Every finding on record at Arc at Bradley

Based on interview and record review, the facility failed to maintain an adequate on-hand supply and/or acquire prescribed medications in a timely manner. This applies to 1 of 4 residents (R1) reviewed for pharmaceutical services. The findings include:On 08/11/26 at 9:42 AM, R1 was sitting on her bed in her room. R1 stated for the entire weekend of 07/24/26-07/26/26, the facility did not have acetaminophen in the building. R1 stated she had current orders to receive acetaminophen every six hours as needed for pain to her right shoulder. R1 stated on 07/24/26, she asked the evening nurse for acetaminophen and was told there was no acetaminophen in the building. R1 stated the pain to her right shoulder was a seven out of ten. R1 stated she was not able to take any medication on Friday night for the pain. R1 stated she did not want the pain to get worse, so she decided to order acetaminophen from the local grocery store through an online delivery service. R1 stated the acetaminophen was delivered to her on 07/25/26. R1 stated when the acetaminophen was delivered to her, she gave the unopened bottle of medication to V4 (RN/Registered Nurse). R1 stated V4 administered two of the pills from the bottle of acetaminophen that she purchased. On 08/11/26 at 11:38 AM, the medication which contained medications for the hall R1 resided on was observed. V2 (DON/Director of Nursing) and V3 (RN) were at the cart with the surveyor. One bottle of Tylenol Extra Strength, Rapid Release Gels 500 mg, 225 gelcaps with R1's name written on the bottle, was found in the bottom of the cart. On 08/11/26 at 2:40 PM, V4 stated he did not work on 07/24/26. V4 stated on 07/25/26 he checked all the medication carts in the building, the overflow carts, and the stock room where there OTC (Over the Counter) medications are kept. V4 stated none of those places had any acetaminophen. V4 stated on 07/25/26, R1 gave him an unopened bottle of Tylenol that she had purchased from the store. V4 stated the seal to the medication was still intact. V4 stated he administered two pills to R1 from the bottle of medication that she gave him. On 08/11/26 at 3:21 PM, V3 (RN) stated a few weekends ago, a nurse was searching through all of the medication carts for acetaminophen. On 08/11/26 at 3:57 PM, V2 (DON) stated she was not aware the facility did not have acetaminophen for the weekend of 07/24-07/26/26. V2 stated if OTC medications are not in the facility, the clinical manager should be informed so they can purchase the medication or get them from the sister facility. V2 stated residents should not have to order their own medications through online delivery services from grocery stores. V2 stated if residents order their own medications, they could get the wrong dose, wrong amount, or it can get into the hands of others. V2 stated if pain medications are not given in a timely fashion, the pain can become uncontrolled and not easily manageable.On 08/11/26 at 9:42 AM R1 provided the receipt from an online grocery delivery and pickup service for a bottle of Tylenol 500 mg. The receipt showed the Tylenol was delivered to R1 on 07/25/26. R1's MAR (Medication Administration Record) for July 2026 showed R1 had an order for Acetaminophen by mouth every six hours as needed for pain. The same MAR showed R1 was administered Acetaminophen on 07/25/26 at 11:20 PM and 07/26/26 at 9:45 PM. The MAR showed R1 did not receive Acetaminophen on 07/24/26. R1's Risk for Pain care plan dated 01/23/26 showed, Interventions: administer analgesia as per orders.The facility's Medication Administration Policy dated 01/2015 showed, Administration of Medications: Medications must be administered in accordance with a physician's order e.g., the right resident, right medication, right dosage, right route, and right time.

Based on observation, interview, and record review, the facility failed to ensure a resident received timely incontinence care.This failure applies to 1 of 3 residents (R1) reviewed for incontinence care.Findings include:R1's health record shows he is a [AGE] year-old male with diagnoses including dystonia (neurological movement disorder), type 1 diabetes, hydrocephalus (brain fluid disorder), muscle wasting and atrophy, and cognitive communication deficit who was admitted to the facility April 17, 2026.On June 08, 2026 at 1:13 PM, V9 (Friend) said approximately 3 weeks ago, R1 was in the dining room during dinner. V9 said R1 had wet through his pants, his chair cushion, and the urine had leaked onto the floor. R1 was wearing double incontinence briefs and leaked through it all. A team leader was called to dining room to see and clean up the urine. V9 said approximately a week or week and a half ago, R1 triggered his call light to be changed, a staff responded by coming into the room, turning the call light off, V9 said she asked the aide to change R1, the aide advised she performs rounds every two hours and although R1 was soaked the aide told her R1 would have to wait until she was doing her rounds. V9 said she believes if residents are soiled, they are supposed to be changed and not have to wait for them to do their every 2 hour rounds. V9 said it was almost 2 hours before that staff member returned. R1's current care plan initiated April 18, 2026, shows he has a self-care performance deficit for activities of daily living related to weakness, impaired mobility, dystonia, and hydrocephalus and, requires assistance with toileting and is incontinence bladder and wears briefs; and R1 has urinary incontinence with interventions including incontinence management program as needed, monitor for incontinence and change as needed; and remind/cue to go to the bathroom.On June 08, 2026 at 10:20 AM, R1 was sitting in the dining area.On June 08, 2026 at 11:23 AM, R1 was sitting in the dining area.On June 08, 2026 at 11:59 AM, R1 was sitting in the dining area.On June 08, 2026 at 12:30 PM, R1 was in the dining area eating.On June 08, 2026 at 12:45 PM, R1 was sitting in the dining area.On June 08, 2026 at 1:10 PM, R1 was sitting in the dining area.On June 08, 2026 at 3:18 PM, V13 (Occupational Therapist) said she transferred R1 to therapy from the dining area at approximately 2:00 PM.On June 08, 2026 at 2:25 PM, R1 was in the therapy room receiving physical therapy.On June 08, 2026 at 3:00 PM, V9 (Friend) said while R1 was in therapy, the therapist said she noticed his wheelchair was wet. On June 08, 2026 at 3:15 PM, V12 (Physical Therapist) said she noticed R1's wheelchair was wet during therapy but wasn't sure what caused the wheelchair to be wet.On June 08, 2026 at 3:59 PM, V8 (Certified Nursing Assistant) said she provided incontinence care to R1 at 9:00 AM and 11:00 AM and he had urinated. V8 said she left the facility close to 2:00 PM and last saw R1 in the dining room before he went to therapy.On June 08, 2026 at 3:05 PM, R1 was transferred in his wheelchair to his room by V6 (Certified Nursing Assistant) then transferred from his wheelchair to his bed by V6 and V7 (Certified Nursing Assistant). R1's wheelchair padding was very wet with a faint urine odor. V7 removed R1's pants to begin incontinence care and said R1's pants were soaked with urine. V6 removed R1's brief and said R1's brief was pretty wet. V7 showed surveyor R1's incontinence brief and it was saturated with urine.On June 09, 2026 at 10:16 AM, V2 (Director of Nursing) said nursing staff should be performing rounds at a minimum of every 2 hours to check residents for incontinence needs. On June 09, 2026 at 11:50 AM, V8 (Certified Nursing Assistant) said R1 heavily urinates and needs to be checked for incontinence frequently. V8 said she attempted to check R1's brief to determine if he needed incontinence sometime after lunch and before she left yesterday around 2:00PM. V8 said she tried to identify what staff would be relieving her to let them know R1 needed to be checked for incontinence however she could not and did not inform anyone else about this before she left for the day.On June 09, 2026 at 11:55 AM, V2 (Director of Nursing) said if V8 last changed R1 yesterday at 11 AM, R1 should have been checked and changed around 1:00 PM. V8 should have let the oncoming staff know to check R1 for incontinence care needs before she left for the day. V1 (Administrator) said V8 also could have informed V2 or the charge nurse that R1 needed to be checked for incontinence care needs.The facility's Incontinence Care Policy received 06/09/2026 shows:The purpose of the policy is To prevent excoriation and skin breakdown, discomfort and maintain dignity. Incontinent resident will be checked periodically in accordance with the assessed incontinent episodes or approximately every two hours.

Based on interview and record review, the facility failed to properly transfer a resident from his bed to the wheelchair. This failure resulted in the resident sustaining an impacted spiral fracture of the left humerus. This applies to 1 of 3 residents (R2) reviewed for injuries in a sample of 3.Findings include:R2 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including heart disease, chronic atrial fibrillation, hypertension, and a history of traumatic brain injury. On 5/15/26, R2 was admitted to the hospital for an impacted spiral fracture of the left humerus and discharged on 5/18/26. On 5/27/26 at 11:35 am, R2 left shoulder and upper arm were observed swollen with purple coloring to the skin.On 5/27/26 at 11:50 am, V7 (R2's family member) said that on 5/15/26, she came to visit R2, and when she touched his left shoulder, he jumped and told her that his shoulder hurt. V7 said she reported it to R2's nurse.On 5/27/26 at 2:35 pm, V5 (Nurse) said she was R2's nurse on 5/15/26 and V7 reported to her that R2's shoulder was swollen and bruised. V5 said she examined R2's shoulder and saw that it was swollen. V5 said she reported it to the doctor and an x-ray was ordered. V5 said the x-rays were done at the facility.On 5/28/26 at 2:17 pm, V1 (Administrator) said he investigated R2's injury of unknown origin and had determined that in the early morning of 5/15/26, V6 CNA (Certified Nursing Assistant), transferred R2 by herself and did not use a mechanical lift, and that was how R2's left humerus was fractured. V1 said when he interviewed V6, she admitted she transferred R2 by herself and did not use a mechanical lift. V1 said that R2 requires two staff and a mechanical lift for all transfers. V1 said that if V6 had used the mechanical lift and had 2 staff for the transfer, R2 would not have had a fracture. On 5/28/26 at 2:39 pm, V2 (Director of Nursing) said that R2 is dependent on staff for all ADL (Activity of Daily Living) care and is unable to get in and out of his bed or chair by himself. V2 said that on 5/15/26, V6 transferred R2 by herself and did not use a mechanical lift and that caused R2's fracture to his left arm.On 5/28/26 at 10:46 am, V9 APRN (Advanced Practice Registered Nurse) said that on 5/15/26, R2 had an impacted spiral fracture. V2 said that an impacted spiral fracture can only be caused by blunt force trauma, compression, and rotation at the same time. V9 said that R2's fracture was not caused by any medical condition, it was caused by blunt force trauma. V9 said that the improper transfer caused this fracture. V9 said that if the staff had transferred R2 using 2 staff and a mechanical lift, he would not have sustained a fracture.On 5/27/26 at 1:47 pm, V3 CNA (Certified Nursing Assistant) said that R2 is a 2-person mechanical lift transfer, but sometimes staff including herself transfer R2 by themselves.On 5/27/26 at 2:27 pm, V4 (CNA) said that R2 is a two-person mechanical lift transfer, but sometimes he has had to transfer R2 by himself.On 5/27/26 and 5/28/26 several attempts were made to interview V6 (CNA), but she would not make herself available.R2's Nursing Note dated 5/15/26 at 4:03 PM, showed that the nurse observed R2's left upper arm was swollen. R2 was examined by the doctor, and X-rays of the left forearm and upper arm were order. R2's 5/15/26 X-ray report showed that R2 had an impacted spiral fracture of the left humerus.R2's 5/18/26 hospital discharge summary showed that R2 was seen by ortho for a left humeral fracture, and R2 is to follow up with an orthopedic physician as an outpatient.R2's 5/19/26 MDS (Minimum Data Set) showed that R2 is dependent on staff for transferring.R2's 1/14/26 care plan showed a focus on ADL (activities of daily living) self-care deficit with interventions including dependent on two staff for transfers with a mechanical lift.The facility's Addendum to the 5/15/26 State Survey Agency Report of Unknown Injury, showed that the cause of R2's fracture was due to an improper transfer by a facility staff.The facility's Transfers- Manual Gait Belt and Mechanical lifts policy dated 12/2025, showed that the purpose is to protect the safety and well-being of the staff and residents and to promote quality care. The policy showed that the mechanical lifting devices shall be used for any resident needing a two person assist.

Based on observation, interview, and record review, the facility failed to maintain residents' rooms and bathroom areas in a safe, clean and homelike condition. This failure applies to 5 of 7 residents (R1, R3, R4, R5, and R6) reviewed for environment.Findings include:1. R5 was a [AGE] year-old male with diagnoses that included a history of brain aneurysm, recurrent major depressive disorder, and presence of vascular implants and grafts who was admitted to the facility March 29, 2022. On May 13, 2026 at 9:35 AM, in R5's bathroom, there was a heavy presence of rust on the ceiling vent and shower tile, a heavy presence of a thick dark substance and stains throughout the floor, cracked and peeling ceiling paint, a loose handle bar, visible rust stains on another handle bar, and on the frame of a toilet commode. R5 said he would like the maintenance issues addressed when maintenance is available to get to it, there is only one maintenance staff. 2. R1 is a [AGE] year-old female with a diagnoses history of paraplegia, spinal cord injury at birth, scoliosis, muscle wasting and atrophy, dependence on wheelchair, cellulitis of toe, and personal history of other mental and behavioral disorders who was admitted to the facility September 10, 2026. On May 13, 2026 at 9:45 AM, in R1's bathroom there was a broken towel rack, a large amount of heavy dark stains on the shower tile. R1 said her bathroom had been in that condition for some time and needs to be cleaned and serviced. 3. R4 is a [AGE] year-old female with a diagnoses history of schizophrenia, recurrent major depressive disorder, COPD, and muscle wasting and atrophy who was admitted to the facility August 25, 2023. On May 13, 2026 at 9:58 AM, in R4's bathroom heavy dust was present under the vent unit, the bathroom tile and baseboard cover was peeling away from the wall in multiple areas, a heavy presence of dirt was visible on multiple areas of the floor and in the corners of the floor, a heavy presence of rust was visible on the ceiling vent cover, and heavy thick dark stains were present in the gaps between the shower tile. R4 said she would like these conditions in her bathroom to be addressed. 4. R3 is a [AGE] year-old male with a diagnoses history of partial paralysis due to stroke, and hypertension who was admitted to the facility February 25, 2026. On May 13, 2026 at 12:55 PM, yellow stains were present on R3's room ceiling above his bed and R3's wallpaper on the wall next to and above his head was heavily tattered and torn in multiple areas. There were several holes present on the ceiling above R3's bed. R3 said the facility is aware of these issues and he would like them to be fixed. 5. R6 is a [AGE] year-old male with a diagnoses history of malignant cancer of the rectum and depression who was admitted to the facility March 06, 2026. On May 13, 2026 at 1:05 PM, in R6's bathroom was a large amount of yellow substance and dust was present in the tub, a heavy thick black substance present in the gaps between the tile surrounding the tub, the ceiling paint above the tub was cracked, peeling, and uneven over a large surface area, a visible brown drip like substance was present throughout the vent unit and wall between the toilet and the vent, a large amount of heavy thick dark substance was present underneath the vent unit and in the corner of the floor, and a heavy amount of dirt, debris, and trash was present on the floor underneath the vent unit and behind the toilet. R6 said his bathroom was in this condition since he was placed in the room. R6 said he would like his bathroom serviced if possible. On May 13, 2026 at 2:11 PM, V1 (Administrator) said there should not be any visible dust, dirt, trash, stains, rust, peeling or cracked paint, peeling tile, peeling baseboards, or broken equipment in residents room areas, the residents rooms, or bathrooms. V1 said he expects maintenance and housekeeping staff to maintain the resident's rooms and bathrooms to be in a homelike condition. V1 said if there is an observation of these conditions they should be addressed promptly. V1 said staff should be monitoring the conditions of the resident's rooms and reporting any issues. V1 said as of three weeks ago they were down to one maintenance staff. In response to a request on 05/14/2026 for maintenance policies the facility provided their Director of Maintenance Job Description which shows:The primary purpose of the Maintenance Director includes maintaining the facility in a safe and comfortable manner.Essential duties and responsibilities include; Repair facility/resident property as necessary. In response to a request on 05/14/2026 for housekeeping policies the facility provided their Housekeeping Supervisor Job Description which shows:The primary purpose of the Housekeeper Supervisor includes assuring the facility is maintained in a clean, safe, and comfortable manner.Essential duties and responsibilities include; Ensure that work/cleaning schedules are followed as closely as practical. Clean, wash, sanitize, and/or polish bathroom fixtures etc. Clean floors including sweeping, dusting, damp/wet mopping.

