it is. R4 said when the facility starts answering the call lights timely, he will start using the call light. On 3/18/22 at 10:46a.m R4 said the facility has not offered him skid free socks since we spoke on 3/16/22, R4 said he does not want staff checking on him every hour he has his wife to help him, R4 said he can do things by himself and he will continue to transfer by himself. When discussing the fall on 2/13/22 and 3/6/22 R4 said she did not fall, he just slid down because his leg was not straight when he got up to transfer himself. R4 continue to say he will use the call light when the staff start answering the call light. R4 hospital records dated 01/20/22 shows in part 66 y.o male with history of [CONDITION(S)], PE, on [MEDICATION(S)], here after a fall 3 days ago, still with ongoing left-sided hip pain. Patient supposedly had an X ray of the initial time of the fall that was supposedly negative, but patient is still having pain. No head injury. Aggravating factors are movement, alleviating factors are rest. There is no [CONDITION(S)] of the pain. No numbness. Patient currently rates his discomfort 7 out of 10. CT pelvis conclusion acute minimally displaced fracture of the left inferior pubis ramus. Additional acute nondisplaced fracture of the left Para symphyseal aspect of the pubis ramus, suspected acute fracture of the left superior pubis ramus extending to the left anterosuperior acetabulum. On 3/16/22 at 12:40p.m V1 was made aware of R4 allegation of falling to the floor when ambulating with no shoes on and socks only and the floor was slippery. On 3/18/22 at 11:23am V1 (Administrator) said the facility has offered R4 a floor mat to place at the bedside, V1 said the mat will not prevent a fall but it could prevent injury. V1 said the facility put a floor mat in place and R4 has yelled at them to remove it and they did. V1 said she has recently offered to purchase R4 house shoes, and he declined the offer, and she will offer again. V1 said she has not offered R4 skid socks because she is not clinical staff, and she didn't think to do so. V1 said R4 would rather bother his wife to assist him with things instead of using the call light for the staff to help him. V1 made aware of R4 concern that staff takes a long time to answer call lights. V1 said R4 gets frustrated when he must wait while staff helps other residents with care, and he transfers himself. V1 said she has not documented any conversations with R4 about the importance of using the call light for assist and safety. V1 said multiple staff have had discussions with R4. V1 said she is not addressing R4 chronic non-compliance that place R4 at risk for falls and injury in QAPI. On 3/18/22 at 2:56pm V2 (DON-Director of Nursing) said the administrator did report to her that R4 mentioned to the surveyor that R4 fall when ambulating with no shoes on, socks only and the floor was slippery. V2 said she replied to administrator that, that is not what R4 reported to her during her investigation. V2 said she did not ask R4 about falling when he did not have on shoes, V2 said she did not follow up with R4 either. V2 says R4 refuse to use the call light and that's why R4 falls. R4 fall incident report dated 01/17/22 shows resident roommate alerted writer that patient had fallen out of his bed and was laying on the floor. Resident stated that he was reaching for candy and rolled out of bed landing on his back/left side. Root cause of fall dated 1/19/22 shows unsteady gait, interventions are to review medications. Fall risk score 19, at risk for falls. On 3/18/22 at 2:56pm V2 said a medication review does not prevent a resident from falling. When asked how she determine the root cause of fall to be unsteady gait when the fall occurred due to R4 reaching for candy while he was in the bed. V2 chuckled, when asked what's funny V2 said she has only been in this role for a short time. V2 did not give response. R4 fall incident report dated 2/13/22 shows resident found on floor with his back beside his bed and wheelchair. Per resident, he was trying to transfer to the wheelchair to go to the bathroom when he suddenly fell and laid on the floor. Offered floor mats but refused. No apparent injuries. Root cause of fall dated 2/14/22 shows gait imbalance, discomfort, refused to use call light, pain medication as per order, lumbar, right, and left hip, and pelvic x ray. Fall risk score 18, at risk for falls. R4 fall incident report dated 03/06/2022 shows resident wife came out and said R4 was in his room on the floor, resident observed in a sitting position on the floor next to his bed. Resident said he had transferred self to the bathroom in his wheelchair and was transferring self-back to his bed when he lost his balance and said he slid to the floor, wife was in the room and said she saw him fall and he did not hit his head. R4 root cause of fall dated 3/7/22 shows resident trying to transfer self to bed without assistance, interventions are to educated resident for proper repositioning and use of assistive device with assistance during transfer to prevent fall and injury. Encourage resident to minimize putting belongings to bedside to have enough room for transfer and repositioning. Fall risk score dated 3/6/22 shows 12, at risk for falls. On 3/18/22 at 2:56pm when asking V2, what assistive devices does R4 use, V2 said R4 can use the bed rails. During this survey on 3/16, 3/17, and 3/18, R4 was not observed to have bed rails in place. R4 care plan does not show to use bed rails as assistive devices when transferring. When asked was R4 belonging preventing a transfer V2 just starred at surveyor and did not give response. When asked what the facility is doing to prevent R4 from falling, V4 continue to say R4 refuses to use the call light. Then V2 said R4 does not want to keep his room door open, so staff can observe him from the doorway. V2 was asked if staff can knock on the door to check on R4, V2 did not response. When asked to have the facility discuss risk and benefits with R4 since the facility knows R4 chronically refuse to use the call light for assistant and fall as a result, V2 said yes, V2 said she did not document it. Review of R4 plan of care, there is no document what are the risk and what are the benefits of using the call light for assistance with transfer. R4 plan of care with initiated dated 1/7/2022 shows I am at risk for falls r/t Gait/balance problems, Unaware of safety needs, left sided weakness, Hx (history of falls) of falls, I will not sustain serious injury through the review date. Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, bed height to be placed where my feet are flat on the floor, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, follow facility fall protocol, PT evaluate and treat as ordered or PRN, review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes, x ray to left hip, left pelvis, LLE and left foot review pain medication. R4 care plan with initiated date of 5/16/2017 shows in-part R4 is at risk for falls related to gait/ balance problems, is non-compliant with keeping his room door open for safety. R4 will be free of falls through the next review date, assess medical condition recommendation [MEDICATION(S)] [MEDICATION(S)] level, continue to educate on safety and continue with restorative programs, R4 need a safe environment with every floors free from spills and/or clutter, adequate, glare free light, a working and reachable call light, send to ER for eval/ TX (treat) and reevaluate transfer upon return, R4 has agreed to allow bed in low position with mat to floor and wait for assistance for all transfers, refuse to keep door open, transfer with gait belt and one assist, bed to be kept into lowest position with mat to side of bed, continue to re-educate R4 with height of bed and call for assistance for safety, ensure R4 is wearing appropriate footwear (education provided on all appropriate footwear, example socks require non-skid footing if walking without shoes,) mark will continue to patriciate in restorative program to build strength, resident reeducated in calling for assistance when transferring self, anticipate and meet R4 needs, be sure R4 call light is within reach and encourage R4 to use it for assistance as needed, R4 needs prompt response to all request for assistance, educate R4 family/ care givers about safety reminders and what to do if a fall occurs, encourage R4 to participate in activities that promote exercise, physical activity for strengthening and improved mobility, frequent checks when door is closed, R4 needs to be evaluated for and supplied appropriate adaptive equipment or devices as needed, pain medication as ordered, lumber, right hip and pelvis x-ray, PT evaluate and treat related to fall on 3/28/21, resident refused floor mat at bed side, resident was educated about the importance of mat at bed side for fall intervention, but refused to have at bed side, he said he has a lot of things in his room and having a mat at bedside is not necessary. On 3/16/22 at 11:30am R7 call lights came on and not answered until 11:37am despite staff walking pass the room with the light on. On 3/17/22 at 9:48am R6 call light observed on, call light answered at 9:57am despite multiple staff observed walking pass the room. See F550. Facility fall prevention program policy with revision date of 11/21/2017 shows the purpose is to ensure 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. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Care plan incorporates identification of all risk/issues, addresses each fall, interventions are changed with each fall as appropriate, preventative measures. Safety interventions will be implemented for each resident identified at risk, footwear will be monitored to ensure the resident has proper fitting shoes and footwear is non-skid. b.R1 is [AGE] years old with diagnosis including but are not limited to History of falling, Alzheimer's Disease, [CONDITION(S)] Disease, Repeated Falls, Psychotic Disorder, Anxiety, and Difficulty in Walking. R1's cognition is severely impaired. On 3/16/22 at 1:27PM V2 Director of Nursing, said on 2/14/22 R1 was not able to sit still and constantly trying to get up from her wheelchair. V2 said the root cause of R1's falls is her confusion. V2 said the intervention following R1's fall on 2/14/22 was to increase monitoring. V2 said increased monitoring means staff bed to the increase their time to monitor the residents. V2 said the standard is every 2 hours. V2 said the facility uses a monitoring sheet to document. The surveyor requested a copy of the sheet. V2 said on 2/19/22 R1 was found on the floor in another resident's room. R1 was grimacing and showing pain and R1 was sent for an evaluation. V2 said R1 dislocated her shoulder when she fell on [DATE]. R1 said the interventions following R1's fall on 2/19/22 is to increase monitoring and add a floor mat. R1 said the floor mat did not address the fall when R1 fell in another residents' room from her wheelchair. On 3/18/22 at 10:18AM V22, CNA, said she was on a 30 minute lunch break when R1 fell . V22 said she was in the break room and not on the floor/unit. V22 said the last person she saw before she went to break was another women resident, but not R1. V22 said she did not know who the other CNA working was but she was in the dining room with other residents. V22 said she didn't know R1 is confused. V22 said if she knows a resident is confused and at risk to fall, she will stay with them to keep them safe. On 3/1822 at 12:03PM V1, Administrator, said root cause analysis are done to get to the bottom of issues. V1 said the purpose of the root cause analysis is to implement new interventions. On 3/18/22 at 2:13PM V25, Licensed Practical Nurse (LPN), said he saw R1 about 30 or 40 minutes in her wheelchair before she fell . V25 said he was not assigned to R1 and not sure who her CNA was. V25 said he did not see how R1 got into the room she fell in. On 3/18/22 at 2:26PM V24, CNA, said she was taking care of another resident, not R1 and had not seen her since dinner time in the dining room. V24 said after dinner she went for a 30 minute break and when she returned she was taking care of her group of residents. V24 said she was not near the hall where R1 lived or fell . V24 said when she came out of a resident's room the ambulance was taking R1. V24 said she did not see R1 before she fell . V24 said she did not see R1 go into the room she was found on the floor or walking that day. On 3/23/22 at 10:26AM during a phone interview V31, Nurse Practitioner, said R1 can be screaming and difficult to redirect at times and at other times is calm and easy to redirect. V31 said one to one sitters are not available in the facility. V31 said R1 requires more supervision than the standard 2 hours. V31 said staff can put R1 in the bed and 2 seconds later she pops back out. V31 said they almost need to follow her around to provide constant redirection. V31 said because of R1's dementia she is confused more often and is only oriented times 1. V31 said R1 requires more frequent supervision than most residents. A Physiatry Progress Note dated 2/11/22 notes fall precautions per facility protocol. According to Fall Initial Occurrence dated 2/14/22 notes R1 sustained an unwitnessed fall in her room. Note written by V3 notes that another notified V3 of R1 being seen on the floor. R1 has laceration and bleeding at right temporal eyebrow area. Bruise on left lower lip and right eye. Facial grimace noted. Predisposing factors note R1 with behavior symptoms, increased agitation, wandered, restless, and wandering. New interventions listed note increased monitoring. Progress Notes for R1 dated 2/14/22 written by V3 at 11:30AM notes 15 minute checks in progress. R1 then left for hospital evaluation. The next progress note at 5:21PM notes R1 returned to the facility. Progress notes follow on 2/15/22 at 2:05PM; 2/16/22 at 5:24AM. A Physician Progress Note written on 2/16/22 at 5:25PM notes R1 requires continued redirection and reorientation. [There are no 15 minute notes to document the increase monitoring.] R1 fall risk assessment dated [DATE] notes she is a at risk for falls. According to Fall Initial Occurrence dated 2/19/22 notes R1 was notified by a CNA that R1 sustained an unwitnessed fall in another resident's room on the floor. R1 complained of pain on that arm and head. New intervention notes increased monitoring. Report #172 notes R1 confused, wandering, and recent fall. The same report noted R1 left for the hospital at 8:00PM. R1's Incident Audit Report dated 2/19/22 notes R1 was sent for hospital evaluation via 911. Hospital X-Ray of the right shoulder dated 2/19/22 at 8:55PM notes Finding/Impression: Anterior, inferior dislocation of the humeral head. At 10:14PM a second X-Ray of the right shoulder notes interval reduction of the right dislocation. The alignment is now anatomic. A falls investigation worksheet completed by V2 on 2/20/22 notes R1 was sitting in her wheelchair at time of the fall. R1 noted wandering and restless. Recommendations notes frequent monitoring. Care plan initiated on 12/9/21 notes R1 is at risk for falls related to weakness, [CONDITION(S)], Unsteady gait, and history of falls. Goal reads will not sustain serious injury. Interventions include anticipate and meet the resident's needs initiated on 1/7/22. Intervention on 2/15/22 note sent R1 for further evaluation. Intervention on 2/20/22 notes diagnostics performed for CT and X-Rays. Also 2/20/22 notes Frequent monitoring due to resident refused assistance while ambulating, wheelchair locked when not in use. Send to hospital for evaluation. Care plan initiated on 12/10/21 notes R1 has impaired cognitive function/dementia related to Alzheimer's and Dementia. Interventions include cue, reorient and supervise as needed. A second fall care plan initiated on 3/15/22 (29 days after fall on 2/14/22) notes R1 is at risk for falls. All intervention initiated 3/15/22. No care plan intervention or focus is present to address