Based on observation, interview and record review, the facility failed to supervise a resident's smoking activity and failed to implement interventions to prevent her from sustaining burn injuries. This failure resulted in a resident sustaining blistered (second degree) cigarette burns.This applies to 1 of 4 (R1) residents reviewed for smoking safety in a sample of 5.The findings include:The facility's Reportable Incident form showed that on 4/6/26 at 11:40 AM, R1 was observed with a wound to left side of chest. [R1] was outside on a smoke break and was wearing the smoker's apron. Resident was observed with what appeared to be a cigarette burn on the left side of her chest. Root cause determined to be burn caused by cigarette ash due to windy conditions, smoker's apron flew up while smoking during smoke break.On 04/29/2026 at 1:31 PM, the resident smoking activity was observed. Staff placed a smoking ring (device that holds a cigarette) on R1's left index finger. R1's smoking apron was placed in a manner that left R1's left upper chest exposed, and the neck ties on the apron were left unsecured. R1's previous burn mark was visible on R1's left chest. R1's bilateral upper extremities and fingers were contracted, and she was positioned in a reclining wheelchair. Staff lit R1's cigarette then cigarette ashes were seen dropping down the front of R1. While R1 was smoking, V6 (Activity Aide) walked away from her to assist another resident into the building.On 04/29/2026 at 1:59 PM, V6 stated she was doing the one-on-one observation of R1 but did not realize she walked away from her while her cigarette was still lit. V6 stated the smoking ring that holds R1's cigarette sometimes slips from R1's finger and has caused her fingers to be burned in the past. On 04/29/2026 at 12:29 PM, R2 stated V6 (Activity Aide) and another unknown Activity Aide were working when R1 was burned. R2 stated R1's smoking apron blew up from the wind when R1 was burned. R2 stated she had to go in and get the nurse because no one was outside when it happened. R2 stated the staff lit the cigarettes then left the residents outside unsupervised. R2 stated it was cold and windy, and the staff don't like to be out in the cold.On 04/30/2026 at 1:02 PM, V2 DON (Director of Nursing) she interviewed R2 and V3 RN (Registered Nurse) about how R1 got burned. V2 stated R1 had been burned before she started working in the facility. V2 stated she expects staff and residents to follow the smoking policy and smoking contracts.V2's 4/7/26 written interview of R2 showed R2 said she was outside and sitting by [R1] during smoke break. She said [R1] had smoker's apron on, it was windy, and the apron flew up. She reported to the nurse what happened. On 04/29/2026 at 4:24 PM, V3 RN (Registered Nurse) stated she was informed by the residents and an Activity Aid when R1 was burned. V3 stated R1 had two blisters that formed on her left upper chest near her clavicle. V3 stated she saw R1 after the staff brought her inside and the smoking apron had already been removed. V3's 4/9/26 written statement about the incident showed another resident, [R2], approached this writer to report that resident [R1] had sustained burns to her chest while smoking in the courtyard.Resident was observed with two cigarette burns on the left side of the chest. R1's 4/5/26 progress note (written by V3) showed R1 observed with two cigarette burns on the left side of her chest. Resident reported stinging pain.The facility's Patient Safety insert for the Smoker's apron showed Instructions: B) Seat resident in wheelchair and drape apron over the resident. Secure the apron by engaging the hook and loop neck strap at the top of the apron. Adjust the neck strap until the apron reaches just below the neckline. C) IMPORTANT: Engaging the side straps- to prevent cigarettes and ashes from falling between the resident and the wheelchair, ALWAYS drape the apron over the arm rests and wrap the side-straps around and under the arm rests and securely engage the side-straps hook and loop to the underside of the apron. The insert continued .The apron is not a substitute for proper supervision.On 04/29/2026 at 1:48 PM, V5 Activity Aide stated she had placed the smoking apron on R1. V5 stated the apron should be secured all the way up to the neck so that residents don't get burned. V5 stated she did not pull the apron all the way up to R1's neck and secure the ties because R1 would complain if she did. V5 stated R1 requires one-on-one smoking assistance since she was burned. V5 stated she was not with R1 when she was originally burned, but the facility did an in-service regarding one-on-one smoking observations and ensuring the apron is properly placed on R1. V5 stated that while staff are monitoring the smoking activity, they should ensure residents are dressed appropriately for the weather and are smoking safely.On 04/29/2026 at 1:21 PM, R1 stated she is unable to tap her ashes and staff don't hold her cigarette for her or tap her ashes and they roll onto her smoking apron. R1 stated when she was burned, the staff were not paying attention to her.On 04/29/2026 at 3:57 PM, R4 stated there are some staff that go inside instead of staying outside with them while they are smoking. R4 stated the staff allowed R1 to smoke by herself and she got burned on her left chest.R1's 2/25/26 Minimum Data Set (MDS) showed R1 was moderately cognitively impaired, and she was dependent on staff for eating, oral hygiene, bathing, and dressing. The facility's Smoking Safety policy (retrieved 04/2026) showed The following behaviors and/or conditions will jeopardize and/or cause revocation of the person's independent privileges: Cognitive impairment, poor judgment, compromised manual dexterity and/or mobility.On 04/29/2026 at 2:18 PM, V4 (Activity Director) stated that the Activity Aides should make sure the residents smoke safely. V4 stated the staff member doing the one-on-one monitoring for R1 should stay near her while she is smoking. V4 stated staff should ensure the smoking apron is all the way up to the neck and secured with ties as well as tucked on the sides to ensure it does not blow up. V4 stated R1 should not have any part of her chest exposed. R1's diagnoses include relapsing multiple sclerosis, scoliosis, chronic obstructive pulmonary disease, age-related macular degeneration, alternating exotropia dysarthria and anarthria. R1's smoking assessment dated [DATE] states she requires assistance and supervision with smoking and a smoking apron. R1's 4/8/24 smoking care plan showed a 12/8/2025 intervention of to wear the proper smoking apron while smoking. R1's electronic medical record contained an earlier progress note from 12/9/25 that showed Resident was smoking a cigarette when the ashes fell on her chest and created a burn. Resident stated that she was smoking, and her bib fell down. Intervention- staff to assist resident when smoking and ensure bib is in place before smoking. A second care plan intervention initiated 4/6/26 and created 4/7/26 showed staff to do 1:1 assistance while resident is smoking. R1's Wound assessment notes from 1/1/26 showed Type- burn; Classification- thermal-heat; Source- facility-acquired; Date Identified- 12/16/25. R1's Wound assessment notes from 4/16/26 showed Type- burn; Classification-thermal-heat; Source- facility-acquired; Date Identified- 4/6/26. On 04/30/2026 at 2:18 PM, V1 (Administrator) stated the Activity Aides need to be outside with the residents when they are smoking to assure the residents are safe and following the policy. V1 stated staff can't effectively monitor the smoking activity from inside the building. V1 stated staff are not required to provide one-on-one observations of R1 during her smoking activity, but staff should not walk away from R1 when she is smoking. V1 stated the smoking apron needs to be up and tied to be effective. If cigarette ashes are falling on a resident's side or chair that is not a safe smoker. On 04/30/2026 at 1:52 PM, V9 (Activity Aide) stated on the day R1 was burned, she was responsible for monitoring the smoking activity. V9 stated she was inside the building watching the residents. V9 stated it is not enforced for them to keep an eye on all the residents while they are smoking. V9 stated when R1 was burned, the smoking apron was not pulled up to R1's neck and tied. V9 stated she was alerted to there being a problem when the residents started yelling for her to come out. V9 stated since being burned, R1 requires one-on-one monitoring. V9 stated that when the other residents are out smoking, she only needs to make sure they aren't sharing cigarettes.On 05/01/2026 at 9:46 AM, V10 (Physician) stated if the smoking apron was applied correctly, it would have prevented R1's burn injury. V10 stated the staff only told him that the apron blew and that caused R1's burn. V10 stated if staff are inside the building while the residents are outside smoking, the residents are not being monitored. V10 stated the facility staff should be present and aware if residents are passing smoking materials around, dropping cigarette ashes on themselves, or if ash is blowing back on the residents.The facility's 4/30/23 Smoking Policy Acknowledgement showed Staff Responsibilities: Assigned staff will monitor Residents on the Smoking Program: Staff will remain in the designated area, during the entire scheduled smoking time with the residents.

Based on observation, interview and record review the facility failed to provide bathing assistance to residents dependent for assistance. This applies to 2 of 4 (R2, R3) residents reviewed for bathing in a sample of 4 residents. Findings include: On 6/17/25 at 11:25 AM, R3 stated she had missed getting showers. R3 stated she was supposed to be switched to evening shift for baths. Last week no one could tell her who the shower aid was. R3 stated was then told she was not on the list for her Tuesday showers. During the interview R3 was noted with an unpleasant odor. On 6/17/25 at 11:36 AM, R2 stated she had not gotten her bed bath on Wednesday the prior week. R2 stated she prefers bed baths to showers. R2 stated there is a regular occurrence that she misses her bed bath. She brought the issue up in the last resident council meeting and had spoken to the social worker about her missed bed baths. R2 stated she never refuses a bed baths because she only gets them twice per week and she wants them done. During the interview R2 was noted with an unpleasant body odor. On 6/17/25 at 11:47 AM, V3 CNA (Certified Nursing Assistant) stated residents receive two showers per week and they are documented on the shower sheet and in the electronic medical record. If residents refuse their showers, they must sign the shower sheet to documents the refusal. On 6/17/25 at 02:04 PM, V5 RN (Registered Nurse) stated there is a shower aid that completes residents' showers and shower sheets. Nurses sign the shower sheets to note any skin issues and verify the shower was completed. On 6/17/25 at 02:17 PM, V8 Social Services Director stated both R2 and R3 have brought concerns of missed showers to her attention. V8 stated R3's shower had been switched to the evening shift On 6/17/25 at 02:29 PM, V6 RN stated R3 is compliant with her care and was not aware of R3 declining to be showered. On 6/17/25 at 02:43 PM, V1 Administrator stated residents are showered twice per week. The showers are documented on shower sheets and in the electronic medical record. If a resident misses their bed bath or shower it is made up the next day. If a resident refuses a shower social service should intervene and do education. On 6/17/25 at 03:03 PM, V2 ADON (Assistant Director of Nursing) stated R2's has had missed bed baths that were made up the following day. V2 stated R3's bed baths had been switched to the evening shift and she had not missed any showers. On 6/17/25 at 03:48 PM, V7 CNA (Certified Nursing Assistant) stated residents receive two showers per week and they are documented on the shower sheet and in the electronic medical record. If residents refuse their showers, they must sign the shower sheet to documents the refusal. R2 submitted a grievance form on 3/27/25 stating she had not been bathed for a week. The resident council minutes from 6/12/25 documents R2's complaint of not being bathed on 6/11/25. R3 submitted a grievance form on 3/21/25 stating she had not been showered after requesting a shower. The facility Care Plan item task listing report dated June 17, 2025, shows R2's showers are scheduled on Monday and Wednesday on the PM shift. R3's showers are scheduled Tuesday and Friday on the AM shift. Review of R2's current care plan states she has an ADL (Activity of Daily Living) self-care mobility performance deficit and requires substantial / maximal assistance with bed baths. R2's Shower sheet documentation show she had four documented bed baths in March 2025 on 3/3, 3/19, 3/24 and 3/31. June 2025 R2 had documented bed baths in June 2025 on 6/2, 6/4, and 6/9. The facility did not provide any computer documentation of baths provided to R2 for March or June 2025. R3's current care plan identifies an ADL self-care performance deficit. R3 requires partial to max assist of one staff with bathing and showering as necessary. R3's shower sheets and electronic medical record documentation shows in March 2025 she was showered on 3/13 and was not showered again until 3/28. The facility policy Bathing Shower and Tub Bath dated 10/2024 states the purpose to ensure resident's cleanliness to maintain proper hygiene and dignity. A shower, tub bath or bed / sponge bath will be offered according to resident's preference, no less than once per week or according to the resident's preferred frequency and as needed or requested.

Based on interview and record review, the facility failed to transfer a dependent resident safely by failing to use a mechanical lift with two staff assistance for one of four residents (R1) reviewed for accidents. This failure resulted in R1 sustaining an acute nondisplaced proximal tib (tibia)-fib (fibula) fracture. Findings include: The facility's 2/24/2025 Report to the State Survey Agency showed R1 .was observed on his right side Stat Xray done .Upon investigation that included review of clinical records, assessment, hospital documentation, and statements of staff on duty; it was found that resident is a 2 transfer assist This serves as final report. On 03/02/25 at 9:42 AM, R1 stated her fall occurred when the CNA (Certified Nursing Assistant) was trying to put her in the shower chair. R1 stated there was only one CNA assisting her to transfer. R1 stated she fell , and her left leg was hurting. R1 stated the CNA told her Your leg is fine. R1 stated her left leg is broken in two places. On 03/02/25 at 1:33 PM, V2 (Director of Nursing) stated An investigation was done; V13 (CNA) used the wrong transfer technique. V2 stated V13 lifted R1 for the transfer by herself and did not use a mechanical lift. V2 stated the correct transfer technique for R1 is a mechanical lift with two assistance. V2 stated the x-ray came back in the afternoon, and it showed an acute nondisplaced proximal tib-fib fracture. V2 stated V13 knew very well that she should have transferred R1 with a mechanical lift and two assist. V2 stated when residents are not transferred appropriately, they could have a fall with injury to both the patient and the staff, adding in this case, the resident had a fall with an injury. On 03/05/25 at 3:10 PM, V13 stated she was the CNA taking care of R1 when she fell and got injured. V13 stated she was trying to lift R1 without a mechanical lift and with no assistance from another staff member. V13 stated R1 became too heavy, and she lowered her onto the floor. V13 stated R1 was complaining of pain to her legs. V13 stated she had worked with R1 before and knew R1 transferred with a mechanical lift. On 03/04/25 at 9:41 AM, V4 (Nurse Practitioner) stated R1 has a non-displaced fracture to the lower left leg. V4 stated the CNA was transferring R1 into her chair, and she slid and fell . V4 stated R1 is supposed to be transferred by a mechanical lift, with two staff members due to her contractures. V4 stated the fracture was the result of the CNA transferring the resident inappropriately and the fracture could have been prevented if the resident was transferred with a mechanical lift and two staff instead on one staff. R1 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, lack of coordination, abnormal posture, dysarthria, reduced mobility, chronic obstructive pulmonary disease, major depressive disorder. R1's MDS (Minimum Data Set) dated 02/19/25 showed R1 had moderate cognitive impairment. R1's MDS dated [DATE] showed R1 had impairments to both upper and lower extremities. The same MDS showed R1 was dependent upon staff for chair/bed-to-chair transfers. R1's progress notes dated 02/20/25 at 11:45 AM showed received resident laying in bed, alert and oriented x4. Resident complains of left lower leg pain. NP (Nurse Practitioner) notified and ordered left lower leg and ankle and foot. Progress notes dated 02/20/25 at 6:11 PM Notified NP regarding x-ray result. NP ordered to send out to ED (Emergency Department) for evaluation. POA (Power of Attorney) made aware. Progress notes dated 02/20/25 at 6:49 PM Resident was sent out at (Hospital) ER (emergency room ) via (Ambulance) for further evaluation and treatment. Management and POA made aware. Progress notes dated 02/20/25 at 9:37 PM Resident came back from (Hospital). (Hospital) ER called and informed this nurse that they did an x-ray, and it was positive for tib-fib fracture and no hip fracture and needs to have an appointment to orthopedics. R1's Radiology Results Report date 02/20/25 at 3:32 PM showed Procedure- left tibia and fibula, two views. Findings- 4 view left tib-fib. No prior study for comparison. Acute nondisplaced proximal tib-fib fracture. Mineralization is decreased with degenerative changes. No radiopaque foreign body. No convincing plain film evidence osteomyelitis. Impression- acute nondisplaced proximal tib-fib fracture. R1's Kardex Report dated 03/02/25 showed Transferring: Transfer- The resident is totally dependent on 2 staff for transferring. R1's ADL self-care/mobility care plan dated 01/26/24 showed interventions: Chair/bed to chair transfer: My usual performance is dependent. I use a mechanical lift for transfer assist. The facility's Transfers- Manual Gait Belt and Mechanical Lifts Policy (last approved 10/2024) showed Purpose: In order to protect the safety and well-being of the Staff and Residents, and to promote quality care, this facility will use Mechanical lifting devices for the lifting and movement of Residents. Guidelines: 1. Mechanical lifting devices shall be used for any resident needing a two person assist, or who cannot be transferred comfortably and/or safely by normal transfer technique. The facility's Fall Prevention Program policy last approved date 10/2024 showed Purpose: 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. Guidelines: Transfer conveyances shall be used to transfer residents in accordance with the plan of care.

Based on interview and record review, the facility failed to ensure a resident was able to get into bed to use his urinal. This applies to 1 of 4 residents (R3) reviewed for incontinence care. Findings include: On 03/04/25 at 1:20 PM, R3 stated on Friday 02/28/25 he had been sitting up in his wheelchair since 11:00 AM. R3 stated at 2:30 PM he was still in the wheelchair in his room. He stated his bed was not working. R3 stated the staff knew his bed was not working before he got out of bed. He stated the staff told him a work order was in place to repair his bed. R3 stated at 2:30 PM he pressed his call light to let his CNA (Certified Nursing Assistant) know that he needed to urinate. His bed still was not working. He stated maintenance came in and tried to repair the bed, but it still did not work. R3 stated the facility called the other maintenance person who was at home. R3 stated he still needed to urinate. R3 stated he was wearing and incontinence brief, but he urinates a lot. R3 stated he wanted to use the urinal and he must lay flat when urinating. R3 stated he can't urinate while in the wheelchair. R3 stated between 5:00-6:00 PM, he urinated on himself. R3 stated the urine was on top of sheets that he placed on the floor, the pad in the wheelchair and his shorts. R3 stated he ate dinner with the urine-soaked clothes on. R3 stated he transfers via mechanical lift. R3 stated he got in the bed between 7:00-7:30 PM. On 03/04/25 at 2:00 PM, V6 (CNA) stated last Friday 02/28/25 around 4:15 PM the housekeeper asked him to help assist with fixing R3's bed. V6 stated It took us about 15 minutes to realize that we could not fix the bed. I told the housekeeper we need maintenance because this an electrical issue with the bed. On 03/05/25 at 9:25 AM, V7 (Maintenance Director) stated on 02/28/25, he received a call after 5:00 PM stating that R3's bed was not working, and he needed to come in. V7 stated the call came after he had already left the building for the day. V7 stated he did not know that R3's bed was not working prior to him leaving for the day. V7 stated a work order was not put in for R3's bed. V7 stated he fixed another bed and brought it to R3's room. V7 stated the whole process took about an hour from the time he came in on call until he was done. On 03/05/25 at 11:50 AM, V8 (CNA) stated she was the CNA for R3 on 02/28/25 from 6 AM-2:00 PM. V8 stated she got R3 out of bed that morning and his bed remote was malfunctioning. V8 stated if you pressed the remote the regular way, it did not work.V8 stated they had to push the remote different ways than normal for it to work. V8 stated she got him out of bed, but did not report that the remote to the bed was not working. V8 stated R3 was up for the rest of the shift. V8 stated I should have reported that the bed was not working when I got him up. On 03/05/25 at 3:18 PM, V12 (CNA) stated she was the CNA for R3 Friday 02/28/25 from 2:00 PM-10 PM. V12 stated that at 2:15 PM, she found out that R3's bed was not working when he told me he needed to use the bathroom. V12 stated that R3 told her that the bed was broken. V12 stated she went to the receptionist and had them to page maintenance. V12 stated R3 really needed to go to the bathroom. He told me two more times that he really needed to use the bathroom. V12 stated R3 was still in his wheelchair for dinner, and he was wet. V12 stated R3 has to urinate while in the bed with the urinal and must be flat. The staff hold the urinal for him. It is impossible for him to urinate in the urinal while he is sitting up. V12 stated the bed was stuck in a very high position and the mechanical lift was not able to go high enough to get R3 on the bed. On 03/05/25 at 3:43 PM V1 (Administrator) stated when equipment is malfunctioning, the staff reports to maintenance. They can go to the front desk and have maintenance paged. V1 stated her expectations are that the staff report broken or malfunctioning equipment immediately. R3 was admitted to the facility on [DATE] with multiple diagnoses, including acute and chronic respiratory failure, need for assistance with personal care, lack of coordination, reduced mobility, morbid obesity with alveolar hypoventilation, diabetes, chronic obstructive pulmonary R3's MDS (Minimum Data Set) dated 01/08/25 showed R3 was cognitively intact. The same MDS showed R3 had impairments to both his lower extremities, required substantial/maximal assistance with toileting hygiene, and was dependent upon staff for transfers. R3's ADL (Activities of Daily Living) care plan revised on 05/31/24 showed Interventions: Chair/bed to chair transfer, my usual performance is dependent-mechanical lift with assist of two between surfaces. Toilet hygiene: my usual performance is substantial/maximal assistance. Toilet transfer: my usual performance is dependent. The facility's Fall Prevention Program policy last approved date 10/2024 showed Standards: Malfunctioning equipment will be immediately reported to maintenance for repair

Based on interview and record review, the facility failed to implement pressure ulcer prevention interventions including completing and documenting physician ordered weekly skin assessments and failed to identify and treat a facility-acquired pressure ulcer for one of three residents (R1) reviewed for skin concerns on a sample list of eight. These failures caused R1 to develop a sacral pressure ulcer that was discovered and noted to be unstageable, upon assessment by a wound physician. Findings include: R1's Face Sheet showed his diagnoses included type 2 diabetes, adult failure to thrive, hypertension, blindness in one eye unspecified, left side hemiplegia and hemiparesis, chronic kidney disease, and acquired absence of left leg below the knee. R1's 1/5/2025 MDS (Minimum Data Set) showed he was cognitively intact and he did not have a behavior of rejecting care. R1 was identified as being at risk for developing pressure ulcer / injury. R1 utilized a manual wheelchair for mobility and was occasionally incontinent of urine and stool. R1 did not have any documented MASD (Moisture Associated Skin Damage) or pressure wounds on the 1/5/25 MDS. R1's 2/7/25 nursing progress note from 1:00 PM showed R1 was readmitted to the facility after a hospital stay. The progress note showed no skin breaks were noted and his skin was warm, dry (normal), skin intact. On 2/20/25 at 1:17 PM, V6 CNA (Certified Nursing Assistant) stated R1 was missing half of one of his legs and he was dependent on staff for assistance. V6 stated R1 would inform staff when he was incontinent and needed assistance. V6 stated she was not aware R1 had any rashes or open wounds. On 2/20/25 at 2:07 PM, V3 ADON (Assistant Director of Nursing) stated resident skin observations are done biweekly on shower days. V3 stated if the physician ordered skin observations, they would be documented on the TAR (Treatment Administration Record) by the nurse. V3 stated there was an order on 2/9/25 documenting R1's scrotal irritation, but no note or any other nursing assessment. V3 stated she had been informed by R1's family member of his scrotal bleeding. V3 stated the Wound Physician (V4) was seeing R1 on 2/11/25 for the scrotal MASD and V4 discovered the unstageable sacral pressure wound. V3 stated towards the last week R1 was in the facility, he was receiving showers every night per family request. V3 stated staff should have completed the scheduled documentation of R1's showers and documented any skin issues. V3 stated staff should have discovered the skin issues before the family did and documented the findings. On 2/20/25 at 3:11 PM, V2 DON (Director of Nursing) stated she was informed of R1's MASD by a night shift nurse. V2 stated she was not informed of any other skin issues, and she was not informed of a sacral wound. V2 stated R1 was dependent on staff for a one person assist with cares. V2 stated nurses were required to document the physician-ordered skin assessment on the TAR every Tuesday. V2 stated a few of R1's assessments had been missed during his stay. V2 stated if staff were doing daily showers, they should have been documented, and when staff perform incontinence care, they should assess the resident's skin. V2 stated R1 had a leg amputation and required the assistance of staff and he was not independent. V2 stated the staff should have seen the sacral wound during his cares and acknowledged the wound was acquired in the facility. V2 stated R1 was not on hospice and she does not know how R1 developed a sacral wound if staff were attending to him. V2 stated pressure wounds can develop from sitting in one spot or not moving, and MASD is from moisture and barrier cream would help prevent that. The wound noted completed by V4 (Wound Physician) on 2/11/25 documented two wounds: Site 1 an unstageable wound (due to necrosis) full thickness of the sacrum. Etiology (cause) documented as pressure, measuring 2 cm x 2cm x 0.1 cm (centimeters). V4 completed a surgical excisional debridement of the sacral wound. Site 2 non pressure wound partial thickness of the scrotum measuring 2.5 cm x 1.5cm x 0.1 cm. Etiology documented as Moisture Associated Skin Damage. On 2/20/25 at 4:17 PM, V4 (Wound Physician) stated in general, MASD occurs from urine, stool or sweat, and barrier cream could possibly have prevented that. V4 stated a pressure wound and MASD could have developed between 2/7/25 and 2/11/25 and stated pressure ulcers develop as result of skin breaking down over a bony prominence and are related to pressure. V4 stated he could not say if staff should have seen the wounds during their cares or if they were even really doing the skin assessments. On 2/20/25 at 5:11 PM, V8 CNA stated she gave R1 a shower on 2/11/25 (the same day R1 was seen by the Wound Physician and the unstageable pressure ulcer was identified). V8 stated R1 had irritation on scrotum. V8 stated she had R1 stand and pivot, she did not note any other skin issues. V8 stated R1 was a daily shower. The shower sheet completed on 2/11/25 by V8 CNA and signed off by V7 RN does not show any documentation of skin issues for R1. On 2/20/25 at 5:16 PM, V7 RN confirmed her signature on R1's shower sheet. V7 stated she did a head-to-toe assessment on 2/11/25 for R1 and did not note any open areas or wounds on R1. V7 also stated that V8 did not report any skin issues for R1. R1's physician orders included weekly skin assessment every Tuesday. Review of R1 TAR (Treatment Administration Record) shows no documentation that physician-ordered skin assessments were done on 12/3/24, 12/20/24, 12/31/24, 1/14/25, and 1/28/25. R1's orders showed MD (Medical Doctor) to be notified of new impairments. Moisture barrier cream to buttocks as needed as preventative; may keep at bedside CNA (Certified Nursing Assistant) may apply. The facility policy Pressure Injury and Skin Condition assessment dated ,d+[DATE] states, residents identified will have a weekly skin assessment by a licensed nurse. Each resident will be observed for skin breakdown daily during care and on assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. Caregivers are responsible for promptly notifying the charge nurse of skin breakdown .