R1's wandering behavior noted on fall reports. No documentation of increased monitoring provided to surveyor when requested from V2 on 3/16/22. c. R13 is [AGE] years old with diagnosis including but not limited to Cerebral Infarction, [CONDITION(S)] and [CONDITION(S)], Dementia, Difficulty in Walking, Unsteadiness on Feet, Lack of Coordination, and Cognitive Communication Deficit. On 3/17/22 at 11:30AM the surveyor observed R13 walk out of his room pushing his wheelchair. R13 pants long and dragging under his feet, gait unsteady. R13 walked in hall 2 rooms past his room towards nurses' station. R13 was observed stumbling and loosing balance, the surveyor alerted V3, RN. V3 immediately ran to assist R13 in the hallway and walked him back to his room. V3 did not answer the surveyor when asked if R13 should be ambulating independently. On 3/18/22 at 11:28PM V23, Director of Rehab, said R13 is not safe to walk alone because he has poor safety awareness and balance issues. V23 said if R13 walks independently he is at risk for falls. V23 said R13 is easy to redirects, cooperative, and easy to work with. R13's Cognitive Patterns assessment dated [DATE] notes a cognitive score of 9, moderately impaired. R13's Functional Status assessment dated [DATE] notes R13 requires 1 person assistance with bed mobility, transfers, waling in his room and in the corridors, dressing, toilet use, and personal hygiene. Balance when seated to standing and for transfers notes R13 is not steady without staff assistance. R13's Care Plan initiated 8/31/21 notes he requires 1 person assistance with transfers, bed mobility, dressing, and toileting. R13 is at risk for falls. The noted interventions include anticipate and meet the residents needs. Physical Therapy Discharge Summary dated 1/31/22 notes precautions for R13 fall risk, poor safety, and poor carryover. Fall Prevention Policy Program Dated 11/28/12 notes Purpose: To assure the safety of all residents in the facility, when possible. Nursing personnel will be informed of residents who are at risk of falling. The resident will be checked approximately every 2 hours, or as according to the care plan, to assure they are in a safe position. The frequency of safety monitoring will be determined by the resident's risk factors and the plan of care. In the event safety monitoring is initiated for 15-30 minutes periods, a documentation record will be used to validate observations. Assigned nursing personal are responsible for completing the safety checks and documenting the same on the record. Safety monitoring will be discontinued when the risk factors requiring monitoring is no longer evident as determined by the supervising nurse or interdisciplinary care team.

Based on interviews and records reviewed, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected 3 of 3 residents (R4, R5, and R3) reviewed for physician orders. This failure resulted in R4's blood glucose not being monitored for 11 days, & R5 missing doses of prescribed medications for 4 days. Findings include: On 2/9/2022 at 11:40 AM R4 states the staff do not check her blood sugar regularly. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R4's blood sugar log documents that R4 had no blood sugars taken on 1/29/2022 through 2/4/2022 and had only one blood sugar taken on 1/27/2022, 1/28/2022, 2/2/2022 and 2 blood sugars taken on 2/5/2022. On 2/10/2022 1:28 PM V5 (ADON) states she expects nurses to follow doctor's orders. On 2/17/2022 at 11:54 pm Surveyor requested that V2 pull up R4's medication orders to view the insulin [MEDICATION(S)] order. V2 states it is her expectation for the nurses to first check the blood sugar because there is a parameter to give additional units. R5 is [AGE] years old with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/10/22 at 1:07PM V2, Director of Nursing, stated medication refusals need to be charted by the staff. If medications on Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R5's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 10mg tablet, [MEDICATION(S)] 1,g tablet, and [MEDICATION(S)] 12.5 mg tablet were not administered on 1/3/22; 1/8/22; 1/9/22 and 1/19/22 at 8:00AM. [MEDICATION(S)] tablet 100mg 7:00AM and 12:00PM not administered on 1/3/22; 1/8/22; 1/9/22 and 1/19/22. Progress Notes for 1/3/22; 1/8/22; and 1/19/22 have no entry related to the missed medications. The facility policy for Medication Administration revised on 8/2020 notes medications are administered as prescribed in accordance with good nursing principles and practices. The individual who administers the medication dose records the administration on the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In no case should the individual who administered the medication report off duty without first recording the administration of any medication. If a dose of regularly scheduled medication is withheld, refused, not available, or given at a times other than the scheduled times the space provided on the front of the MAR for that dosage administration is initialed and circles. An explanatory note is entered. R3's discharge summary dated 1/7/2022 documents R3 is to receive insulin [MEDICATION(S)] with meals. Review of R3's face sheet document's R3 admitted to the facility on [DATE]. Review of R3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review or R3's Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R3' blood sugars document her blood sugars were elevated over 300 mg/dl on 1/8/2022 and 1/9/2022. On 2/10/2022 at 1:28 PM V5 (ADON) stated she expect nurses to follow doctor's orders. The nurse is responsible for putting in doctor's orders. V5 states, on admission the facility usually get orders right away from the hospital. V5 states, new/additional orders we get from doctor within 24 hours. V5 states she expects diabetic medications to be ordered immediately.

Based on observations, interviews, and record review the facility failed to implement effective supervision and monitoring interventions to prevent avoidable incidents for a cognitively impaired residents with history of wandering in the facility This failure affected 2 of 3 residents (R1, R2) reviewed for supervision and avoidable accidents. This failure resulted in R1 sustaining an injury of unknown origin resulting in a acute right intertrochanteric [CONDITION(S)], and R2 being able to get outside of the facility using the front entrance and falling outside of the facility without staff knowledge Findings include: R1 is [AGE] years old with diagnosis including but not limited to Congestive heart Failure, Anxiety, Dementia without behavioral disturbances, Obsessive-Compulsive Disorder, Difficulty walking, Weakness, and Alzheimer's Disease, Vitamin D Deficiency, [CONDITION(S)]. R1's cognitive assessment dated [DATE] notes R1 is severely cognitively impaired and did not respond verbally during the survey. On 2/9/22 at 11:08 AM surveyor observed R1 in her bed and no floor matts on the floor or in the room. The surveyor observed R1 is a small, thin, and frail. On 2/9/22 at 11:14 AM V29, Certified Nursing Assistant (CNA), said fall risk residents have floor matts when they are in bed. On 2/9/22 at 11:23AM V18, Registered Nurse (RN), said R1 used to self maneuver herself in her wheelchair in the hallways. V18 said R1 used to be able to stand with assistance from the staff. V18 said on 12/30/22 the family came to visit R1 and they reported they saw a bruise on her. V18 said she went to look at the bruise on R1, R1 did not complain of pain, the bruise was discolored and her knee was swollen. V18 stated she called the doctor and an X-ray was ordered, and when the results arrived found R1 had a fracture and R1 was sent to the hospital. V18 said we don't really know how R1 got the fracture. Prior to the fracture R1 did not try to get up unassisted, and when R1 was in her bed she stayed in bed. V18 said R1 did not know how to get up without assistance. V18 said she was not aware of R1 having had a fall on night shift prior to 12/30. On 2/9/22 at 1:00PM V2, Director of Nursing, said we were unable to determine how R1 sustained a fracture, so we listed her injury as unknown origin. On 2/9/22 at 1:53PM observed V18 carrying floor mats in the hallway and placed them on both sides of R1's bed. V18 said R1 is supposed to have floor mats because she is on the falling leaf program. On 2/9/22 at 3:10PM V12, RN, said he did not see R1 fall. V12 said prior to her fracture, R1 used to wander in her wheelchair by herself. V12 said R1 is unable to do that anymore. V12 said R1 never tried to get herself up and needed 1 person assistance to transfer prior to the fracture. On 2/10/22 at 9:54AM V8, CNA, stated she has seen R1 wander in the wheelchair in the units. V8 said she had not seen R1 grabbing the rails or trying to get up from her wheelchair in the past. On 2/10/22 at 10:03AM V10, RN, said she never saw R1 trying to get up unassisted by staff. V10 said R1 was cooperative, was a known fall risk because of her dementia. On 2/10/22 at 2:52AM V1, Administrator, said after investigating R1's fracture we determined the fracture was caused by R1 using the banister to propel herself. This was our best determination. On 2/10/22 at 3:13PM V3, CNA, said R1 during care while in the bed R1 would sometimes resist and get still. V3 said during care you have to talk to R1 and reassure her. V3 said she never saw R1 standing unassisted, but had seen her self-maneuvering in her wheelchair. V3 said R1 would maneuver her wheelchair by pedaling her feet. V3 said at times she had seen R1 holding the rails in the hall ways and slowly maneuvering the wheelchair to advance in the hallway. V3 said R1 was not very strong, and was slow and week, and would not have the strength to move quickly in the wheelchair. On 2/16/22 at 10:59AM via phone interview, V34, Primary Doctor, said I saw R1 before her fracture. I have known for her a long time. V34 said R1 was usually in her wheelchair and she would scooch around in her wheelchair, and she wandered. V34 said R1 has been stable and was not someone who needed a ton of mobility care during the day. V34 said the nurses did not mention any fall had occurred. I was told the family had seen redness and pain in the area and that prompted the X-Ray. V34 said in my experience, fractures can occur from a transfer because the hip breaks from the force when the person sits down. V34 said R1 has osteopenia and she has frail and brittle bones. V34 said if the staff is not paying attention or not gentle during a transfer that can cause hip fractures. V34 said he has never seen R1 aggressively resisting cares. V34 said R1 would get around in her wheelchair by taking a couple steps with her legs and then stop to look around. V34 said R1 would place one elbow on the arm of the chair then look around and use her legs to propel her chair forward. V34 said he never saw R1 moving fast. V34 said R1 has upper body weakness and he didn't think she would have the strength to use the rails to push herself in the wheelchair. On 12/30/21 at 2:00PM V1's Progress Notes written by V18, Registered Nurse, note V18 was approached by R1's family member verbalizing swelling on R1's right leg. V18 documented she saw R1's right knee was swollen with bruising on the left foot. Review of R1's X-ray of her right femur dated 1/1/22 notes there is an acute fracture involving the intertrochanteric hip. Review of the facility Investigation Form Summary of Investigation notes out best determination of the probable cause of the injury of unknown origin could have been due to thrusting herself forward by using the banister to propel herself into an unknown object potentially corner of the end of a wall. R2 is a [AGE] year old with diagnosis including but not limited to Chronic Diastolic Heart Failure, Depressive Disorder, Hypertension, Difficulty in Walking, Unsteadiness on Feet, Cognitive Communication Deficit, Weakness, Dementia, [CONDITION(S)]. R2's Cognitive Patterns assessment dated [DATE] notes she has a score of 3, severely impaired. R2's Functional Status assessment dated [DATE] notes she requires Extensive Assistance for Bed Mobility, Transfer, and Locomotion on and off the unit. R2 was not able to answer surveyor questions appropriately. On 2/9/22 at 11:30AM V31, Certified Nursing Assistant (CNA) said V2 is known to come out of her room in her wheelchair and needed redirection often. On 2/9/22 at 2:20PM via phone interview V15, Licensed Practical Nurse (LPN), said she was assigned to R2 on 1/3/22 night shift. V15 said V20, CNA, alerted her that R2 was not in her room, which was not out of the ordinary for her. V15 said she was taking care of another resident and when she came out of that room she saw another staff frantically waving from the front entrance. V15 said we usually have security at the front door at night, but we did not that night. V15 said V20, CNA, was the first to find R2 outside. V15 said R2 was outside the building on the ramp; R2 had exited the building and fallen outside. V15 said R2 was wearing an electronic monitoring device but the alarm for the wander guard was not sounding. V15 said if you press on the front doors for 15 seconds the doors will open. V15 said R2 got past the 2 set of doors before getting outside. V15 said she had last seen R2 about 1:30AM or 1:40AM in her bed in her room. On 2/9/22 at 2:41PM V13, Social Services, said prior to 1/3/22 she cannot remember the last time she tested R2's electronic monitoring device. V13 said she did not document the testing before. On 2/10/22 at 9:52AM V8, CNA, said I am not sure if there is a list with residents who wear electronic monitoring device. R2 is at risk for wandering, she always says she wants to get to the door. V8 said I don't know if R2 has ever gotten to the front door, outside, or if she has fallen. V8 said she would be notified if these things had happened. On 2/10/22 at 11:30AM via phone interview V33 (Receptionist) said R2 sometimes gets to the front door and is redirected back to the unit. V33 said if the electronic monitoring device goes off she contacts maintenance to turn it off. V33 said she has not been made aware than any resident has eloped out of the building. On 2/10/22 at 11:49AM V11, Maintenance, said the electronic monitoring device were serviced recently with the alarm radius being reset so that the alarm will sound when a electronic monitoring device is detected in the vicinity. V11 said he has not been made aware that any resident has gotten out of the facility. On 2/10/22 at 12:57PM V1, Administrator, stated if a resident falls or gets out of the facility, the staff should be aware it. On 2/10/22 at 1:07PM V2, Director of Nursing, said staff should be aware R2 got outside and is at risk to do it again. On 2/10/22 at 1:21PM V24, Regional Nurse, said he was notified when R2 fell outside. V24 said R2 normally wheeled up and down the hallways in her wheel chair. V24 said R2 got past the 2 sets of front doors. V24 said he does not know if the electronic monitoring device door alarm was working in the middle of the night. V24 said I expect staff to know R2 is at risk for falls and has gotten out of the facility. Progress Notes for R2 written by V15, LPN, state at 2:05AM Resident had an unwitnessed fall on 1/3/22 outside on ramp to facility front entrance. CNA found R2 sitting on the ground outside. Blood Pressure 150/90, Temperature 95.4, and Pulse 110. At 2:10AM V15 documented electronic monitoring device on R2's wrist but system not alarmed at entrance R2 exited. R2's Fall Risk assessment dated [DATE] notes R2 is not at risk for falls. No other Fall Risk Assessment was provided. R2's initial Fall Initial Occurrence Note written by V15 notes R2 said I'm cold and she had been outside about 5 minutes. R2's Elopement Leave Risk Review dated 12/3/21 notes R2 is at risk to elope. R2's care plan for cognitive function initiated on 7/24/18 notes she has poor logic, poor ability to understand cause and effect, poor judgement, awareness, insight focus, and poor impulse control.