Based on observation, interview and record review the facility failed to provide call light access. This applies to 2 of 7 residents (R2, R3) reviewed for call light accessibility in a sample of 8. Findings include: 1.R2 has diagnoses that includes quadriplegia, type 2 diabetes and epilepsy. R2's current care plan interventions include ensure call light is within reach and answer promptly. On 2/19/25 at 4:02 PM, R2 was sitting up in his motorized wheelchair. R2's call light that is activated when he blows into it was located on the left side of his bed near the wall and not in reach of his mouth. R2 stated the call light is never left near him when he is up in his wheelchair. R2 stated he must go out in the hall and look for assistance if he needs anything. On 2/20/25 at 1:17 PM, V7 CNA (Certified Nursing Assistant) stated all residents should have a call light available to them to notify staff if they need assistance. 2. R3 has diagnoses that includes hemiplegia and hemiparesis following cerebral infarction, carcinoma in situ of anus and anal canal, hypertension and dysphagia. R3's current care plan interventions includes ensure call light is within reach and answer promptly. On 2/19/25 at 4:33 PM, R3 was lying in bed and her call light was tied to a purple stuffed duck on her nightstand. R3 stated her call light is always left on her nightstand. R3 stated sometimes she needs help but doesn't have the call light to call for staff. On 2/19/25 at 4:40 PM, V5 RN (Registered Nurse) was called to R3's room to observe her call light that was out of reach. V5 stated R3 was alert and could make her needs known. V5 stated if R3 needs assistance she alerts her roommate (R8) will call for staff assistance for her. When V5 attempted to place R3's call light within her reach, it could not reach due to the string being tied in a knot. On 2/19/25 at 4:43 PM, R8's MDS (Minimum Data Set) dated 12/26/24 shows she is cognitively intact. R8 stated she looks out for R3. R8 stated she puts the call light on for R3 when she does not have access to her call light. On 2/20/25 at 3:11 PM, V2 DON (Director of Nursing) stated both R2 and R3 are alert and able to make their needs known. Their call lights should be within their reach. V2 added that it is not any residents' responsibility to call for staff assistance for their roommates. The facility policy Call Light dated 10/2024 states all residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location.

Based on observation, interview and record review, the facility failed to provide shower assistance to a resident. This applies to 1 of 3 (R1) residents reviewed for shower assistance in the sample of 11. Findings include: R1 was admitted to the facility on [DATE]. R1's admission MDS (minimum data set) dated January 30, 2025 showed that the resident was cognitively intact and required total assistance from the staff with shower. The facility's care plan task report showed that R1 was scheduled to receive shower/bathing on Tuesdays and Fridays during the morning. The facility presented only one shower sheet dated January 27, 2025 signed by V10 (CNA/certified Nursing Assistant). On February 4, 2025 at 3:30 PM, V10 stated that she did not provide a shower to R1 on January 27, 2025 but instead provided a bed bath. On February 4, 2025 at 12:22 PM, R1 was in bed, alert and oriented. In the presence of V2 (Director of Nursing), R1 stated that she had not received any shower since admission at the facility. During this observation, R1's hair was observed greasy. V2 informed R1 that she will be given shower that day. At 3:40 PM, in the presence of V2, R1 stated that she still had not have a shower. R1 stated that when she was admitted at the facility, she (R1) was told by the nursing staff that she will receive shower twice a week, but she was never asked for her preferred shower day and time. According to R1, I asked everybody including the nurses every day, when can I get a shower, but no body assisted me to get one. R1 stated that her hair is greasy, and she can smell herself. V2 acknowledged that R1's hair was greasy. During this interview, R1 denied receiving any bed bath at the facility including on January 27, 2025. R1's active care plan showed that the resident has ADL (activities of daily living) self-care deficit. The same care plan had multiple interventions including provision of maximum assistance with bathing. The facility's bathing-shower policy and procedure dated October 2024 showed under purpose, To ensure resident's cleanliness to maintain proper hygiene and dignity. The same policy under guidelines showed, A shower, tub bath or bed/sponge bath will be offered according to resident's preference, no less than once a week or according to the resident's preferred frequency and as needed or requested. On February 5, 2025 at 2:38 PM, V2 stated that though the facility's policy showed to offer residents shower no less than once per week, if the resident prefers and/or request to have a shower twice or more a week, the shower preference and request should be honored. According to V2, the nursing staff are expected to provide ADL assistance including showers to residents, to ensure and maintain their hygiene and grooming.

Based on observation, interview, and record review, the facility failed to provide routine shower/bed bath care for residents who require extensive assistance for activities of daily living (ADL) care. This applies to 2 of 3 residents (R1, R2) reviewed for ADL care in the sample of 3. The findings include: 1. Face sheet shows R1 has multiple medical diagnoses which include acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, chronic kidney disease, chronic diastolic (congestive) heart failure, morbid (severe) obesity with alveolar hypoventilation, encounter for attention for tracheostomy, atelectasis, morbid (severe) obesity due to excess calories, type 2 diabetes mellitus without complications, other asthma, need for assistance with personal care, other lack of coordination, other reduced mobility, abnormal posture, chronic obstructive pulmonary disease. R1's Minimum Data Set (MDS) dated [DATE], shows R1 is alert and oriented and requires substantial/maximal assistance for shower or bathing. On July 1, 2024, at 12:09 PM, R1 stated he prefers to have a bed bath rather than a shower due to his tracheostomy. R1 received a bed bath on Tuesday (June 25), Wednesday (June 26), and on Friday (June 28). Prior to last week, his last bed bath was on a Monday (June 3), afterwards, R1 had not had bed bath from June 4 through June 24, 2024. R1's bed bath was scheduled on night shift or the 3rd shift. According to R1, the staff does not wake him to give him the shower or bed bath. On June 18, 2024, R1 stated he spoke with V2 (Director of Nursing/DON) requesting for his bed bath schedule to be change to evening shift. R1 did not receive a shower or bath from June 18 to June 24, 2024. On June 23rd, R1 requested at 6 AM a bed bath because his family was going to visit him at 11 AM. A staff member informed R1 she was waiting for someone to help her. R1 informed staff he could help by turning and repositioning himself on the bed during the process, however, he still did not receive a bed bath day. R1 was so upset he told the nurse he would call Public Health because of their failure to give him a bed bath. On July 1, 2024, at 1:05 PM, V2 (Director of Nursing/DON) stated she had a meeting with R1 requesting to change shift schedule from night to evening shift because R1 was still sleeping during the bed bath time. V2 recalled after meeting there were staff who were about to give R1 a bath. The facility staff documented in the shower sheet when they provided shower or bed bath. On July 1, 2024, at 3:28 PM, V3 (Assistant Director of Nursing/ADON) stated, The residents receive either shower or bed bath at least once a week and as needed. Some residents receive it every Monday, Wednesday, and Friday because that's how they wanted it. V3 said the facility follows resident's request or preference. They need shower or bed bath for personal hygiene and to prevent any potential infection especially for those who are bigger in size because of the extra folds in their skin, and to promote comfort. On 7/2/24 at 11:28 AM, V3 said R1's bathing schedule was every Monday, Wednesday, and Friday on the night shift, and it was changed on the PM shift on 6/21/24 as per R1's request. According to V3, the staff are to document in the shower sheet every time they give shower and/or bed bath. The facility started implementing the shower sheet documentation on May 1, 2024. On July 2, 2024, at 9:39 AM, V4 (Certified Nursing Assistant/CNA), recalled giving R1 a bed bath but she was unable to recall the exact dates. V4 said when she gives a shower or a bed bath, she documents it on the shower sheet, and she submits it to the nurse as a proof of giving a bed bath or a shower to her assigned residents. On July 2, 2024, at 9:47 AM, V5 (CNA) stated R1 is scheduled every Monday, Wednesday, and Friday. The last time V5 gave R1 a bed bath was on Friday (June 28), and she didn't know she had to document on the shower sheet. V5 added she had given R1 bed bath before but could not recall exact date. On July 2, 2024, at 1:32 PM, V7 (CNA) stated R1 is always cooperative with the ADL care, and R1 never refuses it. R1's updated care plan shows R1 has an ADL self-care/mobility performance (functional abilities) deficit related to limited mobility, lack of coordination, reduced mobility, need for assistance with personal care, abnormal posture. This same care plan shows multiple interventions which include substantial/maximal assistance for shower/bathing. Surveyor requested a copy of R1's shower sheets from June 4 to June 30 and it showed R1 received bed bath on June 25 and June 26, 2024. There was no documentation of R1 refusing any shower or bath for the month of June, 2024. 2. Face sheet shows R2 is [AGE] years-old who has multiple medical diagnoses which include rheumatoid arthritis, type 2 diabetes mellitus, adult failure to thrive and other lack of coordination. R2's MDS dated [DATE], shows R2 is alert and oriented and requires substantial/maximal assistance for shower or bathing. On July 1, 2024, at 11:40 AM, R2 was resting in bed, watching TV, alert and oriented. R2 was unkempt and disheveled with facial hair growth and overgrown fingernails. R2's nailbeds had yellow and brownish discoloration and brown/black substances underneath nails. R2 said he needs assistance with shaving and nail care. R2 stated he was not getting regular shower or bed bath. R2 prefers to get a shower over bed bath because he has arthritis. R2 felt some relief whenever the warm water hits his body during shower time, but unfortunately, he was not getting it regularly or frequently. On July 5, 2024, at 1:25 PM, V6 (CNA) stated she's familiar with R2. V5 usually was the one who gives R2 showers. V5 had never given R2 a bed bath, because R2 prefers to shower over bad bath. V5 documents in the shower sheet each time V5 provides a shower to R2. R2 receives 2 showers per week in the morning shift. V6 said sometimes R2 is cooperative and sometimes R2 refuses. When R2 refuses, the staff notifies the nurse on duty and documents it in the shower sheet. Facility presented a copy of R2's shower sheets for the whole month of June 2024, and it shows he only received on June 9, 12, and 18. There was no indication he received shaving and nail care. There was no documentation of shower or bed bath refusal. Facility's Shower and Bed Bath Policy and Procedures with review date of January 2018, shows the purpose of this is to ensure resident's cleanliness, to maintain proper hygiene and dignity.

Based on observation, interview, and record review, the facility failed to provide a dignified dining experience to residents who require feeding assistance. The facility also failed to provide dignity in wound care by not closing windows during wound care. This applies to 5 of 8 residents (R5, R17, R18, R22, and R24) reviewed for dignified resident care in a sample of 25. The Findings include: 1. R299 is a [AGE] year-old female with severe cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documents that R299 requires partial/moderate assistance with eating. 2. R18 is a [AGE] year-old male with cognition intact as per the MDS dated [DATE] and requiring substantial/maximal assistance for eating. 3. R22 is a [AGE] year-old male with severely impaired cognition as per the MDS dated [DATE] and with an admitting diagnosis, including hemiplegia affecting the right dominant side secondary to cerebral infarction. 4. R24 is a [AGE] year-old female with severely impaired cognition as per the MDS dated [DATE] and requiring partial/moderate assistance for eating. On 5/15/24 at 12:25 PM, observed seven residents (R299, R18, R22, R24, R48, R27, and R62) around a dining table during lunch. Observed R299, R18, R22, and R48 were not fed while V11 (MDS coordinator) was feeding R48, V12 (Certified Nursing Assistant/CNA) was feeding R27, and V13 (CNA) was feeding R62. On 5/15/24 at 12:30 PM, R18 stated, - I want to eat. I am hungry. On 5/15/24 at 12:30 PM, V11 stated, We are on the way to feed remaining residents. On 5/16/24 at 10:05 AM, V5 (Assistant Director of Nursing/ADON) stated, The residents should have a dignified feeding experience. They should have called for more staff to feed those not fed and watch feeding other residents. 41384 5. On 05/14/24 at 11:26 AM, R17 was being provided wound care to her lower abdominal area. V5 Assistant Director of Nursing (ADON/Wound Nurse) attempted to close the blinds but there were several missing panels, therefore leaving the blinds open. V5 then provided wound care to R17, leaving R17 exposed from her abdomen to her upper thighs. R17's room was right next to the sidewalk that leads to the patio and gazebo, all viewable from the window. On 05/16/24 at 10:29 AM V1 (Administrator) said that the nurse should have put something up on the window to prevent people from seeing in for privacy purposes. The facility's Dignity policy dated 2/2018 showed, the facility shall promote care for resident in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.

Based on observation, interview, and record review the facility failed to provide activities for 4 residents (R17, R29, R50 & R44) based on their care plans in a sample of 25. 1. on [DATE] at 11:44 AM, R17 was observed in her room. V15 (R17's son) was present at the time. V15 said that the facility does not provide activities for his mother. V15 said Someone used to come around and spend time with her, but she died . Now no one comes by. V15 said that he is at the facility everyday A review of R17's electronic health records showed no 1:1 activity for the last 30 days. R17's [DATE] care plan showed activities care need with interventions including, express satisfaction with level and type of involvement in leisure activities during one on one visits ,d+[DATE]xweekly. 2. During tours of the facility on [DATE], [DATE] & [DATE], R29 was never observed in any 1:1 activity. A review of R29's last 30 days of 1:1 activity program showed, No documentation. R29's [DATE] Care plan showed a care need for activities with interventions including, will accept/participate in 1:1 visits, 2 times per week, and the facility will provide 2 1:1 visits weekly. On [DATE] at 10:50 AM V1 (Administrator) said that R17 should have been receiving daily activities. 3. On [DATE] at 9:15 AM, R50 was observed sitting at a table next to the nurse's station with a word puzzle in front of him and no writing utensil present. R50 was observed with his eyes closed and rocking in his chair attempting to get up. V4 (Nurse) said that R50 could not do the puzzle and removed it. There were no stimuli like music or a TV on at the time of the observation. R50's electronic health record showed that R50 is a [AGE] year old male admitted to the facility on [DATE] with diagnoses including severe dementia and severly impaired cognition. On [DATE] a review of R50's last 30 days of 1:1 activity program showed, No Documentation. R50's [DATE] care plan showed a care need for activities with interventions including, listen to music, watch television, and keep up with the news. [DATE] 11:06 AM V1 (Administrator) said that R50 should be provided daily activities that he can do according to his abilities. V1 said that R50 should not have been given a word puzzle because it was not suitable for him. V1 said that R50 should be given things according to his care plan that he enjoys, like music. On [DATE] at 2:33 PM V3 (Activities Director) provided the facility's One on One List (no date), R17, R29, & R50) were on the list. V3 said that the list was for the bed bound residents and the facility only scheduled one on one activities once a week but has not been able to provide one on one services for the last 2 to 3 months. The facility's Activities Program policy dated ,d+[DATE] showed, the purpose is to provide an ongoing program of activities designed to appeal to the residents' interest and to enhance his or her highest practical level of physical mental and psychosocial well-being. Guidelines show identify and involve each resident in an ongoing program of activities that is designed to appeal to his or her interest and needs. The staff shall record residents' activity attendance and participation on a daily basis. 46003 4. R44 has diagnoses that includes aphasia, type 2 diabetes, hemiplegia, depression, pseudobulbar affect and epilepsy, R44's current activities care plan focus states activities to visit one to one ,d+[DATE] times weekly as tolerated. Review of R44's activities program does not show any 1 to 1 activity provided.