Based on interviews and records reviewed, the facility failed to follow their policy and ensure all staff had met the Covid Vaccination requirements or an approved Covid Vaccine exemption. This failure had the potential to cause Covid 19 infections in 5 residents (R17, R18, R19, R20, and R21) who have contracted Covid 19 at the facility in the last 4 weeks. Findings include: On 2/15/2022 at 3:30 PM V1 (Administrator) stated the only documentation that they have for F888 compliance are the request for exemption forms. V1 states she will check with corporate for any approvals and declination forms. On 2/17/2022 at 11:50 AM V1 states the corporate office approves exemptions. V1 stated the facility only has 2 exemptions from people that currently work at the facility. Those were forwarded to surveyor. V1 states the approvals are on the Covid 19 Vaccine Declination forms. Review of Covid 19 Vaccine Declination form for the 2 staff (V35 and V36) provided on 2/16/2022 and dated on 2/16/2022 documents all listed reasons for declination. There is no statement of approval on the request for exemption or declination forms. All of staff members filled out the exemption request form, but no further action was noted by the facility. There was no approval of a medical exemption with documentation from a physician. On the Religious exemptions, only one had a religious leader sign off on request, but there was no evidence of an approval Anyone who requested an exemption was able to work. There were 5 requests for exemptions 2 staff V35 and V36 (nursing staff) are still employed at the facility. V35 and V36 have been working at the facility since they requested an exemption in October. V1 via email on 2/16/22 documents that 5 residents (R17, R18, R19, R20, R21) have contracted Covid-19 at the facility in the last 4 weeks. The facility's Employee-Vendor Covid-19 Vaccinations policy dated 2/11/22 documents the following: 2. Religious Exemption Employees may also seek a religious exemption if the vaccination conflicts with a sincerely held religious belief and practice. An employee seeking a religious exemption must complete a Request for Religious Exemption Form, which can be obtained from and returned to, the Human Resources Department. Once a Religious Exemption is approved, the employee must complete COVID-19 Vaccination Declination Form, which will be provided by Human Resources.

Based on interview and record review the facility failed to follow their policy preventing facility staff from physically attacking 1 of 3 residents (R1) reviewed for physical abuse. This failure resulted in R1 being assaulted by a facility staff member (V2) where R1 sustained a closed nondisplaced fracture of the left finger and clinical impression of [MEDICATION(S)] head trauma. Findings include: R1 face sheet shows R1 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 emergency room records dated 01/01/22 shows in-part stated complaint: assault. [AGE] year-old female with a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient states that someone at the nursing home assaulted her, states she was asking a staff member to help her brush her teeth and patient states that staff member hit her on the head and also bent her fingers back. Patient is a poor historian but repeats the story same each time. Positive for stated complaint. Redness to cheek consistent with recent injury. No hematoma or deformity, no abrasions or skin breakdown. Left hand tenderness and bony tenderness present. Left hand mild swelling without deformity to base of l ring finger. She is able to flex and extend but with pain. Radiology findings conclusion acute nondisplaced impacted fracture dorsal base middle phalanx left 4th digit. A finger splint was applied to the left ring finger. Clinical Impression: [MEDICATION(S)] head trauma, and closed nondisplaced fracture of phalanx of left finger. Review of the facility final resident abuse investigation form dated 01/07/2022 shows in part date of incident occurrence, location: resident room, police report number 22- , incident reported by employee, type of alleged abuse-verbal, and physical, resident injuries- no, on initial body assessment no injuries were noted, per family request resident was sent out for further evaluation. Injuries requiring medical attention-yes, per family request resident was sent out for further evaluation. Based on hospital evaluation R1 has closed nondisplaced fracture of phalanx of left ring finger. Name of person accused (V2) CNA. Summary of interview with the person reporting the incident: V6 states V2 reported R1 spitting on and being verbally aggressive with her. Management reviewed the clinical records of R1. Employees and residents who may have information regarding the alleged incident were interviewed. R1 is a current resident of the facility and is the resident identified to have the alleged incident. R1 cannot see well and pulled my hands to be closer to her. R1 was redirected if she could recall details of the CNA touching her face. R1 states she needed to get ready to go to [CONDITION(S)] and wanted to brush her teeth. R1 states CNA just gave her a cup. R1 then said the girl just started pulling my hair and scrunched my hand. R1 could not recall any other details regarding the alleged incident. R2 is a currently resides across the room from R1. R2 states on the day of the alleged incident she could hear R1 yelling and cursing at the CNA V2. R2 states she continued to hear R1 shouting and heard R1 spit and slap the CNA and she saw V2 walked immediately out the room to report the incident to the nurse. R2 states she also goes to [CONDITION(S)] center and R1 is always being mean to the staff at the [CONDITION(S)] center. V2 states on the day of the alleged incident she was not assigned to R1 but her transportation was here and she was asked to assist in getting R1 ready. V2 states she came in and told R1 it was time for [CONDITION(S)]. V2 states that R1 started shouting to her that she needed to brush her teeth. V2 transferred R1 to her wheelchair and brought a cup and brush to brush her teeth. R1 started shouting she wanted to go to the washroom to brush her teeth. V2 states she went to wheel R1and R1 held the wheels with her hands and shouted stop. V2 states she immediately stopped because she was not aware, R1 was holding the wheels, at this time R1 started spitting at her and started cursing and shouting at her. V2 immediately stepped out of the room and reported the incident to the nurse. R1 progress notes dated 01/04/22 completed by the physician shows in-part, CC: Alleged abuse, Subjective: This is a [AGE] year-old female was seen today for alleged abuse within in the facility. The patient alleged abuse by a staff member. Administration was notified. She was sent to hospital for assault workup. She was found to have a fracture of the left 4th digit, splint in place. No [CONDITION(S)] or ecchymosis noted elsewhere. Pain controlled. Denies headache, chest pain, abdominal pain, N/V/D, numbness and tingling, fever or chills. Past medical history: Diabetes Mellitus, heart failure, asthma, history of acute respiratory failure, moderate protein calorie malnutrition, [CONDITION(S)], [CONDITION(S)], hypertension, metabolic [CONDITION(S)], [CONDITION(S)], secondary [CONDITION(S)], and pulmonary hypertension. Family history: Reviewed, no pertinent family medical history. Social history: Denies nicotine, alcohol and illicit drug use. Allergies: NKDA. Code: FULLROS: a 6 point review of symptoms negative other then mentioned in HPI. medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Resp: clear to auscultation bilaterally. Skin: warm, dry and intact. Right chest perma cath. Musc: fracture to left digit, splint in place. Neuro: No focal or sensory deficit. Psych: A/O x 2. Labs 01/03/21. CT Head: negative for depressed calvarial fracture, coup/contracoup intraparenchymal contusion, [CONDITION(S)] or further evidence of acute intracranial process. Chronic encephlomalacic changes are demonstrated in right occipital lobe, in the vascular territory supplied by the right posterior cerebral artery. Senescent changes of parenchymal volume loss with sequela of chronic microvascular ischemic diesase. Large vessel arthrosclerosis. Xray: Acute non displaced impacted fracture dorsal base middle phalanx left 4th digit. Assessment and Plan 1. Fracture of left 4th digit: splint in place. Pain controlled. 2. Suspected dementia: increased. Poor historian. CT of head illustrated senescent changes of parenchymal volume loss with sequela of chronic microvascular ischemic diesase. Continue safety precautions and memory care. 3. Neuropathy: stable. Continue [MEDICATION(S)]. Pain controlled. 4. Insomnia: stable. Continue [MEDICATION(S)]. Sleeping through the night. R1's progress note dated 01/03/2022 at 9:54 am shows in-part late entry for 1-3-22 8:30am. V6 (Nurse) reported that R1 made an allegation that V2 (CNA-Certified Nursing Assistant) was, touching all in her face. CNA V2 had already left for the day. She was called and notified she was suspended pending investigation. V6 performed an assessment and no bruising, swelling or marks to face and body were noted. Family Notified and MD notified. On 01/29/22 at 11:59a.m V2 CNA(Certified Nursing Assistant) said she did not hit R1 in the face, she did not hit R1 in the left cheek, she did not hit R1 in the right eye, V2 said she did not pull R1's hair, V2 said she did not fight with R1. V2 said this was the first time she was interviewed about slapping R1 in the face, this was the first time she was interviewed about hitting R1 on the left cheek, and this was the first time she was interviewed about pulling R1's hair. V2 said this was the first time that she was interviewed about the injury to R1's finger. V2 said this was the first time she was interviewed about hitting R1 in the right eye. V2 said she did receive a call and was informed that she was suspended pending an abuse allegation alleged by R1. V2 said on 1/03/22 around 6:00, her shift was ending, she was asked to assist R1 with getting up in the chair because R1's transportation had arrived to take R1 to [CONDITION(S)]. V2 said she was not R1's aide but she was helping because R1's aide had left for the day and the nurse asked V2 to assist. V2 said she transferred R1 to the wheelchair, and R1 requested to brush her teeth before going to [CONDITION(S)]. V2 said she gave R1 a cup so that R1 could brush her teeth at the bed side but R1 wanted to go to the bathroom sink to brush her teeth. V2 said R1's hand was on her lap and she remembers this because R1 had a magnifying glass in her hand, V2 said she began to back the wheelchair up to turn around to take R1 to the bathroom to allow R1 to brush her teeth. V2 said that's when R1 yelled out my hand V2 said as she leaned in to assess R1's hand and R1 spit on her and R1 started yelling and swearing at V2. V2 said R1 also pushed the bedside table into her. V2 said she'd had enough when R1 spit on her and so she left the room and reported to the nurse that R1 spit on her and she was going home. V2 said she does not know what happened to R1's finger, maybe R1 tried to stop the wheelchair because R1 thought V2 was taking her out of the room and on to the transportation that was waiting instead of to the bathroom to brush her teeth. V2 said before she left the facility she reported to the V6 that R1 had spit on her she does not know if she reported that R1 had complained about her hand, V2 said she did not report that R1 pushed the table into her. On 1/29/22 at 1:18p.m V6 (Nurse) said