Based on observation, interview, and record review the facility failed to identify environmental hazards that poses risks for potential accidents. This applies to 6 of 6 residents (R6, R8, R28, R33, R39, and R61) reviewed for accidents/hazards in the sample of 25. The findings include: 1. On 05/14/24 at 12:20 PM R39 was not in the room. A portable oxygen tank (cylinder) was stored in R39's closet without a cart or stand. On 05/15/24 at 3:11 PM the portable oxygen tank (cylinder) was still in the closet without a storage cart or stand. On 05/16/24 at 10:44 AM the portable oxygen tank continued to be stored in R39's closet without a storage cart or stand. On 05/14/24 at 2:55 PM R39 said he does not use oxygen and does not know why the oxygen is stored in his closet. On 05/16/24 at 11:51 AM V5 (Assistant Director of Nursing) said the portable oxygen (cylinder) tanks are stored in the front oxygen room. The portable oxygen is stored in a crate that is individualized for each tank. No oxygen should be stored in a closet without being secured. V5 said secured means that the oxygen is in a holder. V5 said no oxygen should be stored in a residents room that does not have an order for oxygen and does not use oxygen. V5 said if unsecured oxygen falls on the floor, it can explode, and someone could get hurt. A fire can start and everyone in the area could be affected. V5 said the expectation is that all oxygen tanks are stored in the storage closet. R39's Face Sheet showed R39 had diagnoses of lack of coordination, abnormal posture, reduced mobility, chronic respiratory failure with hypoxia, diabetes mellitus with diabetic ophthalmic complication, diabetes with diabetic peripheral angiopathy without gangrene, asthma, angina pectoris, morbid obesity due to excess calories, chronic obstructive pulmonary disease, pulmonary fibrosis, rheumatoid arthritis, benign prostatic hyperplasia without lower urinary tract symptoms, bipolar disorder, depression, anxiety, obstructive sleep apnea, and hypertension. R39's MDS (Minimum Data Set) dated 02/23/24 showed R39 was cognitively intact. R39's Physician Orders showed no orders for oxygen. 2. On 05/14/24 at 12:19 PM R61 roommate of R39 was observed in his room where the oxygen was stored. R61's Face Sheet showed R61 had diagnoses of diabetes with diabetic neuropathy, unsteadiness on feet, obesity, atherosclerotic heart disease of native coronary artery without angina pectoris, osteoarthritis, left hip pain, chronic kidney disease, benign prostatic hyperplasia without lower urinary tract symptoms, and abnormalities of gait and mobility. 3. On 05/14/24 at 12:14 PM R33 was in his room, next door to where the oxygen was stored in the closet. R33's Face Sheet showed R33 had diagnoses of unspecified sequelae of cerebral infarction, lack of coordination, abnormal posture, repeated falls, cognitive communication deficit, diabetes, ataxia, hemiplegia, and hemiparesis following cerebral infarction affecting left non dominant side, contusion of left hand, low back pain, benign prostatic hyperplasia without lower urinary tract symptoms, and contusion of left hip. 4. On 05/14/24 at 12:12 PM R6 was in his room, next door to where the oxygen was stored in the closet. R6's Face Sheet showed R6 had diagnoses of dysphagia, lack of coordination, abnormal posture, reduced mobility, acute respiratory failure without hypoxia, pressure ulcer of sacral region, bipolar disorder, pleural effusion, unspecified intestinal obstruction, vein compression, spondylolysis, sciatica, benign prostatic hyperplasia with lower urinary tract symptoms, wedge compression fracture of T11-T12 vertebra, and wedge compression fracture of first lumbar vertebra. 5. On 05/14/24 at 12:08 PM R8 was in her room, across the hall from where the oxygen was stored in the closet. R8's Face Sheet showed R8 had diagnoses of lobar pneumonia, lack of coordination, reduced mobility, abnormal posture, morbid obesity, diabetes, acute respiratory failure with hypoxia, anemia, major depressive disorder, essential tremor, paroxysmal atrial fibrillation, pressure ulcer of right buttock, and weakness. 6. On 05/14/24 at 12:38 PM R28 was in the dining room. R28's room was across the hall from where the oxygen was stored in the closet. R28's Face Sheet showed R28 had diagnoses of pulmonary embolism, dysphagia, unsteadiness on feet, lack of coordination, abnormalities of gait and mobility, protein calorie malnutrition, chronic kidney disease, weakness, dementia, acute myocardial infarction, right shoulder pain, chest pain syncope and collapse, and displaced fracture of upper end of right humerus. The facility's Storage Policy for oxygen cylinders showed: *oxygen cylinders must maintain a minimum distance of 20 ft from combustibles (5 ft is room is sprinkled) or be placed within an enclosed cabinet having a fire rating of at least a half hour. *cylinders must be secured in racks or by chains.

Based on observation, interview, and record review, the facility failed to contain, replace, and date respiratory equipment. This applies to 4 of 4 residents (R5, R11, R15, R38) reviewed for respiratory equipment in a sample of 25. The findings include: 1. On 5/15/24 at 10:45 AM, during initial tour, surveyor went to R11's room. R11 was not in his room. On R11's end table, his face mask to his AVAPS (Average Volume Assured Pressure Support) machine was not dated or contained in a plastic bag. R11's POS (Physician Order Sheet) shows the following order: AVAPS: When sleeping maximum pressure 30 PS Min/Max 10/15 EPAP Min/Max 10/15 Rate: 20 Tidal Volume: 600 Insp. Time 0.88 2 liters oxygen. 2. On 5/15/24 at 11:15 AM, R15 was not in his room. His concentrator was left on. R15's oxygen tubing was not dated. R15's nasal cannula was uncontained and left on his recliner. R15's POS shows the following order: Oxygen per Nasal Cannula at 2 Liters/Minute continuous every shift related to unspecified chronic bronchitis. 41384 3. On 05/14/24 at 1:55 PM, R38's nasal cannula, BIPAP mask, & nebulizer mask was not covered, and her 02 humidifier container was dated 4/21/24, (23 days later). R38's 5/6/24 orders showed change out, date, and label O2 humidifier every Sunday. On 05/16/24 at 11:37 AM V1 (Administrator) said that respiratory equipment, BIPAP masks, nasal cannulas, and nebulizer masks should be in plastic bags for infection control purposes. The facility's policy, Oxygen & Respiratory Equipment - Changing/Cleaning (date 1/2019) showed, the purpose is to minimize the risk of infection transmission. Nasal cannulas, handheld nebulizers, and BIPAP masks should be stored in a clean plastic bag with a zip lock or drawstring, marked with a date the setup was changed. Oxygen humidifiers shall be changed weekly or as needed and will be dated when changed. 34410 4. R5 is a [AGE] year-old female with mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. R5 is admitted with an admitting diagnosis including acute and chronic acute respiratory failure, chronic obstructive pulmonary disease, and obstructive sleep apnea. On 5/14/24 at 11:42 AM, R5 was observed in her room with nasal cannula on. Observed a nebulizer mask, not contained in a plastic/zip lock bag, hanging from the bedside drawer and C-PAP mask on the table without containing. On 5/15/24 at 10:24 AM, V5 (Assistant Director of Nursing/ADON) stated, The respiratory equipment including nebulizer mask and C-Pap mask should be stored in a plastic zip lock bag.

Based on observation, interview and record review the facility failed to provide adequate staffing to meet the care needs of residents. Staffing was insufficient to provide residents with assistance in Activities of Daily Living, a dignified dining experience and answering of call lights. This applies to 11 residents (R5, R9, R16, R18, R22, R24, R29, R32, R38, R46, R51) reviewed for staffing concerns in a sample of 25. Findings include: On 5/14/24 at 9:45 AM, a strong stench of urine was noted upon entry into the facility. On 5/15/24 at 02:08 PM, during the Resident council meeting 1. R51 stated there are only four C.N.As (Certified Nursing Assistant) for the entire facility at nights. R51 stated staffing for the facility is terrible nights and weekends. R51 stated they hear residents calling out for help every night and weekends. 2. R38 stated there are only four C.N.A at nights and on weekends and two nurses at night. R38 stated staffing is short on weekends. R38 stated staff see her at the end of the shift like she is an afterthought. R38 stated she did not like that the facility smelled of urine but did not think anything could be done about incontinent residents. 3. R16 stated there is not enough help for the residents. R16 stated it takes staff too long provide him assistance. 4. R46 stated the facility smells because residents aren't receiving incontinence care. On 5/16/24 at 11:02 AM, V19 C.N.A stated her residents don't appear to have received catheter care when she is off. On 5/16/24 at 11:50 AM, V20 C.N.A. stated there have been mornings she has come in to find residents soaked in urine and soiled with stool. V20 stated staffing is short when agency staff leave early or don't show up. Sometimes the staff is not replaced. On 5/16/24 01:52 PM, V18 C.N.A / Staffing Scheduler stated the C.N.A at night has 19 residents each. V18 stated that is not a lot of residents because they are just supervising. The night C.N.As don't do cares at night they just watch the residents and do not provide incontinence care. Night shift C.N.As only have to get up three residents each morning. V18 stated she has had staff complain they need more staff. V18 stated staff have complained to her that residents are super saturated with urine and have not been changed. V18 stated the complaints are usually on weekends behind agency staff. On 05/16/24 at 2:18 PM, V5 ADON (Assistant Director of Nursing) stated night shift staff are expected to reposition and provide incontinence care to all residents that require it every two hours. V5 stated even residents that are independent should be checked on every two hours. 34410 5. R299 is a [AGE] year-old female with severe cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documents that R299 requires partial/moderate assistance with eating. 6. R18 is a [AGE] year-old male with cognition intact as per the MDS dated [DATE] and requiring substantial/maximal assistance for eating. 7. R22 is a [AGE] year-old male with severely impaired cognition as per the MDS dated [DATE] and with an admitting diagnosis, including hemiplegia affecting the right dominant side secondary to cerebral infarction. 8. R24 is a [AGE] year-old female with severely impaired cognition as per the MDS dated [DATE] and requiring partial/moderate assistance for eating. On 5/15/24 at 12:25 PM, observed seven residents (R299, R18, R22, R24, R48, R27, and R62) around a dining table during lunch. Observed R299, R18, R22, and R48 were not fed while V11 (MDS coordinator) was feeding R48, V12 (Certified Nursing Assistant/CNA) was feeding R27, and V13 (CNA) was feeding R62. On 5/15/24 at 12:30 PM, R18 stated, - I want to eat. I am hungry. On 5/15/24 at 12:30 PM, V11 stated, We are on the way to feed remaining residents. On 5/16/24 at 10:05 AM, V5 (Assistant Director of Nursing/ADON) stated, The residents should have a dignified feeding experience. They should have called for more staff to feed those not fed and watch feeding other residents. 9. R9 is a [AGE] year-old female admitted on [DATE] with moderately impaired cognition as per the minimum data set (MDS) dated [DATE]. MDS also indicates that R9 requires substantial/maximal assistance on toilet hygiene. On 5/14/24 at 11:30 AM, the writer observed R9's room with intense urine/feces smell. In response to this writer's request V8 (Certified Nursing Assistant/CNA) checked on R9 and found with thick watery bowel movement with stool smeared all around perinium up to below her abdominal fold. On 5/14/24 V8 stated that she checked R9 at 6:15 AM and they are supposed to check on residents for incontinent care every two hours. On 5/15/24 at 10:24 AM, V2 (Director of Nursing/ DON) stated that incontinent care should be provided every two hours and as needed. A review of R9's bowel and bladder incontinent care plan document: Check and change x 3 times every shift and as required. Wash, rinse, and dry perineum. 41384 10. On 05/14/24 at 12:41 PM, R29 was observed with long jagged nails and facial hair on her chin, about 1/2 inch long. On 05/15/24 at 12:14 PM R29 was observed with long jagged nails and facial hairs on her chin. R29's 5/21/24 care plan showed R29 had an ADL self-care/mobility performance deficit that may fluctuate with activity throughout the day. R29's 3/20/24 MDS (minimum data set) section GG showed under personal hygiene that R29 was dependent for personal hygiene. On 05/16/24 at 10:44 AM V1 (Administrator) said that R29 should not have had facial hair and her nails should have been maintained for dignity, hygiene and self-feeling good and safety. V1 said R29's jagged nails could cause her to scratch herself or someone else. 11. On 05/14/24 01:45 PM R32 was observed with facial hair on both sides of her mouth up to 2 inches in length. R32 was asked how she felt about the facial hair and her reply was that she felt neglected. R32 said that staff does not want to help her shower when she requests it. R32 said that she smells, and that she doesn't get showers when she asks. R32's 2/13/24 MDS (minimum data set) section GG showed under personal hygiene, needs supervision or touching assistance and under Bathing needs partial moderate assistance. R32's 5/7/24 care plan showed R32 has and an ADL self-care/mobility performance deficit that may fluctuate with activity throughout the day. R32's electronic health records under Task showed for the last 30 days for Shower/Bathe - No documentation, and for the last 30 days of, Bathing Tuesday and Friday PM showed only 4 days of documentation (5/3/24, 5/7/24 & 5/10/24). On 05/16/24 at 11:02 AM, V1 (Administrator) said that R32 should receive a shower or bed bath as needed or according to her care plan. The facility's Morning Care policy dated 01/2018 showed that the purpose is to promote comfort, cleanliness and dignity. The facility's Nail Care policy dated 01/2018 showed observe condition of resident's nails during each time of bathing. Note cleanliness, length, uneven edges.