V2 reported to her before she left that morning that R1 spit on her and she was going home. V6 said V2 did not report that R1 had complaints about her hand. V6 said once V2 informed her that R1 spit on her she went to R1's room to find out what happened and that's when R1 reported to her that V2 slapped her in the face, and pulled her hair (R1 made motioning of being hit). V2 said R1 did not mention anything about her hand at that time. V2 said she did an assessment, and she did not notice any bruising, scratches, or marks on R1's face. V2 said R1 went to [CONDITION(S)] as scheduled. V2 said she reported what R1 told her to V7 (regional consultant) as soon as he arrived at the facility, and she also paged and called the Director of Nursing with no response. V2 said she wrote a statement, and in her statement she documented that R1 said V2 slapped her in the face and hit her. V6 said she did not report to the facility that V2 was touching all in R1's face. V6 said V2 had already left the facility for the day, so she did not have to send V2 home. On 01/29/22 at 11:43a.m V1 (Administrator) said she conducted the investigation of the above allegation of abuse, V1 said she did not ask V2 if she slapped R1 in the face and hit R1 as reported by V6, she did not ask V2 if she pulled R1's hair, as documented by V6 in her investigation. V1 said R1's story kept changing. V1 said R1 did not mention that V2 hit her in the cheek. V1 was made aware of the allegation of R1 being hit in the check and in the right eye. V1 said all allegations of abuse should be investigated. On 01/30/22 at 11:40a.m V1 said she asked R1 about the touching of the face because that what was originally reported by R1 and she got this information from the progress notes. V1 said the staff should not be touching a resident in the face if the resident does not want to be touched in the face. V1 also said V2 could have been helping R1 wash her face and that can be considered touching. V1 said she did not ask R1 if V2 was appropriately touching her face during care. V1 said she interviewed R1, but she did not review V6's statement and ask R1 about the information in V6's statement. On 01/30/22 at 2:19p.m V1 said R1 said she does feel safe in the facility. V1 said V2 is not allowed to work with R1, V2 works on a different unit from R1. V1 said she informed R1 that V2 is still employed at the facility however V2 will not be working with her. V1 said R1 was okay with the plan. V1 said V2 was suspended pending investigation and there were no findings and V2 was allowed to return to work. V2 said the facility does inservices with staff for abuse prevention and staff should report all allegations of abuse, they should report all details of occurrences during the investigation. Staff must report all incidents and complaints from residents. V1 said reporting is important for gathering information and conducting a thorough investigation. V1 said all residents are at risk for abuse. V1 said R2 is interview able and if R2 said she heard a spitting sound followed by a slapping sound, she believes that's what happened. V1 said the facility concluded that the fracture to R1's finger was due to R1 abruptly stopping the wheelchair when V2 was wheeling R1, V1 said the fracture was not a result of abuse. V1 said the facility is not trying to cover up alleged abuse. On 01/30/22 at 11:43a.m V7 said the nurse reported to him that R1 said V2 was touching her in the face, V7 said he reported this as soon as he found about it, he called V3 (friend of R1) and informed him that the police would be called, and V3 arrived to the facility and requested that R1 be sent to the hospital for an evaluation. V7 said per the request R1 was sent to the hospital. V7 said he did not get the information confused, he knows this because he reported it right away to IDPH. On 01/29/22 at 10:40am V4 (Nurse) said she is the nurse responsible for R1's care today, V4 said R1 has behaviors of hitting and spitting on staff, R1 swears at staff and R1 uses racial slurs towards staff. V4 said R1 also pulled her by the neck and she hurt her back as a result and required physical therapy for 6 weeks. V4 said there's nothing particular that sets R1 off, R1 has behaviors throughout the day. V4 said she heard that R1 was fighting with the aide and that's how R1's finger got broken. V4 did not say who told her about R1 fighting. Review of the initial report to IDPH shows the time the initial report was sent to IDPH was at 10:46 on 01/03/22. Review of V6's handwritten statement shows she reported to V7 at 8:15am on 01/03/22. Review of R1 abuse investigation was documented by V1, shows in-part that R1 mentioned that V2 pulled R1's hair. V6's handwritten statement produced by V1, documents that R1 alleged V2 slapped her in the face and hit her. Review of V2's hand written statement does not document that R1 pushed a table on her, there is no documentation that R1 made a complaint about her hand during that interaction with V2, there were no documentation that R1 slapped V2. Review of R1 abuse /neglect screening dated 01/03/22 shows a score of 6, 6 represents high risk on abuse screening. Review of R1's plan of care, R1 does not have a plan of care in place for abuse prevention. On 01/30/22 at 9:42am R2 was observed self-propelling in wheelchair, request made to interview R2, R2 agreed. Interview conducted in R2's room. R2 observed to be alert and oriented to person, place and time, and situation. R2 said she was sitting in her doorway across from R1's room on 01/03/2022, V2 said she was up early because she had to go to [CONDITION(S)] that day. R2 said she heard when R1 spit on V2 and slapped V2. R2 said V2 then came out of R1's room and reported to the nurse that R1 spit on her. R2 said she did not see R1 spit or slap V2, she heard the spit sound followed by the slapping sound. R2 said she has never had any concerns with V2. Review of R2 BIMS dated 10/14/2021, R2 has a score of 15, and R2 is cognitively intact. Using reason person concept, it is reasonable to conclude that the slapping sound that R2 heard was the slap allegedly initiated by V2 towards R1 because V2 did not mention that R1 slapped V2 to the surveyor. V2 did not report to V6 that R1 slapped her that morning, V2 did report to V1 that R1 slapped her during the facility investigation. Also, V2 did not document in her statement that R1 slapped her during that interaction with R1 on 01/03/2022. Although V1 stated R1's statement changed throughout the facility investigation, R1 reported to the nurse that V2 slapped her in the face. When V1 interviewed R1, V1 approached the interview with R1 by stating could you recall details of the CNA touching her (R1) face. The information was not presented how R1 initially reported it to the nurse. Using a reasonable person concept it cannot be concluded that R1 initially changed her statement. Facility policy Titled Abuse Prevention and Reporting dated 11/2016 shows in-part under internal investigations, any incidents or allegation involving abuse, neglect, exploitation, mistreatment, or misappropriation of residents property will result in an investigation. Internal reporting requirements and identification of allegation: employees are required to report any incident, allegation or suspicious of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property they observe, hear about, or suspect.

Based on observation, interview, and record review, the facility failed to follow fall prevention interventions for a resident assessed to be at risk for falls and fall related injuries. As a result of this failure, R1 fell , while unsupervised, and sustained a fracture of the left condylar process of the mandible. This applies to 1 of 3 (R1) residents reviewed for falls and injury from a total sample of 5. The findings include: R1 is a [AGE] year-old resident with numerous diagnoses that include the following: Heart Failure, Renal Failure and [CONDITION(S)], Dementia with Behaviors, History of COVID 19, Anxiety Disorder and History of Falls. A review of the facility's fall incident logs documents that R1 sustained falls on the following days: 6/7/21, 6/29/21, 7/4/21, 7/5/21, 7/11/21, 7/13/21, 7/27/21, 8/3/21, 8/7/21, 10/16/21, 11/20/21, and 11/22/21 with no injuries except the fall on 11/20/21 (fracture of the left condylar process of the mandible). Per the facility reported incident, R1 was sent out to the hospital emergency room for evaluation, after a fall at 9:31PM, on November 20, 2021. R1 returned later to the facility with computerized tomography (CT) of the head/brain dated 11/21/21 that documented an acute fracture of the left condylar process of the mandible. On 12/18/21 at 1:30 PM, V10 (R1's nurse on 11/20/21) stated, R1 fell , in the bathroom, during PM shift ,while I was passing medications. We had three CNAs scheduled for the PM shift, but only two CNAs showed up for the PM shift. We could have monitored R1 more effectively with an additional CNA. On 12/18/21 at 12:30 PM, V2 (Director of Nursing) stated, Care plan interventions should be implemented effectively to prevent resident fall. Staff should have monitored R1 when she went to the bathroom to avoid fall. On 12/18/21 at 1:30 PM, V10 added, R1 was saying her face was hurting, and we noticed a small nosebleed when R1 was assisted back to bed. We continued monitoring, and informed V7 (physician). V7 ordered to send R1 to the emergency room (ER) for further evaluation. R1 came back from ER the next day, early morning. On 12/18/21 at 1:30 PM, V7 (R1's attending physician) stated, R1 has dementia and is very impulsive. They keep her close to the nurses' station most of the time. R1 shouldn't be left naked. Fall intervention implementation can help to reduce fall occurrence and injury. CNAs should pay attention to this resident to supervise and maintain a clutter free environment. On 12/20/21 at 5:15, V11 (Oral Surgeon) stated, R1 had a significant fracture of the left condylar process of the mandible. It's not a hairline fracture. We can't do surgery with her condylar process; it has to heal by itself. R1 is coming tomorrow for a follow-up appointment, and is not going to have any surgery. We downgraded her diet to a liquid diet. During the survey on 12/18/21 at 9:55 AM, R1 was observed, naked, sitting at a low bed, with a soiled incontinent brief on the floor, and pants trapped on the wheelchair leg. The wheelchair was close to the resident, with the left break unlocked. The call light was observed on the floor, and no floor mats were at the bedside. On 12/18/21 at 10:00 AM, upon surveyor notification, observed V8 (Night Nurse) picking up the incontinent brief from the floor, untrapping R1's pants from the wheelchair leg, and locking wheelchair left leg. V8 grabbed the call light from the floor and placed it within R1's reach At 10:05 AM, V8 stated, I was working last night; I will dress her up, and her room should be clutter free to prevent accidents, and call light should be reachable for the resident. Record review on fall risk assessment dated [DATE] document that R1 was at risk for fall and record review on fall care plan indicates interventions including: floor mats to the side of the bed, resident to have anti-rollback applied to the wheelchair, resident to be in the supervised area while awake, call light is within reach, safe environment with even floors free from spills and/or clutter, and working and reachable call light. The facility provided fall policy revised on 11/21/17 document: Safety interventions will be implemented for each resident identified at risk.