Based on observation, interview, and record review, the facility failed to: wear appropriate PPE (Personal Protective Equipment) when going into an isolation room, monitor and track residents who were on isolation, obtain physician orders for isolation, develop care plans for isolation, and perform hand hygiene during wound care. This applies to 4 of 4 residents (R17, R21, R31, R62) reviewed for infections in a sample of 25. The findings include: On 5/15/24 at 11:24 AM, V5 (Registered Nurse/Assistant Director of Nursing/Infection Preventionist) stated, I work full time here. I started in August in 2023. The facility's last annual survey was in April 2023. I don't have a separate logbook of residents who were on isolation since then. I didn't know we were supposed to log those. Surveyor asked V5 who was on isolation currently. She stated that R62 was the only resident on isolation. When asked who were the residents that were on isolation for the past couple of months, V5 could only remember two other residents-R21 and R31 because she never created any logs for residents were on isolation precautions. 1. On 5/15/24 at 11:15 AM, R62 was sitting in his reclined chair outside of his room. V7 (Housekeeper) was mopping R62's floors in his room. She was not wearing gown and gloves when cleaning his room. On 5/15/24 at 11:30 AM, V5 stated, (R62) has ESBL (Extended Spectrum Beta Lactamase) in the urine. He can come out of his room as long as his catheter is contained and he's not urinating all over. But (V7) should have followed the guidelines and worn the appropriate PPE. (R62) has ESBL in the urine, which is contact precautions. (V7) should have worn gowns and gloves before entering that room. What if there is urine on the bed or floor? She could have come in contact with it. R62's lab results report dated 4/5/24 show that he tested positive for ESBL. R62's progress notes document the following: On 4/4/24 at 1:19 PM, This resident's urine is positive for ESBL. Nurse Practitioner ordered IV (Intravenous) Ertapenem q 24 hours for 1 week via midline access. Notified brother of (R62) and gave verbal consent via phone to insert a midline access. Placed an order with the lab company. On 5/4/2024 at 11:11AM, Received resident UA (Urinalysis) C&S (Culture & Specimen) results with positive for ESBL. This nurse telephoned resident (Medical Doctor) and discussed resident's results. Received telephone order to give resident Amoxicillin 875 mg PO for 14 days, then repeat UA C&S, refer to Infectious Disease MD Dx Recurrent ESBL in the urine. This nurse notified (R62's) brother. DON (Director of Nursing) notified. Review of R62's POS (Physician Order Sheet) shows there is no order for isolation and contact precautions and no care plans. 2. On 5/15/24 at 11:40 AM, V5 stated, (R31) had ESBL in the hospital. He was readmitted to us with that diagnosis. The doctor put him on Ertapenem 500 MG (Milligrams) for 12 days. I don't understand why there's nothing mentioned in his progress notes about his isolation or the ESBL. The admitting nurse didn't document anything that he was on contact precautions or had ESBL. I remember I got the signs out for contact precautions and put in on his door. He was in isolation. There are no orders for the isolation and there is no care plan. I don't know what happened. I don't have a log of resident infections or isolations. R31's Transfer form from hospital dated 3/11/24 documents: Isolation type: contact. Isolation precautions--ESBL. Facility's March 2024 POS shows no orders for contact isolation for ESBL. R31's McGeer's criteria dated 3/11/24 shows Ertapenem 500 mg daily x 12 days--complicated UTI (Urinary Tract Infection), ESBL. R31's progress notes show that on 3/4/24, His left side nephrostomy tube is leaking upon assessment. Notified doctor and ordered to send to hospital. On 3/11/24, (R31) was readmitted back to facility. Nothing was mentioned in the progress notes about ESBL or contact precautions. R31's infection charting notes do not mention anything about ESBL. R31's care plans didn't document anything about the ESBL or isolation. 3. R21's transfer report dated 4/9/24 from the hospital shows he had MRSA (Methicillin Resistant Staphylococcus Aureus) and ESBL in the urine. Progress notes show he went to the hospital for a schedule procedure on 4/8/24. Nursing notes document the following: On 3/29/23 at 10:00 PM-Received culture result from lab. Positive for ESBL to right flank wound. Ordered Bactrim DS twice a day x 7 days. Referral to ID (Infectious Disease). (R21) placed on contact isolation. POA (Power of Attorney) update. Will continue to monitor. On 4/9/24 at 5:10 PM, (R21) returned from the hospital. Vitals stable. No new order. R21's POS for March 2024 and April 2024 do not show any isolation orders for MRSA and ESBL. R21's care plans do not document anything regarding isolation, MRSA, and ESBL V5 confirmed that R21 did not have any isolation orders or care plans developed. Facility's policy titled Infection Prevention and Control Program (3/2024) shows 6. The program provides for the recording of each suspected infection and surveillance activities as they relate to individual resident infections. A log is maintained of suspected and actual infections on a day to day basis. 15. All facility personnel should adhere to the Infection Control Program in the performance of their daily assignments. 18. Contact precautions in addition to standard precautions will be initiated as specified in the specific isolation policy. Facility's policy titled Infection Precaution Guidelines (3/2024) shows: It is the policy of this facility to, when necessary, prevent the transmission of infections within the facility through the use of Isolation Precautions. The 2007 Centers for Disease Control and Prevention (CDC) Guidelines for Isolation Precautions will be utilized in this facility with some modifications. 3. Contact Precautions: In addition to Standard Precautions, use Contact Precautions for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact, such as handling environmental surfaces or resident care items. All personal protective equipment (disposable isolation gowns, mask, gloves, etc) should be used once and discarded in either trash or used linen receptacle before you leave the room. Facility's policy titled Infection Surveillance, Tracking and QA Reporting (11/2023) shows: Complete infection tracking log for all residents with an infection . Facility's policy titled Care Plan Coordinator (2/16/24) shows Complete care plan on admission, quarterly, and as needed for reach resident according to regulatory time frames. Ensures completeness and thoroughness of documentation. Responsible in formulating and revising care plans and assists disciplines. Ensures that resident's present/potential problems are identified and prioritized; realistic goals are established and nursing intervention is appropriate. 41384 4. On R17 05/14/24 at 12:01pm, R17 was receiving wound care to her left lower abdominal area. V5 Assistant Director of Nursing (ADON/wound nurse) was providing the wound care. V5 cleaned the wound, removed her gloves, put on clean gloves, and then applied a medicated blue sheet and a boarder gauze with her uncleaned gloved hands. V5 then repositioned the resident's personal items with her dirty gloved hands, and then removed her gloves and gown. On 05/16/24 at 10:29 AM, V1 (Administrator) said that the nurse should have cleaned her hands after cleaning the wound and before putting on new gloves for infection control. The facility's Hand Hygiene/Handwashing policy dated 3/2023 showed, when to perform hygiene: if hands will be moving from contaminated body site to a clean body site, before glove placement and after glove removal.

Based on interview and record review, the facility failed to utilize a standardized tool to determine the necessity of antibiotics prescribed to residents. This applies to 6 of 6 residents (R11, R25, R38, R47, R58, R60) reviewed for antibiotics in sample of 25. The findings include: 1. R11's POS (Physician Order Sheet) shows Amoxcillin-Potassium Clavulanate Tablet 875-125 MG (Milligrams): 1 tablet by mouth every 12 hours for infection for 7 days with an order date of 8/3/23. The August Monthly Infection Log shows the following for R11: Infection site: skin (ssti) left lower leg; Onsite date of 7/27/23; Signs/Symptoms: Left lower leg swelling erythema (+) drainage. Lab/Diagnostic Results Wound Culture/ MRSA (Methicillin-resistant Staphylococcus aureus) and VRE (Vancomycin Resistant Enterococci). R11 did not have a McGeer's criteria form in the infection control binder or uploaded into his electronic medical record. 2. R25's POS shows Ciprofloxacin HCL 500 MG: Give one tablet by mouth every 12 hours for UTI (Urinary Tract Infection) for 5 days with an order date of 9/7/23. The September Monthly Infection Log shows the following for R25: Infection site--UTI, Onset date: 9/7/23, Sign/symptoms: Change in mental status, tea colored urine, lag/diagnostic results--urine culture + nitrates. R25 did not have a McGeer's criteria form in the infection control binder or uploaded into her electronic medical record. 3. R38's POS shows Ciprofloxacin HCL Tablet 500 MG: Give 1 tablet by mouth one time a day for UTI/Infection for 5 days with an order date of 8/4/23. The August Monthly Infection Log shows the following for R38: Infection site--UTI, noncatheter, Onset date: 7/31/23; Signs/symptoms: Dysuria, lab results--urinalysis E.coli >100,000. R38 did not have a McGeer's criteria form in the infection control binder or uploaded into her electronic medical record. 4. R47's POS shows an order date of 7/11/23 with the following order: Moxifloxacin HCL Ophthalmic Solution 0.5% --Instill 1 drop in both eyes 3 times a day for eye infection secondary to MRSA for 7 days until finished. Apply to both eyes. Keep order active until eye infection is resolved. The July 2023 Antibiotic Stewardship log shows a start date of 7/12/23 for Moxifloxacin HCL Ophthalmic Solution 0.5% and end date of 719/23; Agent--Routine, order for antibiotic. R47 did not have a McGeer's criteria form in the infection control binder or uploaded into his electronic medical record. 5. R58's POS shows Ciprofloxacin HCL tablet 500 MG--Give 1 tablet by mouth every 24 hours for infection for 5 days with an order date of 3/27/24. The March Monthly Infection Log shows: Infection site--urinalysis, Facility acquired--no mcgreer's criteria, Symptom onset date 3/37/24, Symptoms: Burning and itching, Culture results--urinalysis/culture. R58 did not have a McGeer's criteria form in the infection control binder or uploaded into her electronic medical record. 6. R60's POS shows Doxycycline Monohydrate Oral capsule 100MG--1 capsule my mouth two times a day for infection for 1 day and give 1 capsule by mouth one time a day for infection for 7 days with an order date of 2/12/24. The February Monthly Infection Log shows: Infection site--skin, Facility acquired, Symptom onset: 2/12/24, Signs/symptoms: Red irritated lump under armpit, no culture done. R60 did not have a McGeer's criteria form in the infection control binder or uploaded into his electronic medical record. On 5/15/24 at 11:24 AM, V5 (Registered Nurse/Assistant Director of Nursing/Infection Preventionist) stated, I work full time here. I started in August in 2023. Corporate reminded me that the nurses were supposed to fill it out, but they were not doing it. It's both the nurse and my responsibility to do the McGeer's criteria. We need to do the McGeer's criteria because we want to make sure the residents are not getting the wrong antibiotics. They don't need too much antibiotics and we don't want them to get resistance. We have to wait for the lab results first and then administer the antibiotics. I can't find the antibiotic log sheets for October and November 2023. I'm not sure what happened to them. Facility's policy titled Infection Prevention and Control Program (3/2024) shows 15. All facility personnel should adhere to the Infection Control Program in the performance of their daily assignments. Facility's policy title Antibiotic/Antimicrobial Stewardship Program-Mission Statement and Guidelines (11/2023) shows: 5. Tracking-Monitor at least one process measure of antibiotic use and at least one outcome from antibiotic use. This facility utilizes the McGeer's Criteria for determining if an infection meets criteria for treatment with an antibiotic. Facility's policy titled Infection Surveillance, Tracking and QA Reporting (11/2023) shows: Infection tracking includes but is not limited to: Review documentation of clinical signs and symptoms to determine if McGeer's criteria for infection were met and antibiotic use is appropriate.

Based on observation, interview and Record review the facility failed to provide a comfortable wheelchair for one (R65) resident reviewed for mobility in a sample of 25 residents. Findings include: R65 was admitted to the facility on [DATE]. R65's MDS (Minimum Data Set) dated 3/11/24 shows he is cognitively intact with a BIMS ((Brief Interview for Mental Status) score of 15. R65's MDS shows the use of a wheelchair for mobility. R65's diagnoses include morbid obesity, abnormal posture, lack of coordination, reduced mobility, osteoarthritis, and chronic gout. R65's physician orders include may participate in outings. R65's current care plan includes ADL (Activities of Daily Living) / mobility performance deficit that may fluctuate with activity throughout the day related to limited mobility, musculoskeletal impairment, abnormal posture and lack of coordination. No documentation found in R65's EMR (Electronic Medical Record) the reason for his refusal to use the facility provided wheelchair. Review of R65's EMR show he was discharged from physical therapy on 1/15/2024. The facility did not provide a policy on resident required equipment. On 5/14/24 at 11:55 AM, R65 was observed gowned and lying in bed. R65 stated he did not have a wheelchair to get out of bed. R65 stated the wheelchair the facility previously provided to him was too small and was too painful to use. R65 stated the facility does not have a wheelchair that is comfortable for his size and body type. On 5/16/24 at 10:46 AM, V17 Director of Rehab) stated R65 was offered a wheelchair and he refused it because it was too low for him. V17 stated there are wheelchairs that are a little higher. V17 stated if R65 required a higher sitting wheelchair it would have to be customed ordered. V17 stated therapy would need to coordinate with the Nurse Practitioner and the wheelchair company to be approved. V17 stated the process to obtain a custom wheelchair was never started. On 5/16/24 at 4:40PM, V16 Facility Consultant stated she did not have documentation as to why R65 refused to utilize the wheelchair previously provided.

Based on observation, interview and record review, the facility neglected to monitor a resident's change in condition, follow the orders to monitor a resident's vital signs and blood pressure as ordered and failed to notify the advanced practice nurse of signs and symptoms of a stroke. This failure resulted in a delay of treatment for R1 and causing a hemorrhagic stroke and right-sided weakness. This applies to 1 of 3 residents (R1) reviewed for facility response to change in condition and treatment in a sample of 3. The findings include: R1 is a [AGE] year-old male admitted on [DATE] having a mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. On 11/07/23 at 10:15 AM, V8 (Hospital Registered Nurse) stated, On 10/31/23, R1 said to multiple staff at multiple times to send him to ER (emergency room ) as he was experiencing right side numbness and tingling. But they don't let him for whatever reason. R1 said he began to tell people to send him to the hospital on 10/31/23 at around 9-10 AM. He was sent to ourER on [DATE] with a right-side weakness and facial droop. He had a Hemorrhagic stroke as per CT (Computerized Tomography) scan. On 11/2/23 at 12:40 PM, V9 (Hospital [NAME] President of Nursing) stated, R1 was transferred to another hospital as we don't have any neurosurgeon available with our hospital. On 11/2/23 at 5:45 PM, R1 was observed in the neurology unit of the second hospital. R1 was observed on his bed, with his right sided weakness. R1 was unable to lift his right arm or right leg. On 11/2/23 at 5:45 PM, R1 stated, I know my body, and I knew something was going wrong on Tuesday, 10/31/23. I was so scared as I had numbness and tingling in my right arm. I told my nurse to send me to hospital right away. My nurse was V5 and said 'No' to my request. On 11/2/23 at 5:50 PM, V10 (Hospital Registered Nurse) stated, I just received R1 from neuro ICU (Intensive Care Unit) to regular neuro floor. R1 had a thrombectomy done due to his stroke, and his right side is weak. On 11/2/23 at 1:45 PM, V5 (R1's nurse on 10/31/23 Day Shift) stated, On 10/31/23, R1 was complaining of right arm tingling/numbness. I took his vitals, and his blood pressure (BP) was elevated at 177/102. I notified the nurse practitioner about his elevated blood pressure, who ordered Metoprolol and Hydralazine. On 11/2/23 at 11:00 AM, V6 (Nurse Practitioner/NP) stated, One of the Physical therapists called me saying that R1 was not feeling well. I assessed him, and he said he was not feeling well after breakfast. He was feeling dizzy. He was afebrile not complaining of chest pain. His BP was elevated at 172/109. When I checked his medication profile, there were no BP medications on his medication list. So, I ordered metoprolol 50 mg daily and Hydrochlorothiazide 25 mg. I was not notified of his right-side tingling. I would have ordered a CT if I knew he had right-side tingling along with elevated blood pressure. They should have notified the provider if R1 continued to have numbness and tingling after blood pressure medication was given. On 11/2/23 at 1:45 PM, V5 added, Maybe I didn't mention R1's right arm tingling/numbness to NP because I was worried too much about his blood pressure. I endorsed to the night nurse to monitor him as he was given two blood pressure medications (new to R1) due to his elevated BP. Record review on progress note and vitals record indicates that R1's vital signs and BP were not monitored or documented during the night shift of 10-31-2023. On 11/2/23 at 1:45 PM, V12 (R1's agency CNA on 10/31/23 night shift) stated. I am not supposed to do vitals unless the nurse tells me to take vitals. The nurse on duty that night was an agency nurse, V13. V12 stated V13 never requested to have R1's vital signs and blood pressure monitored. V13 was not available for interview during the investigation. V12 added, nurses are the ones who usually take vitals and V12 was unsure if V13 monitored R1's blood pressure and vital signs. On 11/2/23 at 10:25 AM, V11 (Registered Nurse for R1 on 11/1/23 AM shift) stated, I worked yesterday, and I was the one who transferred R1 to the hospital at around 6:20 AM. My CNA (Certified Nursing Assistant) notified me that R1 was found on the floor while I was getting the shift report at around 6:15 AM. He was bleeding from his right eyebrow. His BP was high at 157/95. He was not on any BP medications and was very independent. R1 told me that he also reported to the night nurse about his right arm numbness/tingling. On 11/2/23 at 10:25 AM, V11 added, The night agency nurse (V13 was unavailable for the investigation) endorsed me to monitor R1 due to his increased confusion. She (V13) never mentioned to me about his right-side numbness. R1 had slurred speech and elevated BP, and his arm strength was not symmetrical when I assessed him after the fall. He was telling me something was happening to him and sending him out to the hospital. R1 is a resident who never calls for unnecessary things. If he complains about something, there is something serious, and the staff should listen to him closely. When I called the hospital for follow-up, the nurse told me that R1 was admitted there for hemorrhagic stroke. Record review on Emergency Department Physician Report dated 11/01/23 (Page 5/15) documents that R1 arrived in ER with right-sided facial droop, right upper and lower extremity weakness, right-sided sensory deficit, mild dysarthria, and aphasia concerning acute stroke. The ER physician report documented that the patient is outside of the window for TNK administration (clot buster). CT of the head demonstrated acute intraparenchymal hemorrhage in the left globus pallidus. On 11/7/23 at 12:00 PM, V2 (Director of Nursing / DON) stated, I was here on 10/31, and I knew about R1's elevated BP. I wasn't notified of his numbness and tingling even after his blood pressure came down. The nurses should have notified the Physician/NP If he still felt numbness.