Based on interview and records review. the facility failed to follow care plan interventions to elevate head of the bed 30-45 degrees to prevent complications in one resident (R1) of 3 reviewed with a feeding tube. This failure resulted in R1 being transferred to the emergency room for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R1 is [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 9/1/20 Order Summary report R1 receives tube feeding formula for 22 hours. On 10/5/21 at 10:44AM V3, Certified Nursing Assistant (CNA), said R1 is on a feeding tube and must have the head of bed elevated to prevent choking. On 10/5/21 V6, Registered Nurse (RN), stated she saw R1 around 5:00PM on 9/28/2021. V6 stated the feeding tube was flushed with water, and R1 was left in the upright position, in bed. V6 said R1 was not coughing or congested during this time. V6 said At 6:00 or 6:30PM, was called into R1's room by V15, CNA. V15 was not assigned to R1, but she was walking by and saw R1 needed help. V6 said V15 told V6, she noted R1 was laying flat and was aspirating. V6 stated when she entered R1's room, she saw yellow/white, foamy/frothy secretions coming from R1's mouth. V6 stated the doctor told her to send R1 to the hospital. V6 said the purpose of keeping R1's head of bed elevated is to prevent aspiration. V6 said she did not find out how or who lowered R1's bed. On 10/5/21 at 12:25PM,via phone interview, V8, CNA, said V16, CNA, was assigned to R1 on 9/28/21. V8 stated any person on a feeding tube should be sitting up or have the head of bed elevated because they can choke or aspirate. On 10/5/21 at 1:15PM V2, Director of Nursing, stated V6 called and notified V2 that R1 was aspirating and V6 reported she had raised the head of the bed up. V2 stated after a feeding has been completed, it would be necessary to leave the head of bed elevated because the resident may still have residual feeding and need time to digest. On 10/5/21 at 1:28PM V13, Care Plan Nurse, said the care plan for residents with feeding tubes should include: elevate the head of bed for 30 to 60 minutes after a feeding to prevent aspiration for patients. V13 said anyone with a feeding tube is at risk for aspiration. V13 stated it should be a nurse who lowers the head of the bed following a feeding. On 10/6/21 at 9:19AM, V17, Nurse, said during a phone interview, when she entered R1's room she observed a liquid, like the feeding formula, coming out of R1's mouth. V17 said R1's bed was at about a 15 degree angle and we sat her up higher by raising the head of bed more. V17 said when a feeding is infusion , the residents' bed should be elevated 30 degrees. On 10/6/21 at 10:19 AM, V16, CNA, said; On 9/28/21, I noticed V6, RN, came out of R1's room frantic. V16 said When I walked into R1's room, the head of the bed was down and R1 was choking on fluids. V16 said V6 was screaming how did the head of the bed get down? V16 said he had been assigned to R1 and had checked R1 earlier, and the head of the bed was elevated. On 10/6/21 at 10:58AM V18, R1's doctor, said R1 was at risk for pneumonia. When V18 was notified of the incident, V18 was told R1 had low oxygen saturation. V18 insructed them [facility nurse], to send R1 to the hospital. V18 said R1's head of bed not being elevated puts R1 at risk for aspiration. V18 said when the feeding is infusing, the patient's bed should be elevated at minimum 30 degrees. V18 said if no feeding is running , the head should remain elevated up to an hour. V18 said R1 is at high risk for aspiration because she is deconditioned and her gag reflux is poor. V18 said aspiration pneumonitis is caused by something irritating the lungs and is not an infection. V18 said Pneumonitis causes increased secretions to be produced. Review of R1's Progress Notes written by V6, RN, on 9/28/21 effective 6:15PM states CNA found resident aspirating. Raised the bed to 90 degree angle, suctioned the secretions, checked for peg tube residual, checked vital signs: Blood Pressure: 170/96, Heart Rate: 126, Respiration Rate: 25, Oxygen Saturation at 78%, provided her oxygen support, advised physician and was told to send the resident out to the hospital DON and family member advised of transfer. Review of R1's care plan initiated on 10/23/19 states R1 will be free of aspiration through the review date. Interventions dated 10/23/19 noted elevate head of bed 30-45 degrees (semi-flower's position) during feedings and at least 1 hour after feeding to prevent aspiration/pneumonia. The facility policy for Gastrostomy Tube Feeding and Care revision date 8/3/20 notes5. Position resident wth head elevated to mimimal 30 degrees and preferable 45 degrees. Review of the ambulance run sheet from 9/28/21 for R1 notes crew was informed from staff that the patient was being fed using [gastric tube] G-tube while lying flat. Upon entering patient had foreign matter coming from mouth and patient was in visual. severe respiratory distress. Review of R1's Hospital Records from 9/28/21: Discharge Summaries states R1 presented for respiratory failure. Noted [CONDITION(S)] into the 60s per EMS on arrival and patient was found laying flat, receiving tube feeding. Noted tachypneic and coughing. Suctioned with thick liquid consistent with tube feed removed and her breathing became labored. Hospital Course: Aspiration pneumonitis.

Based on record review and interview the facility failed to timely identify and treat a resident's urinary tract infection (UTI) by not following a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This applies to 1 of 40 sample residents ( R74). As a result, R74 was allowed to remain in pain for 13 days after reporting the urinary pain to medical doctor. Findings include: R74 is a [AGE] year old admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimum Data Set updated 7/22/2021 indicates R74 is cognitively intact. On 8/23/202 12:00PM, R74 was observed in her room, sitting in a wheelchair. R74 said I saw the doctor a few days ago and I told him that I was having burning when I go pee. Nobody is doing anything about it. It is still painful, and I already have pain everywhere else in my body. I haven't been given anything for it. 08/25/21 11:56 AM, V2 (Director of Nursing) stated No one documented that R74's culture and sensitivity were relayed to the doctor. I expect for the nurses to relay abnormal labs as soon as they received the results. I would say that failing to report a positive Urinalysis result two days after it was received by the nurse is a delay in treatment, is a delay on care. 08/26/21 01:54 PM V32, Nurse Practitioner, said I see the residents weekly, every Wednesday. R74 was complaining to me on 8/11/2021 of dysuria and difficulty emptying her bladder. I originally ordered a Urinalysis and Culture Sensitivity for the next day and the resident said that she provided a sample, but I don't know what happened, as I never received any results for it. I then re-ordered the labs to be done on 8/18/2021. No one ever gave me any verbal notification of the lab results. I saw the results on 8/24/2021 while rounding and I placed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] R74's medical record dated 8/12/2021 at 8:45 pm, states Physician ordered a urine and culture and sensitivity test to be done one time only for hematuria for 2 Days. R74's medical record had no indication of results received for this order, no progress notes waere written by nursing regarding this order. According to R74 electronic record 8/18/21 3:15PM indicated a Physician wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] R74 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . States she gave a urine sample, no results have been updated. R74's lab order results indicate: Urine specimen was collected 8/19/2021 at 4:12PM. Urine specimen was received by the laboratory on 8/20/2021 at 3:19PM. On 8/24/2021 at 7:35PM, order was written for oral antibiotic to be taken by mouth twice daily, start 8/24/2021 at 8:00PM. On 8/25/2021 4:05PM, Physician's Progress Note states: Urinary tract infection: positive. Complaints of dysuria. Denies hematuria. Begin oral antibiotic twice a day for 7 days. Facility presented: Physician -Family Notification-Change in Condition policy dated: revision date 11-13-2018, states: Purpose is to ensure that medical care problems are communicated to the attending physician or authorized designee 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; and if known, notify the resident's legal representative or an interested family member when there is: 9B) A significant change in the resident's physical, mental, or psychosocial status.

Based on observation, interview and record review the facility failed to maintain appropriate water temperatures while showering a resident for 1 of 3 residents (R1) reviewed for accident/incidents. This failure resulted in R1 being sent to the local hospital after receiving a shower due to redness and peeling of the skin and being admitted to the Burn Intensive Care Unit with a [DIAGNOSES REDACTED]. Findings Include: The Minimum Data Set ((MDS) dated [DATE] documents that the resident is alert and oriented with a BIMS Score of 15 indicating the resident is cognitively intact and requires 1 person physical assist with all activities of daily living (ADLs). The Nurse's Notes dated 10/17/19 at 06:50am documents that R1 was noted with excoriated peeling skin to the forehead and top of the scalp after a shower. R1 had complaints of pain and the Medical Doctor (MD) was notified. The Physician's Note dated 10/17/19 at 9:05am documents that R1 was assessed for skin changes and noted with redness and peeling to the forehead and other parts of the face and scalp. R1 had complaints of a burning sensation even after the scalp and face was rinsed and the resident was given a cold cloth to apply to the affected areas. R1 was transferred to the local hospital for evaluation and treatment. The hospital records dated 10/17/19 at 07:59am documents that R1 was admitted to the hospital with [REDACTED]. R1 was noted with superficial [MEDICAL CONDITION] the neck, scalp and upper torso. Per Paramedics, the facility's staff raised concerns about the shampoo/body wash used on the resident. However R1's skin findings were more consistent with a thermal burn rather than chemical burn or allergic response. The distribution of [MEDICAL CONDITION] the body are likely due to hot [MEDICAL CONDITION] the shampoo/body wash was used on the entire body and there are no other signs of skin irritation. R1 was transferred to the burn unit/ICU at a neighboring hospital. The hospital records dated 10/17/19 at 1:31pm documents that the resident was a direct admit from a local hospital and presented with [MEDICAL CONDITION] the nose and right chest, and partial [MEDICAL CONDITION] the forehead, bilateral cheeks and nasal bridge. R1 was admitted to the Burn Intensive Care Unit for treatment. On 10/18/19 at 12:10pm V3 (Nurse) and at 12:27pm V4 (CNA) were interviewed and said that R1 was being showered by V5 (CNA). The resident complained once about the temperature being too hot, the temperature was adjusted and there were no other complaints. V3 and V4 left the shower room for approximately 10 minutes and then noticed R1 [MEDICAL CONDITION] the face and skin peeling on the forehead and cheeks upon re-entering the shower room. On 10/18/19 at 1:25pm V6 (Physician) said that R1 was admitted to the emergency room with [MEDICAL CONDITION] caused by hot water based on the distribution of the injury and blisters to the face, ear lobe, scalp, and chest. The injury was consistent with a splash pattern and there were no other irritations to the skin. R1 was transferred to the burn unit/ICU. On 10/18/19 at 1:35pm V5 (CNA) confirmed that R1 was given a shower and never complained after the temperatures were adjusted. V5 received assistance from V3 and V4 and both staff members left the shower room and returned in approximately 10 minutes; R1 was then observed with redness and peeling to the face and neck. V5 denies R1 was ever burned while showering. On 10/18/19 at 2:22pm V7 (Maintenance Director) said that water temps are done daily. The temps stay between 108 and 110 degrees. On 10/18/19 at 2:47pm, R2 said, the water is too hot, I have to ask staff to add some cold water. I let them know you will not scald the skin off me. The water is so hot that you can take the feathers off a chicken. The water is good and hot. On 10/18/19 at 2:52pm, R4 said, when I shower the water gets hot and I have to ask staff to turn down the water. On 10/18/19 at 3:10pm, R3 said, I can control the water when I take a shower but other residents can't. All you have to do is turn the water on in the sink for 2-3 minutes and you will see how hot it will get. The water feels like it reaches more than 115 degrees. 10/22/19 at 1:10pm R1 observed sitting up in the chair. The face, neck and chest was red and the resident had scabs on the nose and the cheeks. The resident said I got burned with hot water. I said it's hot, it's hot and they turned it down.

Based on observation, interview and record review, the facility failed to ensure that staff follow facility protocol while providing incontinence care and failed to ensure staff provide toileting assistance at the time of request. This deficient practice affected one resident (R49) of three residents reviewed for urinary tract infections in the sample of 75. This failure caused R49 to be diagnosed with [REDACTED]. coli) and Proteus Mirabilis organisms which required the use of intravenous antibiotics. Findings include: R49's Admission Record documents an admission date of [DATE]. R49's MDS (Minimum Data Set), a comprehensive assessment tool that is used by the facility, documented on 8/29/18 that R49 was continent of urine. R49's MDS dated [DATE] documented that R49 had frequent incontinence episodes but had at least one episode of continence. On 6/24/19 from 9:28am to 9:33am, R49 was seated in the hallway and was heard asking four times to be brought to the bathroom. The first request was ignored. V31 (RN-Registered Nurse) answered R49's second request with, You'll be okay (R49). On the third request, V31 stated, There's someone in the bathroom right now. We'll bring you as soon as we can. And on the fourth request, V31 pushed her medication cart passed R49 and did not answer her. V31 stated to the surveyor, She has that behavior of asking but she can't really go. At this time, V6 (LPN-Licensed Practical Nurse) walked over to R49 and stood her up to bring her to the bathroom. V6 stated to V31, You know she can walk, right? At 9:34am, V31 walked R49 to the bathroom. R49 voided a large amount and her incontinence brief was dry. R49 was also able to have a bowel movement in the toilet. On 6/24/19 at 9:39am, V30 (CNA-Certified Nurse Assistant) provided incontinence care for R49 as R49 stood at the rail in the bathroom. V30 wiped R49 four times from back to front using an incontinence wipe. On the 4th wipe, there were still brown streaks on the wipe. V30 did not wipe R49's buttock area again. Instead, V30 looked in between the front of R49's legs and wiped from back to front. V30 has been an employee of the facility for the past [AGE] years (hire date 12/2/2002) and according to V30, R49 is one of the residents in her regularly assigned group. On 6/24/19 at 1:52pm, V31 stated (R49) ends up trying to get up. So I had to tell her those things so she wouldn't get up. Basically, I was trying to buy time for the aid to get to her and assist her. We are all responsible for the care of the residents. Nurses can also toilet the resident. V31 confirmed that R49 currently has a urinary tract infection [MEDICAL CONDITION]. V31 stated, If a resident holds their urine or urinates in a incontinence brief, there is a higher risk for UTI. On 6/24/19 at 1:55pm, V30 stated that for female residents, Clean from front to back. If cleaned from back to front there is a higher risk for infections. I didn't touch her vagina when I wiped from back to front. It was just easier with the position we were in. On 6/25/19 at 2:00pm, V2 (Interim Director of Nursing) indicated that the facility protocol is to wipe female residents from front to back to prevent urinary infections. R49's medical record documents: 5/31/19 - R49 positive for [NAME] Coli in urine. R49 was started on oral antibiotics for the UTI.[MEDICATION NAME] milligrams (mg) one time a day from 6/2/19 to 6/4/19. [MEDICATION NAME] 100 mg two times a day for seven days from 6/4/19 to 6/12/19. R49's Medication Administration Record [REDACTED]. 6/15/19 - R49 positive for Proteus mirabilis in urine. A midline catheter was started on 6/19/19 for administration of IV antibiotics. [MEDICATION NAME] 2.25 grams intravenously every six hours for UTI was ordered to be given for seven days. On 06/26/19 at 11:10am, V36 (Physician) stated, E. coli comes from when stool is introduced into the urinary tract or urethra. If a female resident is wiped from back to front, this can push poop into urinary tract and can cause Proteus Mirabilis and E. Coli. Proteus mirabilis and [NAME] coli are two different organisms. Proteus Mirabilis is introduced into the urinary tract the same as [NAME] coli. Improper incontinence care can definitely be the cause of p. mirabilis and e. coli infection in the urine. If the staff is wiping residents from back to front then the staff needs to be coached on proper incontinence care. R49's Care Plan initiated on 10/25/18 documents: Focus: (R49) has a history of Urinary Tract Infection. Interventions: Good hygiene practices: Females to wipe and cleanse from front to back, Clean peri area well after BM (bowel movement) in order to prevent bacteria in urinary tract. Void at first urge. Do not hold urine for extended amount of time. Take the full course of antibiotic therapy even if much improved after a few days of therapy. A facility policy dated 12/14/18 and titled, Incontinence Management, urinary, long term care documents: Advise the resident to urinate whenever the urge arises and never ignore it.

Based on observation, interview and record review the facility failed to administer pain medication to one resident (R486) of three residents in the sample of 75 reviewed for pain management. This deficient practice resulted in R486 experiencing unrelieved severe pain over a 30 plus hour period, which led the resident to suffer diminished capacity to complete activities of daily living and emotional distress. Findings include: R486 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R486's physician order, dated [DATE] documents: [MEDICATION NAME] HCL Tablet 50 mg every 4 hours for Pain-Severe On [DATE] at 10:40 am R486 stated she was upset and in pain because she did not receive her scheduled pain medication ([MEDICATION NAME]). R486 was told by a nurse the medication ran out and it's not available in the facility. R486 stated, her pain was 8 out of 10 on a pain scale of 10 (with Zero being no pain and ten being the worse possible pain). When asked the location of her pain, R486 stated, she feels pain in her right arm (history of fracture), back, and legs. R486 stated, the only other medication I have ordered for pain is [MEDICATION NAME], but it doesn't help. On [DATE] at 11:04 am, V3 (Licensed Practical Nurse) was asked to pull R486's [MEDICATION NAME] pain medication. V3 stated, R486's pain medication ran out and had to be re-ordered. V3 stated, R486's prescription was faxed this morning to R486's physician to sign. V3 stated R486 last received [MEDICATION NAME] on [DATE] at 8 am. V3 verified R486 is scheduled to receive [MEDICATION NAME] every four hours for pain on a routine basis. V3 stated medications should be reordered 3 days before they run out. When asked if [MEDICATION NAME] was available in the facility's convenience box V3 stated no. On [DATE] at 12:10 pm R486 stated she continued to feel severe pain. R486 stated her pain score remained at 8 out of 10. R486 stated she feels down today due to not receiving her scheduled pain medication and stated she would feel much better if her pain was under control. On [DATE] at 10:59 am V4 (Licensed Practical Nurse), stated [MEDICATION NAME] was delivered to the facility and administered to R486 on [DATE] at 12:30 am. V4 stated, R486 received the scheduled doses for the morning as ordered. All total, R486 went close to 41 (40.5) hours with 8 missed doses of the scheduled pain medication, all the while experiencing consistent pain levels of 8 out of 10 on a pain scale of 10. On [DATE] at 11:50 am, R486 stated, she takes [MEDICATION NAME] for pain on a regular bases. R486 stated, with [MEDICATION NAME] her pain is managed/controlled, but without it, her pain level is considerably higher. When asked to describe her pain and how it has affected her over the past couple days R486 stated, I wanted to lay down and die on Sunday ([DATE]). I'm a very independent person, but because of this pain it's difficult for me to get around. The pain has slowed me down. My daily routines (hygiene and grooming, getting dressed, transferring into wheelchair, etc.) have taken me longer than usual. R486 stated her son came on Sunday and she was crabby with him due to her pain. R486 stated it was not the first time the facility has run out of her medication. On [DATE] at 12:03 pm V2 (Interim Director of Nursing) stated, medications should be reordered 7 days before running out. V2 stated she does not know why it took so long to reorder R486's [MEDICATION NAME] because the order is active and not expired. V2 stated she would assume Tylenol is not supplemental to [MEDICATION NAME]. On [DATE] at 12:04 pm, V35 (R458's physician) stated in V35's medical professional opinion, V35 would only order [MEDICATION NAME] every 4 hours rather than PRN (as needed) if the resident had constant pain. V35 stated, if [MEDICATION NAME] is ordered every 4 hours and the resident doesn't receive it than the resident will obviously be in pain. V35 stated R458 should have gotten the medication as ordered. R486's pain care plan dated [DATE] documents R486 has potential for generalized pain and pain in right shoulder. The care plan documents intervention: Administer pain medication as ordered. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. R486's Medication Administration Record [REDACTED] R486's Controlled Substances Proof of use of [MEDICATION NAME] HCL Tablet 50 mg, Date received [DATE], 18 count, documents last dose (dose #18) administered [DATE] at 09:07 am. The facility didn't faxed R486's physician request for prescription signature and DEA number until [DATE] at 6:51 am at which time R486 had missed five doses of the scheduled [MEDICATION NAME] and experienced ongoing severe pain. R486's Controlled Substances Proof of use of [MEDICATION NAME] HCL Tablet 50 mg, Date received [DATE], 30 count, documents first dose (dose #1) administered [DATE] at 12:30 am. Facility policy, (Revised (MONTH) 2012) Ordering & Receiving Medication documents: Reordering Procedures: Medication refills should be requested when a ,[DATE] day supply remains.

Based on interview, record review and observation the facility failed to identify, accurately assess and document pressure ulcers, provide the treatments as ordered and follow Infection Control policy for three of four residents (R17, R20 and R24) reviewed for pressure ulcers in the sample 23. These failures resulted in R17 and R24s' pressure ulcers deteriorating and R24 developing an additional stage II pressure ulcer. Findings include: The facility policy for Skin Management dated 8/2012 documents, A pressure ulcer is defined as any lesion caused by unrelieved pressure resulting in damage of underlying tissue. Pressure ulcers are usually over boney prominences an are staged to classify the degree of tissue damage observed. Wound Classification: The following Staging Classification is consistent with the National Pressure Ulcer Advisory Panel (NPUAP). Stage II: Partial thickness of skin loss involving epidermis and /or dermis: the ulcer is superficial and presents clinically as an abrasion, blister or shallow crater. Unstageable: When eschar is present, accurate staging is not possible until the eschar has sloughed or the wound has been debrided. Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage to underlying soft tissue from pressure and\or shear. the area may be preceded by tissue that is firm, mushy, boggy, or warmer or cooler as compared to adjacent tissue. The policy also documents, Newly admitted residents: Upon admission, all residents are assessed for skin integrity by completing a head to toe physical assessment of skin condition completing a Braden Scale. The Braden Scale Score Risk will be completed weekly for 3 additional weeks for a total of 4 weeks. Residents admitted with skin impairments will have: a physician's orders [REDACTED]. the policy documents, A Care Plan will be developed. Wounds are tracked acquired and are assessed and documented on the Weekly Pressure Ulcer Record. These records are maintained in the resident's Treatment Record (TAR) while in use. A physician's orders [REDACTED]. The facility's Glove Use policy (2012) documents the following: When gloves are indicated, disposable single-use gloves should be worn. Used gloves should be discarded into the nearest waste receptacle inside the room. Nonsterile gloves should be used primarily to prevent the contamination of the employee's hands when providing treatment or services to the resident and when cleaning contaminated surfaces. Perform hand hygiene after removing gloves. Disposable (single-use) gloves must be replaced as soon as practical when contaminated, torn, punctured, they exhibit signs of deterioration, or when their ability to function as a barrier is compromised. 