Based on interview and record review the facility failed to provide safe motor vehicle transport. This failure resulted in R2 suffering multiple fractures and injuries requiring hospitalization when R2's improperly secured wheelchair tipped forward causing R2 to fall on vehicle floor. This applies to 1 of 3 residents (R2) reviewed for injuries in a sample of 6. Findings include: R2's Admission Record dated 04/13/2023 documents diagnoses which include muscle wasting and atrophy, repeated falls and severe protein-calorie malnutrition. The facility's incident report dated 05/31/2023, completed by V2 Director of Nursing, documents Resident (R2) experienced an unwitnessed fall during transportation from an orthopedic appointment. Resident was assessed, resident had a laceration on left eyebrow and no other visible injuries. NP (Nurse Practitioner) notified and orders for the resident to be sent to the ED (Emergency Department) for further evaluation was placed. The facility's Final Report dated 06/07/2023 documents Resident (R2) experienced an unwitnessed fall during transportation from an orthopedic appointment. Residents wheel chair was strapped, including the seatbelt .facility van in service. Staff to ensure wheel chair properly secured for all transports. On 5/31/23 at 3:11 PM, V2 stated they called me- they needed my help I went into the bus and saw [R2] lying on the floor face down. R2's 5/31/23 Nurse Practitioner progress note from 11:40 AM showed, R2 was strapped in his wheelchair for a ride from a doctor's appointment when his wheelchair flipped over him as they pulled up to the facility's main entrance. On 06/14/2023 at 11:57 AM V16 Certified Nurse Aide/Facility Van Driver stated, What I think happened is the straps that hold the wheels act like the seatbelts .they give a bit back and forth until you hit the brakes or are involved in a crash. Then they lock down. I went over a bump in the driveway that sent (R2) flying face down with both back wheels in the air while the front wheels were in place. The straps didn't lock down because I wasn't on the brakes. The facility's wheelchair locks manual showed .3. Attach the four tie-down hooks to solid frame members or weldments, near seat level. Ensure tie-downs are fixed at approximately 45 degrees do not attach hooks to wheels, plastic, or removable parts of wheelchair. 4. Ensure all tie-downs are locked and properly tensioned. If necessary, rock the wheelchair back and forth or manually tension retractor knobs (if present) to take up additional webbing slack . On 06/15/2023 at 02:12 PM V17 Equipment Mechanic Technician stated, There is no play in the straps that hold the wheelchair wheels to the floor in these vans. When these wheels are strapped down correctly there is no play or give .Anytime! When secured correctly, the wheelchair would be demolished before separating from the floor. If the person was face down with the rear wheels in the air and the front wheels still secured whoever was doing it used two straps not four. They obviously didn't secure the wheelchair as they should have. On 06/16/2023 at 02:37 PM V18 Nurse Practitioner for R2 stated, This is a failure for (R2). He just is recovering from hip fracture and healing well. Now this. He's altered so he can't say what really happened and just suffers with the neck collar and pain he experiences. These injuries were all avoidable. R2's Hospital emergency room record dated 05/31/2023 documents (R2) states R2 was a restrained passenger on a wheelchair in a van (going at unknown speed) where the driver braked quickly and patient tipped over and hit his head on the floor and the right side of his body. The Findings include: acute displaced fracture involving the distal right clavicle, scalp hematoma, acute right C6-C7 (spine) perched facet joint demonstrating associated displaced fracture fragments of the inferior articular facet of C6 and the superior articular facet of C7, displaced fracture fragment of inferior endplate of C6 posteriorly, traumatic mild anterior subluxation of C6 and C7 and fracture fragments of C6-7 resulting in partial narrowing of the central canal and the right neural foramen. The emergency room History and Physical for R2 dated 05/31/2023 at 02:28 PM documents, Because of the patient's clinical condition involving fall resulting in injuries (conditions requiring hospitalization ), the patient requires treatment with possible surgical intervention, and I expect that the patient will stay more than 2 midnights based upon accepted standards of medical practice and patient-specific clinical circumstances. The patient is a risk for worsening symptoms and death. Due to the severity of the illness and intensity of services, the patient's care can only be provided safely and effectively as an inpatient observation. R2's Minimum Data Set, dated dated dated [DATE] documents him as requiring the extensive assistance of one person for movement while in a wheelchair, requiring the extensive assistance of one person for dressing, the extensive assist of 1 staff and with bilateral lower extremity impairments.

Based on observation, interview and record review, the facility failed to provide physican ordered pain medication to treat pain. This applies to 1 of 6 residents (R5) reviewed for pain in a sample of 9. This failure resulted in R5 experiencing untreated pain during the provision of care. Findings include: An 8/1/2022 Nurse Practitioner Advanced Care Planning Note, completed by V3 (Nurse Practitioner), documents R5 with a change in status due to end stage liver failure. On 8/5/2022 at 9:35 AM R5 laid in bed, unresponsive and with no signs of pain. R5's skin was very jaundiced (yellow) and she had an indwelling catheter draining bright red blood. V17 (R5's Niece) was present at bedside and stated she has been at the bedside off and on for the past two days to check on R5. V17 stated the evening of 8/1/2022 R5 was placed on hospice care and [MEDICATION(S)] was ordered. V17 stated on 8/2/2022, V17 came to the facility, sometime in the early afternoon, and noticed R5 was grimacing, her eyes were watering and R5 would not allow V17 to touch her. V17 stated she asked the nurse (V21) if she could administer R5 some [MEDICATION(S)] for her pain and V21 stated she could not administer her [MEDICATION(S)] because it was not available. On 8/5/2022 at 9:08 AM V4 (Wound Nurse) stated on 8/1/2022 V4 tried to do an initial wound assessment on R5 after she returned from the hospital and R5 was in pain just removing the tape, so she stopped and did not complete the assessment. V4 stated the facility policy is to provide pain medications for pain or contact the physician if needed. V4 stated she was going to administer [MEDICATION(S)] at the time but V17 refused it. V4 stated V5 (Physician) and hospice came and evaluated R5 right after this occurrence and [MEDICATION(S)] was ordered for R5's pain. On 8/6/2022 at 12:06 PM V15 (Nursing Assistant) stated she cared for R5 on 8/1/2022 between 2-10 PM and R5 was yelling out when being provided care during the shift. V15 stated, prior to R5 being sick she had sensitive skin and would sometimes tell you she was in pain or yell when she was being provided care. On 8/8/2022 at 9:05 AM V22 (Nurse) stated she worked the evening of 8/1/2022 until 6 am 8/2/2022. V22 stated R5 could still make her needs known, although she was intermittently confused, but would at times respond to questions asked. V22 stated R5 denied pain and did not exhibit any signs of pain except for once between 4-5 AM while being provided care. V22 stated R5 went to sleep after being provided care and did not exhibit any further signs of pain. On 8/5/2022 at 4:26 PM V20 (Nursing Assistant) stated she cared for R5 on 8/2/2022 between 6 AM-2 PM and R5 was yelling out when being provided care during this shift, but she did not notice R5 in pain at any other time. R5 stated prior to R5's recent change in status, R5 would yell out while being provided care when she was in pain. On 8/5/2022 at 9:08 AM V4 (Wound Nurse) stated on 8/2/2022 she went to change R5's dressings and she had pain just being touched. V21 could not find R5's [MEDICATION(S)] to medicate R5 for pain. V4 stated, I am not sure why hospice or the physician wasn't called earlier. On 8/5/2022 10:04 AM V8 (Hospice Nurse) stated, she was called to the facility on [DATE] because the facility was unable to locate R5's [MEDICATION(S)] which had been ordered and provided to the facility the prior evening. V8 stated when she assessed R5 on 8/2/2022 around 12 PM, R5 was having so much pain when touched that R5 wouldn't allow her dressings to be changed. On 8/5/2022 at 11:15 AM V3 (Nurse Practitioner) confirmed [MEDICATION(S)] was ordered for pain management by hospice for R5 on 8/1/2022 due to a significant change in status from liver failure. V3 confirmed if R5 was having pain at any time, even just during positioning, she should have been administered [MEDICATION(S)] for pain management. V3 stated she was unaware of any issues and stated R5 having pain is unacceptable. V3 stated the purpose of hospice is comfort and she should not have been in pain. R5's Hospice Visit Summary dated 8/2/2022 at 12:22 PM, completed by V8, documents R5 is comfortable unless she is touched, then she yells in pain. This note also documents the facility does not have the ordered [MEDICATION(S)]. V8 documents R5 was observed by V8 lying comfortably in bed and when touched, she yells in pain. R5's Hospice Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's Order Summary Report 7/30-8/31/2022 documents an order with a start date of 8/2/2022 for [MEDICATION(S)] Sulfate 0.25 ml every hour as needed for end of life pain. R5's Controlled Substance Proof of Use documents R5 did not receive her first dose of [MEDICATION(S)] on 8/2/2022 until 3:20 PM The Hospice Pre-Admission Summary documented 8/1/2022 at 5:54 PM by V23 shows R5 assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility policy, Pain Management Program, dated 7/6/2018 documents it is the goal of the facility to provide resident comfort. The quality, duration and location of pain will be used to evaluate the pain and identify changes in pain. When the resident is unable to describe pain, physical signs such as grimacing, body posturing, and changes in behavior will be used to determine the presence of pain. The management of pain includes use of pain medication as appropriate.

Based on observation, interview and record review the facility failed to ensure residents were positioned safely in bed to prevent falls and minimize fall risk. This failure resulted in one resident (R1) falling from bed and sustaining a 7 cm (centimeter) laceration to her leg. This applies to 3 of 4 residents (R1, R3 and R4) reviewed for falls in the sample of 4. The findings include: 1.) R1 was admitted to the facility on [DATE], per the admission face sheet and was discharged to the hospital on July 7, 2022. The physician orders dated July 1, 2022, showed that R1 had diagnoses of [CONDITION(S)], diabetes, anxiety, depression, [CONDITION(S)] stage 3, and dysphagia. R1's progress notes dated July 7, 2022 showed that at 1:04am, R1 was found on the floor between the wall and the bed. The note showed that R1 had a laceration to the right leg and was sent to the community hospital for evaluation and treatment. R1's July 7, 2022, Emergency Department Procedure Note showed R1 received sutures to a 7 cm laceration to her right lower leg. The note also showed R1 believed she rolled out of bed and fell to the floor. On July 8, 2022 at 6:30pm V6 RN stated, I found R1 on the floor (on July 7). She had a cut on her right leg. We stopped the bleeding with a gauze wrap, assessed her vital signs, and sent her to the hospital. The bed was about waist high and the wheels on the bed were not locked. On July 11, 2022, at 7:50am V7 CNA (Certified Nursing Assistant) stated she could hear R1 calling out for help. I went with another staff member and R1 was on the floor between the wall and the bed. The bed was in a high position and the wheels were not locked. R1 had a cut on her right leg. I know she went to the hospital. [R1] did not return. V7 said that the wheels should be locked and the bed should be in the low position. R1's Fall care plan showed a June 16, 2022, intervention that R1 used a bariatric-sized bed, and her July 5, 2022, MDS (Minimum Data Set) showed that R1 requires extensive assistance from two or more staff members for bed mobility. The clinical record showed that a fall risk assessment was not done until after the fall on July 7, 2022, and showed that R1 was at risk for falls. The facility policy for falls dated November 11, 2017, showed that fall risks should be done on admission. The policy showed that safety interventions would be implemented for each resident identified at risk for falls and that all assigned nursing personnel were responsible for ensuring ongoing precautions were maintained consistently. On July 8, 2022 at 12:15pm V1 Interim DON (Director of Nursing) stated, The fall assessments should be completed on admission. The staff are to make sure the wheels are locked. V1 verified that R1's clinical record does not reflect a fall risk assessment on admission. On July 8, 2022, at 11:45am V3 Restorative Aide stated, R1 is at risk for falls even though she is bed bound. R1 requires total assistance with toileting and transfers. R1 can reach for things and will put her legs over the edge of the bed. R2 and R3 are also at risk for falls. R3 requires the bed to be in a low position and mats to the floor. I do not do the fall risk assessments and have no input in making the care plans. I assist on implementing what is put on the care plan. 2). R4 was admitted to the facility April 26, 2021, per the admission face sheet. The physician orders dated July 1, 2022, showed that R4 was admitted to the facility with diagnoses of cerebral infarction, repeated falls, left sided weakness, respiratory disease, [CONDITION(S)] heart disease and pain. On July 12, 2022, at 8:45am, R4 was lying in bed trying to eat oatmeal and the oatmeal was dropping onto her gown. Approximately four inches of R4's right shoulder was hanging off of the edge of the bed. R4's body was angled to the right side with a rolled blanket under the left shoulder blade (R4's weaker side). The call light was placed to the left side of her body. R4 had a fall precautions bracelet to the left wrist, and R4's bed was in the high position. The head of R4's bed was at a 45 degree angle. R4 stated, I do feel uncomfortable lying like this, but I can't straighten myself out. I can't pull the light cord. My left side is weak. The surveyor activated R4's call light. Staff came in the room to see why the light was on. After prompting, the staff repositioned R4 to the center of the bed but R4 remained on her right side, and staff left her bed in the high position. R4's current care plan for falls showed that R4's bed should be kept at the lowest level, and a pillow be at her side to remind her where the edge of the bed is. On July 12, 2022 at 11:10 am V9 Administrator stated, The staff should not be laying R4 on her right side to eat, and that there should not be a rolled up blanket under R4's left shoulder. R4's fall risk assessment dated [DATE], showed that R4 is at risk for falls. R4's June 15, 2022, MDS showed that R4 had moderate cognitive impairment, and requires extensive assistance of at least two staff members for bed mobility. 3.) R3 was admitted to the facility June 13, 2022, per the admission face sheet. The physician order sheet dated July 1, 2022, showed that R3 had diagnoses of lack of coordination, cognitive communication deficit, dysphagia, kidney failure, dementia, [CONDITION(S)] disorder, anxiety disorder and spondylosis in the cervical region. R3's July 1, 2022, fall risk assessment dated showed that R3 is at risk for falls, and R3's current care plan does not include a care plan for falls. On July 8, 2022, at 10:30am R3 was lying in bed. R3 was non-verbal. R3's June 20, 2022, MDS showed that R3 was severely cognitively impaired and R3 required extensive assistance of at least two persons for bed mobility. On July 12, 2022, at 9:00am, V8 CNA prepared to change R3's incontinence brief. V8 stated, R3 is new to me. I have never taken care of him before. I have not changed him yet. I can change him myself. Sometimes residents fall. Haven't you noticed that they are short-staffed everywhere? As V8 rolled R3 away from her in the bed, R3 was stiff and resisted being turned, and R3 grabbed at and reached out into the air for something to hang on to. V8 continued trying to turn R3 to his left side and R3's body was approximately five inches away from the edge of the bed. V8 pulled out one side of the sheet from under R3. R3 could not hold a side lying position without assistance and fell backwards onto his back while V8 went around the other side of the bed. V1 DON entered the room to check on R3 and V8. V1 said that R3 requires two staff for bed mobility. On July 12, 2022, at 11:10 am V9 Administrator stated, R3 requires 2 staff for positioning in the bed . There is always enough staff to assist.