1. R17 was readmitted from the hospital 6/6/2017. E4 Licensed Practical Nurse (LPN) documented the Admission Data Collection Assessment,( R17) a pressure area on the sacrum described as deep tissue pressure sore, purple in color. The wound measurements were omitted from the assessment. R17's 6/6/2017 the Progress Notes document, Resident came back to facility with a stage 2 deep tissue pressure ulcer to sacrum. Dr. requested that resident have ([MEDICATION NAME]) dressing applied every three days and (as needed). On 6/7/2017 E38 (R17's Physician) documented a readmission History and Physical, Skin, stage 2 sacral ulcer with healing parameters. On 6/8/2017 E38 visited documenting an order to Cleanse sacral wound with normal saline/ wound cleanser: apply calcium alginate soaked in [MEDICATION NAME] solution, apply gauze, cover with boarder gauze, secure with (tape) every day until healed. On 6/15/2017 Z2 Wound Care Specialist provided treatment for [REDACTED]. The wound measured 8.0 centimeters (cm) x 8.5cm x immeasurable cm. The tissue is 40 percent (%) devitalized tissue and 50% granulation tissue. Z2 documented he removed necrotic tissue and established the margins of viable tissue. Z2 recommended treatment, Santyl once daily, dry protective dressing. Zinc Sulfate 220 milligrams (mg) daily for 14 days, vitamin C 50mg twice daily and a multivitamin daily. On 6/20/2017 at 12:30PM, E5 LPN cleansed R17 sacral pressure ulcer with wound cleanser, covered the wound with a [MEDICATION NAME] soaked calcium alginate dressing, applied a boarder gauze and large absorbent dressing then taped the perimeter of the dressing. The sacral wound was triangular in shape, approximately 8.5cm 8.5cm, unstageable with gray/brown eschar tissue covering the wound bed. On 6/20/2017 E5 documented in the Treatment Record (TAR) the treatment completed was Cleanse sacral wound with normal saline/wound cleanser. Apply Santyl and dry dressing every shift. The June 2017 TAR has an order for [REDACTED]. Cover with gauze and border gauze. This treatment has not been documented as completed the entire month of June. On 6/21/2017 at 2:15PM , E4 stated, We (the nurses) do not measure the wounds. The Wound Nurse and Wound Doctor measure the wounds. (R17) had that wound before he went to the hospital. It is worse now than when (R17) returned from the hospital. During this interview E5 LPN verified she did the treatment of [REDACTED]. E5 stated, that is the current treatment, I think. E4 and E5 thought E11 LPN is the nurse in charge of making rounds with the wound doctor and measuring wounds. On 6/21/2017 at 2:30PM E11 stated, The wounds or any skin issue should be measured upon admission or readmission by the nurse. I did not know (R17) had a wound before he went to the hospital but I do not take care of (R17). I only see him when the Wound Doctor makes rounds. E11 stated, E2 (Director of Nursing) and I follow-up with the wound doctors ordered on the following day. On 6/15/2017 Z2 debrided the necrotic wound and when he finished the wound bed was pink. On 6/21/2017 at 4:45PM, E38 assessed R17 and stated, The resident did not have a dressing on. The wound has eschar present and is worse. I think he may be dehydrated and needs to go back to the hospital. E38 stated he preferred, the sacral wound dressing to be a calcium alginate soaked in [MEDICATION NAME] because the [MEDICATION NAME] keeps down the infection. I like Santyl however, it is a better treatment in a hospital situation since it is more likely the treatment will get done on a daily basis rather than being missed or having no dressing. That is not good at all. On 6/22/2017 at 4:00PM E8, Minimum data Set Coordinator (MDSC) stated R17 did not have a Care Plan for the pressure ulcers on his sacrum. On 6/22/2017 at 3:00PM, Z2 Wound Care Physician stated, I saw (R17) last week. I debrided the sacral wound. It was 50% necrotic and 40% slough. I debrided the slough but it remained unstageable. It was actually clean in some parts of the wound. It was two wounds but I measured it all as one because one was like a satellite of the other. If the wound was covered in eschar/ slough, it has deteriorated. The treatment of [REDACTED]. The [MEDICATION NAME] is drying and defeats the purpose of the calcium alginate. It is a concern if the wound has deteriorated and there was not a dressing in place when his doctor saw (R17) last night. 2. R24's Braden Scale for Predicting Pressure Sore Risk dated 2/27/17 documents R24 responds only to painful stimuli, cannot communicate discomfort except by moaning or restlessness or has a sensory impairment which limits the ability for R24 to feel pain or discomfort over half of R24's body. The pressure sore risk assessment also documents R24 is chairfast with walking ability severely limited or non-existent, makes occasional slight changes in body position, and is unable to make frequent or significant changes independently. The pressure sore risk assessment documents that R24 has a problem with friction and shear requiring staff to completely lift R24 off the bed to prevent skin damage from sliding against the sheets during repositioning. R24's physician's orders [REDACTED]. R24's POS dated 5/26/17 documents R24 was prescribed a treatment to a blister to R24's left inner heel and right heel blister every three days and as needed. R24's POS dated 1/28/17 documents that R24 was prescribed a protective barrier cream to both sides of R24's buttocks and perineal area, every shift for skin health and as needed (PRN) post incontinent care. R24's nurses' notes dated 5/11/17 at 3:56p.m., state, Noted with blackish discoloration on the right bunion area. Affected area dry, no discharge noted. Nurse's notes document R24's wound a second time on 5/11/17 at 6:01p.m. at which time the wound was described as a blackish skin discoloration, with no other wounds being mentioned in the documentation. R24's nurse's notes do not document any information about R24's right bunion wound or any other wounds after 5/15/17. A list of the facility's residents with pressure ulcers dated 6/19/17 does not include R24. R24's Treatment Administration Record (TAR) dated 6/2017 documents R24 is receiving a treatment to a bunion to the right foot two times weekly and an adhesive gauze dressing to a right heel blister every three days and as needed. R24's TAR also documents R24 is receiving protective skin barrier cream to both sides of R24's buttocks and perineal area every shift as well as after episodes of incontinence. R24's Registered Dietitian Nutrition Note dated 5/18/17 states that R24 was being reviewed for a significant weight loss with a weight of 96.8 pounds (LBS) and with an eight percent (8%) weight loss over the last 90 days. The note also documents that R24 has, Intact skin per 5/2017 wound note. The nutrition note does not include dietary recommendations to aide in the healing of R24's wounds. R24's current comprehensive care plan does not include documentation that R24 is at risk for the development of pressure ulcers or that R24 had any wounds to R24's heels, or a blister to R24's right bunion. R24's care plan does not include any interventions for the prevention of pressure ulcers. R24's Skin- Head to Toe Skin /Checks assessment dated [DATE] documents R24 had an existing non-pressure ulcer and an existing blister to the right heel which was described as dry. R24's Skin- Head to Toe skin checks dated 6/8/17 and 6/15/17 document R24's, right bunion ulcer remains the same. On 6/22/17 at 7:55a.m., E9 (Registered Nurse) entered R24's room to look at R24's dressing covering a blister to the right foot. E9 removed R24's sock and pulled the dressing back which was covering R24's foot near the big toe. The wound underneath the dressing was round and approximately 2.5cm (centimeters) in diameter with a dressing packed inside the wound which was saturated with a brownish drainage. R24 also had a dressing to the right heel which E9 stated was not covering a wound but being used as a protective measure. E9 rolled R24's right bunion dressing back into place and stated E9 would replace it later in the morning when she had time. E9 stated that she did not know if R24's right bunion wound was considered a pressure ulcer or if weekly measurements were being documented. E9 stated she did not know if R9 was being treated by a wound specialist or why R24's wound treatment had not been changed since it was initiated 5/12/17 when R9's wound was documented as an unstageable blackish skin discoloration. On 6/22/16 at 12:45p.m., E9 (Registered Nurse), E12 (Director of Care Management), E2 (Director of Nurses), and E17 (Director of Clinical Services) entered R24's room to remove R24's right bunion dressing and right heel dressing, to perform a skin and wound assessment. E9 removed R24's soiled right bunion adhesive dressing then pulled the packed gauze out from inside the wound. The gauze was saturated in a brownish drainage. The wound bed was a whitish tan center surrounded by a reddish colored tissue. E17 used a paper ruler to measure R24's wound which measured as 2.4cm wide x 1.8cm long x 0.4cm deep. E17 stated that the wound was a pressure ulcer and deep at 0.4cm but because of the whitish tan area in the center of the wound, it is considered unstageable. E9 removed the dressing to R24's right heel and also a dressing which was on the left heel. Both heels had dark brown wound beds covering the bottom right side of each heel. E17 stated that the dark brown areas to R24's right and left heels were unstageable pressure ulcers. E17 decided to examine the skin around R24's coccyx area to ensure the skin in that area was still intact. E17 noted that R24 was laying on a regular mattress without a draw sheet to enable staff to reposition R24 without sliding R24 across the sheets. E9 left the room and then returned with a draw sheet to place under R24. R9 was totally dependent on E9 and E17 to move up in bed. When E9 and E17 removed R24's incontinence brief, R24 had a new round open wound measuring approximately 0.8cm wide x 0.6 long x 0.1cm deep. E17 stated R24's new wound was a stage two pressure ulcer. E17 stated that R24's wounds should be measured weekly with the measurements and a description of the wounds should be recorded in R24's medical record. R24 stated that when R24's right bunion wound did not improve within two weeks of the initial treatment 5/12/17, and in fact had worsened from the original description of a blister. E17 stated that R24's physician should have been contacted for additional treatment orders when R24's wound did not improve after a couple weeks. On 6/22/17 at 2:50p.m. Z2 (Wound Physician) stated that the facility had contacted Z2 to examine R24 that afternoon. Z2 stated that R24's right bunion wound is considered an unstageable pressure ulcer but that Z2 expected the wound to become a stage three or four once the dead tissue is removed. Z2 stated that he would expect the facility to monitor pressure ulcer wounds, document weekly wound measurements, and to contact the physician for a change in treatment orders if the wounds have not improved within around two weeks. Z2 stated that R24 has unstageable pressure ulcers to the right and left heels, and a stage two pressure ulcer to the coccyx area also. 3. R20's current electronic physician's orders [REDACTED]. Cleanse sacrum with normal saline, apply calcium alginate soaked with [MEDICATION NAME] and dry dressing every day shift. Cleanse left ischium with normal saline, apply calcium alginate soaked with [MEDICATION NAME] and dry dressing every day shift. On 6/20/17 at 11:35 AM, E10 (Licensed Practical Nurse) performed R20's pressure ulcer treatments. E10 removed R20's sacral wound dressing exposing a Stage IV pressure ulcer approximately 8 centimeters in length x 10 centimeters wide. E10 cleansed R20's sacral wound with normal saline and then placed [MEDICATION NAME] soaked calcium alginate dressing on the sacral pressure ulcer. E10 did not remove E10's contaminated gloves, perform hand hygiene and put on clean gloves after cleaning R20's sacral pressure ulcer and prior to placing R20's [MEDICATION NAME] soaked calcium alginate dressing on R20's sacral pressure ulcer. E11 (Licensed Practical Nurse/Unit Manager) then assisted R20 to move to R20's right side exposing R20's Stage IV left ischium pressure ulcer that was approximately 3.5 centimeters in length x 3.5 centimeters wide. E10 placed a [MEDICATION NAME] soaked calcium alginate dressing over R20's left ischium wound and then covered it with a dry dressing. E10 did not cleanse R20's left ischium pressure ulcer with normal saline prior to placing the [MEDICATION NAME] soaked calcium alginate dressing on R20's pressure ulcer. On 6/20/17 at 12:20 PM, E10 verified that E10 did not remove E10's contaminated gloves, perform hand hygiene and put on clean gloves after cleaning R20's sacral pressure ulcer and prior to placing the [MEDICATION NAME] soaked calcium alginate dressing on R20's sacral pressure ulcer. E10 stated that E10 should have removed E10's gloves, performed hand hygiene and put on clean gloves after cleaning R20's sacral pressure ulcer and prior to placing the [MEDICATION NAME] soaked calcium alginate dressing. E10 also verified that R20's order documents that R20's left ischium pressure ulcer is to be cleaned with normal saline before placing the [MEDICATION NAME] soaked calcium alginate dressing. E10 verified that E10 did not cleanse R20's left ischium pressure ulcer with normal saline prior to placing the [MEDICATION NAME] soaked calcium alginate and dry dressing on the pressure ulcer.

Based on observation, interview and record review, facility failed to ensure administration of [MEDICATION NAME] as ordered for one resident (R1) out of three reviewed in a total sample of three. The failure to administer [MEDICATION NAME] as ordered resulted in R1 having a [MEDICAL CONDITION] which required treatment at a hospital. Findings include: R1's computerized face sheet lists a date of birth of 6/22/31 and [DIAGNOSES REDACTED]. Physician order [REDACTED]. For treatment of [REDACTED]. In addition to [MEDICAL CONDITION] medications, R1's Medication Administration Record [REDACTED]. [MEDICATION NAME] is a blood thinner. R1's October Medication Administration Record [REDACTED]. HOLD FEEDING 1 hour prior and After. R1 receives [MEDICATION NAME] 1.2 60 ml(milliliter) via [DEVICE](gastrostomy), off 2:00 pm, on 4:00 pm. October MAR for dates of 1, 2 and 3 lacks documentation for administration of [MEDICATION NAME] 150 mg at 8:00 am and 4:00 pm. Nursing note of 10/3/16 5:30 pm states, Res(R1) observed having Tonic Clonic [MEDICAL CONDITION] activity. 5:44 pm nursing note reports, Active [MEDICAL CONDITION] still ongoing. Increased intensity of [MEDICAL CONDITION]. Still ongoing. At 5:55 pm paramedics have arrived and R1 is transferred to the hospital. emergency room encounter dated 10/3/16 for R1 lists an arrival time of 6:02 pm. R1 is discharged back to the facility after receiving a bolus of [MEDICATION NAME] from the emergency room . Documented under the emergency room physical exam portion, R1 is found to acutely have [MEDICAL CONDITION] disorder(primary encounter diagnosis), Breakthrough [MEDICAL CONDITION], [MEDICATION NAME] level too low, and these can carry with them a high risk of complication or comorbidity Initial [MEDICATION NAME]([MEDICATION NAME]) level on admission to the emergency room is listed as critically low at less than 2.5. Facility's last [MEDICATION NAME] level prior to R1's [MEDICAL CONDITION] was within normal limits at 18.3 on 8/8/16 with a referance range of 10.0 - 20.0. On 10/18/16 at 3:20 pm, Z5(Pharmacist Consultant) via telephone was asked to determine the cause of the low [MEDICATION NAME] level and [MEDICAL CONDITION]. Z5 responded, .1st suspicion whatever caused [MEDICATION NAME] to be low caused [MEDICAL CONDITION]. Possibility not receiving for 3 days could make it(level) low. I would expect level greater then 2.5 if giving with feeding . Z5 added, .continuous enteral(by gastrostomy) feeding interferes with [MEDICATION NAME] absorption and low serum concentration affecting up to 80% (absorption) in some patients. On 10/18/16 at 2:30 pm via telephone Z1(Attending Physician) for R1 stated, Could affect absorption, giving [MEDICATION NAME] with tube feeding . Level goes down placing resident (R1) at risk for [MEDICAL CONDITION]. [MEDICAL CONDITION] could be life-threatening. Could aspirate. Long [MEDICAL CONDITION] also detrimental. I've never seen anyone die. Low level could have breakthrough [MEDICAL CONDITION]. Low level caused by? I don't know. Could be feeding or could be didn't get medicine. Don't know of anything else. Don't know if didn't get medication. E1(Director of Nursing) maintains the nurse(E5) on duty for time period of October 1st reports administering the [MEDICATION NAME] and presented copy of a write up for failure to document administration of [MEDICATION NAME]. On 10/21/16 at 1:20 pm E5(Licensed Practical Nurse) stated, .I didn't know you supposed to turn feeding off 1 hour before and after(administration of [MEDICATION NAME]). I was putting her feeding back on immediately after giving [MEDICATION NAME]. They gave inservice. On 10/13/16 from 8:50 am until 11:35 am continuous observations consisting of walking back and forth the entire length of wing 2 were completed. Continous Observations without interruption were resumed on the 2nd wing specifically for R1 at 2:55 pm and completed at 4:30 pm. On 10/13/16 at 11:25 am, E7(Licensed Practical Nurse) stated, Started with dining room for medication pass. Started at 7:15 am. First person I gave medications to after 1 person in dining room was (R1). Gave (R1) meds between 7:30 am and 8:00 am. 8:00 am medication pass, gave [MEDICATION NAME], Vitamin C. Gets pleasure feed. Gastrotomy feeding was on at 7:30 am and 8:00 am. Turned off feeding to put on hold for medications. Feeding on hold. Gave medications. Turn feeding back on. Feeding on hold for 5 to 6 minutes before gave medications which included [MEDICATION NAME] and everything due for, then (enteral) feeding resumed. E6(L.P.N) worked with R1 during the evening shift of 10/13/16. E6 at 4:20 pm drew up R1's [MEDICATION NAME] and medications taking them into R1's room. Medications were administered and at 4:25 pm, E6 turned the enteral feeding of R1 back on. On 10/13/16 at 4:26 pm E6(L.P.N) stated, (R1) check for placement(of feeding tube), took blood pressure. Flush Gastrostomy tube. Gave medications of metropolol, [MEDICATION NAME], magnesium oxide, Vitamin C, [MEDICATION NAME] 150 mg, [MEDICATION NAME] Acid. Gave medications, flush, then feeding started of [MEDICATION NAME] 1.2 @ 60 cc/hr. Hung at 4:25 pm. Medications given right before feeding. E1, E6, and E7 failed to turn enteral feeding off for an hour prior to and after administration of [MEDICATION NAME] for R1 as per the written instructions on the medication administration record. This failure contributed to subtherapuetic [MEDICATION NAME] level on 10/3/16 which led to R1 having a [MEDICAL CONDITION]. Z5(pharmacist) in her statement of 10/18/16 notes the [MEDICATION NAME] level was so low at 2.5 it was more probable R1 had not received her [MEDICATION NAME] doses at all for time period prior to 10/3/16 [MEDICAL CONDITION]. The nurses administration of the [MEDICATION NAME] with the enteral tube feeding had been occuring longer then early October timeframe as 2 out of 3 nurse observations/interviews for administration of [MEDICATION NAME] confirmed improper administration of the [MEDICATION NAME]. Nursing notes from August through October 2 do not document any [MEDICAL CONDITION].

Based on observation, interview and record review the facility failed to have an alarm or other methods in place to alert staff when a dementia resident, high risk for falls, was attempting to transfer self from a wheelchair and have two staff members available for physical support during a resident's shower and/or transfer to prevent a fall. This applies to two of three residents (R1, R3) reviewed for falls in the sample of five. As a result, R3 a dementia resident, had an unwitnessed fall and fractured the right distal femoral shaft (leg fracture). R1 slid from a chair in the shower and obtain a head injury and a laceration to the left forehead. Findings Include: 1. May 26, 2015 at 1:05 pm, R1 was sitting in the dining room in a chair with a soft helmet on head. R1 had a dressing to the left forehead from the fall incident on 5/13/15. R1's Fall Risk Evaluation: March 5, 2015 and May 18, 2015 had a score indication R1 was at high risk for falls. In March, R1 was admitted post craniotomy with a head injury. Care Plan - March 6, 2015 and 5/12/15 notes R1 as a 2 people assist with showers at all times. Minimum Data Set ((MDS) dated [DATE] and 5/27/15; documents Transfer is 4/3 indicating -Total dependence with 2 person assist. Toileting and bathing is 4/3 indicating -Total dependence with 2 person assist. Nursing Notes: May 12, 2015 at 4:10 pm documented: E5 (nurse)was called to the shower room. E5 arrived and found R1 naked on the shower floor in the stall bleeding from the left side of the head. Another nurse (E7) was in the shower room providing first aid. The left eyebrow area was cleansed and a pressure dressing applied by E7. E7 left the shower room when E5 the primary nurse for R1 arrived. May 28, 2015 at 2:30 pm E7 (nurse) stated, I am the nurse on unit 1, because the shower does not work on unit 2, the residents from unit 2 (R1) used this shower. I heard a loud cry for help from E6 (nurse aide)coming from the shower room. When I arrived to the shower room, R1 was sitting on the floor bleeding from the head. E6 stated that R1 had fallen on top of her back when E6 was cleaning feces off the floor and R1 slid out of the shower chair. I cleaned head and applied a cold compress and a pressure dressing. I left after R1's nurse (E5) arrived. May 28, 2015 at 1:20 pm E6 (nurse aide) stated, I took R1 into the shower room and soaked her body with soap and water. R1 had a bowel movement on the floor while I was showering; so I bent down to clean it up so that R1 would not slip in it. Before I could rise back up R1 was sliding out of the shower chair and fell on top of me. R1 hit head on the rail in the shower. E6 was asked if she knew R1 was a two person assist in bath. E6 stated her colleagues had their own residents to take care of. E6 was asked if a communication book is available to tell how residents are transferred or cared for. E6 responded we do not have any book or anything to tell us about the resident. E6 stated this was her first time showering R1. I did not know R1 was a two person assist. I feel very bad that I hurt R1, I like R1 ' s family and was just trying to clean R1 up. May 28, 2015 at 2:16 pm E5 stated, while passing medications on unit 2; I was called to unit 1 for an emergency. I went to unit 1 shower room, R1 had fallen the shower. Another nurse E7 had given first aid to (R1). I took over the treatment; E5 was still with me in the shower. R1 was sitting on the floor naked and very soapy. R1's head was hit on the safety bar when R1 fell out of the shower chair. R1 was assisted to the wheel chair by 4 staff; because R1 was very slippery from being soaped up in the shower. E5 was asked if E6 was made aware of R1 ' s two person assist when bathing/transferring. E5 stated we usually bath R1 in the bed because R1 moves so much. R1 was assessed, physician and family made aware of the incident and injury. Physician requested that R1 be sent to the local hospital for evaluation. June 3, 2015 at 12:02 pm, Z1 (Primary Physician) stated I am very shocked regarding R1's injuries/incident falls. R1 is very high risk for falls; R1 came to us a couple months ago with a helmet on head from a previous craniotomy. R1 has to wear the helmet all the time. Due to R1's weight and weakness, R1 is too weak and the staff needs to be more attentive and assist more frequently when needed. R1 needs to always have two people to help with bathing/transfer. I was made aware of the injury when it happened; I ordered the patient be sent out chair while being to the hospital right away. Incident/Accident Report: May 12, 2015 at 4:10 pm, R1 in shower stall on floor with gash on left eyebrow, abrasion to left eyebrow. Incident Reporting to Public Health: Initial and Final documents dated 5/13 and 5/18/15; R1 propelled self out of shower chair. Hit head on floor causing lacerations. Resident sent to hospital and returned with three sutures. Hospital emergency room Records dated May 12, 2015 documented the following: Impression- [AGE] years old with head injury and laceration to the forehead from a fall in the shower at nursing home. Computerized Tomography (CT) scan was performed without intravenous contrast. R1 had a subdural hematoma from a previous surgical procedure (craniotomy) in March 2015. An acute infarction may not be apparent on CT for up to 24-48 hours. No fracture of the spine is indicated. Three sutures applied to the left forehead. 2. May 27, 2015 at 11:10 am, R3 was in the dining room sitting in wheel chair. R3's left upper lip was very swollen, under the nose the entire bottom part of face is swollen with discoloration of redness. Incident Report May 25, 2015 at 6:10 pm indicated, R3 was noted sitting on floor in front of bathroom door, bleeding from mouth and bridge of the nose. Nurse Notes May 25, 2015 at 10:00 am, R3 noted with swollen lip bruising under the left eye and redness to bridge of the nose status [REDACTED]. The fall Investigation Report: Notes nurse was making rounds at 5:45 am and found residents sitting on floor bleeding, fall was un-witnessed. Care Plan- Falls: R3 has history of falls, balance problem with standing, decreased muscle coordination, seizures and osteoporosis. Bed and chair alarm to be applied. SBAR Communication Form: status [REDACTED]. Interdisciplinary Post Fall Review: Resident stated she was going to washroom, noted in sitting position in bathroom doorway. Bleeding noted from mouth and bridge of nose is red. Bed alarm applied to bed. Another incident Report dated November 26, 2014 documented: R3 observed in sitting position in bath area, resident got up to go to the bathroom to get dressed. No apparent injuries noted. Nursing Notes: No documentation on the incident for 11/26/2014 from any shifts. Nursing Notes 11/27/14 10- 6 shift (not indicated if am or pm); resident aroused for signs and symptoms of discomfort. No pain rating was documented, no other information documented. Nursing Notes 11/28/2014, 10-6 shift (not indicated if am or pm) resident observed sleeping in bed, complaining of pain in right knee area. Tylenol 650 mg. was given. X-ray negative for fracture. Faxed to Z1 (physician), family made aware of the incident. Nursing Notes 11/28/14 at 10:10 am, Z1 called regarding swelling and pain to knee. Z1 ordered R3 be sent to local hospital. Nursing Notes 11/28/2014 at 2:30 pm, facility received call from local hospital that R3 was admitted to the hospital for a leg pain and hip fracture. Incident reporting to Public Health: Initial Report -November 28, 2014, Resident attempted to self transfer from bed. Final Report December 3, 2014, Resident attempted to self transfer from bed. Interdisciplinary Post Fall Review: November 26, 2014- R3 was observed in sitting position on bathroom floor, resident got out of bed unassisted. Tab alarm for bed and chair. Place pad alarm to bed. Fall Risk Evaluation: November 2014 = 17 - May 2015 = 18. Total score of 10 or above represents High Risk for fall. Fall Care Plan - R3's care plan was not updated since 3/13/15, R3 had another fall on 5/25/15. E1 (Administrator) and E2 (Acting Director of Nursing) was asked for the policy and procedures of updating care plans after an incident. E1 and E2 stated the facility has no such policy. Minimum Data Set (MDS) assessment dated [DATE] and 5/29/15, R3 was scored as a 3= Extensive assistance in self performance and a 2= One person physical assist. R3's hospital record for the admission 11/28/2014 documented: [AGE] years old with multiple medical problems including dementia for evaluation of femur fracture after a fall in nursing home. Plain films femur fracture with distal femoral shaft. Resident is unable to relate any information related to the fall. 12/02/14- Underwent a surgical procedure - Percutaneous repair of right distal femur fracture. R3 was discharged from the hospital back to the facility on [DATE]. June 3, 2015 at 12:05 pm, Z1 (Physician) stated it was shocking to hear about the fall on 12/4/14. R3 is very dementia and requires that the staff watch her more closely and frequently address her needs. Z1 stated R3 needs more supervision because of the age, weakness and dementia. I was made aware of the fracture of the femur. Z1 was asked if resident is able to get up and go to the bathroom by self. Z1 stated no, R3 is too weak and frail. Z1 stated the incident on 5/25/15 resident is too weak and requires a two person assist to help with all care all the time. Z1 stated I do not feel these residents can transfer themselves without 2 person assist due to age and weakness.