Based on interview and record review the facility failed to provide dressing changes as ordered for a pressure ulcer. This applies to 1 of 3 residents (R1) reviewed for pressure ulcers in a sample of 3. This failure contributed to the deterioration of R1's sacral pressure ulcer. Findings include: R1's initial Skin and Wound Evaluation Report dated February 1, 2022, completed by V4 (Wound Nurse), documents R1 with a stage 3 pressure ulcer to the left buttock measuring 6.0 X 3.0 X undetermined depth in centimeters and a stage 3 pressure ulcer to the right buttock measuring 1.5 X 0.6 X undetermined depth in centimeters. R1's February 2022 Treatment Administration Record (TAR) documents R1 with orders to cleanse the right and left buttock pressure ulcers with normal saline, cover with calcium alginate and a gauze dressing beginning on February 2, 2022. Neither the TAR or the Order Administration Notes (Progress Notes) document these treatments as occurring on February 3 and 4, 2022. R1's Wound Evaluation and Management Summary Physician Report dated February 9, 2022, completed by V3 (Wound Physician), documents R1 with an unstageable full thickness pressure ulcer to her right buttock measuring 1.2 X 1.2 X unmeasureable depth in centimeters and an unstageable full thickness pressure ulcer to the left buttock measuring 10 X 9.3 X unmeasureable depth in centimeters. The ordered treatment plan for both of these pressure ulcers was to apply Santyl, Calcium Alginate and a cover with a dressing every day. R1's February 2022 Treatment Administration Record (TAR) documents R1 with orders to cleanse the right and left buttock pressure ulcers with normal saline, apply Santyl to the wound bed and cover with calcium alginate and a gauze dressing beginning on February 10, 2022. Neither the TAR or the Order Administration Notes (Progress Notes) document these treatments as occurring on February 10, 13 and 14, 2022. On February 22, 2022 at 12:20 PM V1 (Administrator) confirmed if a treatment is not documented on the TAR it is not considered completed. R1's Wound Evaluation and Management Summary Physician Report dated February 17, 2022 documents R1's left and right buttock pressure ulcer as deteriorating, now coalesced and classified as a stage 4 sacral pressure ulcer measuring 9.5 X 11.5 X 3.7 in centimeters. On February 23, 2022 V3, Wound Physician, stated R1 is a [AGE] year old who had multiple risk factors, including a decreased appetite after a Covid infection in January which contributed to her developing pressure ulcers. V3 confirmed R1's pressure ulcer to the sacral area deteriorated rapidly. V3 stated R1's sacral pressure ulcer deterioration was multi-factorial related to age, a recent Covid infection, poor nutritional intake and the failure to change her pressure ulcer dressings as ordered.

Based on interview and record review the facility failed to ensure residents were free from verbal abuse. This failure resulted in R2 suffering embarrassment when V1 (Administrator) yelled at her in the dining room in front of other residents for sitting in the wrong area. R2 feels uncomfortable if V1 returns and will not leave R2's room if V1 is in the facility. This applies to 2 of 3 residents (R1 and R2) reviewed for abuse from a total sample of 5. The findings include: 1. R2 was admitted to the facility January 10, 2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's most recent minimum data set assessment on June 30, 2021, documented that R1 was cognitively intact, required limited assistance for most activities of daily living except supervision only for eating, and that it was very important to R2 to participate in her favorite activities. On August 19, 2021 at 12:30 PM, multiple residents were noted in the dining room eating lunch, seated at tables with 1 to 3 residents per table. Staff were noted seated throughout and assisting residents as needed. One resident was noted seated at the back of the dining room alone. On August 19, 2021 at 12:35 PM, R2 was noted seated in her room (on a non-quarantine unit) in a wheelchair, with the door open and her lunch tray on her overbed-table between her and the television. R2 was not yet eating. When she was asked why she was eating in her room, R2 stated she eats in her room and was never going to the dining room again. R2 explained this was because V1 (Administrator) yelled at her in the dining room while she was seated at the table with two other residents. R2 stated these residents were her friends and they visited together. R2 continued, and stated V1 was yelling and told me 'You can't sit here you have to go to the back of the room to eat. R2 acknowledged that she was to sit at the back of the room because she refused the Covid vaccine because she is allergic to many things, and was afraid to take it. R2 added, I will never eat there again. She (V1) just yelled at me and she didn't have to do that. It made me feel like sh*t. Others in the dining room heard it for sure. During the interview R2 was seated with her head down and shoulders rounded, and did not make eye-contact during the interview. On August 19, 2021 at 12:45PM, R3 (Resident Council President) was seated across the hallway in her room watching television. R3 was cognitively intact and confirmed that she was present and sitting at the same table with R2 when V1 (Administrator) yelled at R2, and told R2 to sit in the back of the room. R3 stated the incident began with (V1) coming into the dining room [ROOM NUMBER] or 3 times and not saying anything, and then on the fourth time, she (V1) just yelled at (R2). I felt bad for (R2). I know she isn't vaccinated, but I have been, and she lives across the hall, we're friends and visit all the time. R3 continued, And (R2) has a roommate too, and she's vaccinated too I think. R3 added there was another resident seated at the table with R2 and R3 during the incident, and stated she (R3) didn't say anything, because I don't want it to come back on me. On August 30, 2021 at 1:05 PM, during follow-up interview R2 was in her room finishing up her lunch. R2 appeared in improved mood, was seated upright in her chair and made socially appropriate eye-contact through out the interview. R2 stated she wanted to know if V1 (Administrator) was returning to the facility. R2 stated she did not feel comfortable with V1 returning to the facility, and stated if V1 does return to the facility, she will stay in her room, and not come out for meals or any other reason. R2 added that she feels the staff is not as moody since V1 has not been at the facility. R2 explained that the staff do their work and seem less anxious. August 30, 2021 at 3:00PM, V2 (Director of Nursing) provided copies of the Final Abuse Investigations for both the current allegations, and stated they were already faxed to the IDPH. It was noted in the section Summary and Analysis of the Evidence of the report of investigation regarding R2's allegation, (V18), CNA, reported that she overheard the Administrator speaking inappropriately to (R2) regarding the incident between R2 and V1. On September 1, 2021 at 12:15 PM, V2 confirmed she interviewed V18 and clarified the completion of the sentence should include the information that V18 confirmed hearing V1 speaking inappropriately to R2 regarding eating in the dining room and wearing a mask. The facility provided email documentation of a follow-up interview by V5 (Social Services Assistant) with R2. The document reported R2 wanted to know if V1 was returning to the facility, that R2 stated she feels uncomfortable with V1 returning, and that if V1 does return, R2 stated she will stay in her room if the (V1) is here. It was noted this document was shared with V15 (Regional Vice President of Operations). 2. R1 was admitted to the facility August 11, 2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was documented cognitively intact on his admission Minimum Data Set (MDS) assessment, and required limited assistance for his activities of daily living. On August 19, 2021 at 10:30AM, V1 (Administrator) stated there were no active abuse investigations at the facility, and stated she was not aware of any allegations of abuse. V1 provided three folders documenting three reportable facility investigations that she stated had been reported to the Illinois Department of Public Health/IDPH. On August 19, 2021 at 11:50 AM, R1 was noted in his room wearing oxygen by nasal cannula, in bed initially appeared agitated, and this agitation eased as the interview progressed. When asked if there was an incident where staff cursed at him R1 acknowledged, It happened, but I didn't want to take it further because I thought that would make it worse. R1 stated he did not report the incident to the facility or to IDPH. R1 stated, A few nights ago on the evening shift he put his call light on for medication. R1 explained he has anxiety and could feel it was getting worse. R1 continued, the girl came in and said the nurse would be there soon. I told her I needed my med. She turned off the call light. The nurse did not come. It happened again that I put on my call light and the CNA came. R1 stated the CNA spoke to him and turned off the call light. R1 said that the nurse had not yet come when he put his call light on again for the third time. R1 stated the CNA came to his room again, and he told her to leave the light on because he wanted her to remember to see him. R1 stated he was getting upset. R1 continued, when the nurse finally came V9 (LPN) he was upset. He stated the nurse put the medication cup down on the table, and he looked at it, and it appeared to him that there were too many pills in the cup, so he did not take it. R1 stated the nurse said, I have 20 other patients, not just you. As she walked out of the room I heard her say 'f*ck this sh*t. Then I yelled out to her in the hallway f*ck you too b*tch. R1 continued, I'm supposed to get my meds at 6, and now it was between 7 and 8. I felt bad, thinking maybe she had some problem at home. But then I'm here for help too. R1 added, I just have this anxiety and need my med or it gets worse to paranoia. R1 stated he was not sure the date of this occurrence, and stated the nurse was (V9) Licensed Practical Nurse/LPN, and that it was dark outside, adding so it must have been during the night. On August 23, 2021 at 12:50PM, V9 (LPN) reported that she regularly worked the night shift, 6 PM to 6 AM, and that she was assigned to R1 on a night when he was repeatedly put on his call light, and cursing between herself and the resident ensued. She reported that R1's concern was his medication. V9 added, That night it must have been around 10 or 11 because (V11, CNA) the night CNA was here, standing in the (R1's) door. On August 24, 2021 at 10:25 AM, V11 (CNA) confirmed she worked the night shift, and that her schedule was 10 PM to 6AM. V11 reported that she worked on the night shift on the quarantine hall where (R1) resided. V11 stated she was the only CNA assigned to the hall the night that that R1 repeatedly put his call light on for the nurse (V9), and there was cursing between the resident and the nurse. V11 stated that V9 was was the nurse assigned to the quarantine hall and another hall. V11 confirmed that R1 had put on his call light regarding his oxygen and medications. V11 stated she answered the call light and, I told him I'd get the nurse (V9). I told her. She was busy with other residents. V11 continued, I left and 15 minutes passed and he (R1) turned on the call light, and I came back. That's when he said he was having trouble breathing. I noticed he had taken off his oxygen from his nose. I went to get V9. (R1) was mad at me because he thought I didn't go to the nurse, and I went to get the nurse. V9 came and she asked me to come in the room with her. V11 (CNA) continued, We were both in the room with him. They ended up cursing at each other. V9 did first, saying 'I can't f*cking do this anymore' while she was in the room facing him. (R1) was cursing when she (V9) turned her back and was walking away, and she was all the way down the hall. The two residents in other rooms close by probably heard it. Both those residents are no longer here. The facility provided their policy, Abuse Prevention and Reporting dated January 22, 2019, which stated in part, Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting .mental anguish, and Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on observation, interview and record review the facility failed to provide post fracture care as ordered by the neurosurgeon for 1 of 3 residents (R1) reviewed for falls in a sample of 11. This failure has caused R1's second cervical vertebra fracture to have delayed healing and required R1 to continue to wear the neck collar, which R1 finds uncomfortable. Findings include: R1's Admission Record dated 9/27/19 documents R1 as a [AGE] year old with [DIAGNOSES REDACTED]. R1's Brief Interview of Mental Status dated 9/1/19 documents R1 as cognitively intact. A Incident Report dated 5/14/19 documents R1 was found on the floor in his room. R1 complained of pain to the right side of his head and was transferred to the hospital for evaluation. R1's hospital Cat Scan of the Cervical Spine dated 5/14/19 documents an acute fracture of 2nd cervical spine vertebrae. R1's Progress Notes dated 5/15/19 documents R1 returned to the facility with a neck collar. On 9/26/19 at 9:20 AM, R1's neck collar was in place. R1 stated he didn't want to wear the brace because it was uncomfortable. V9's (Neurosurgeon) physician progress notes [REDACTED]. This note documents Please make certain his collar is correctly applied and his chin is resting on the chin rest V9's physician progress notes [REDACTED]. This note further documents the cervical collar must fit snuggly and R1 should not be able to turn head or move his chin up or down. A recommendation was made to initiate use of a bone stimulator. V9's physician progress notes [REDACTED]. On 9/27/19 at 9:30 AM, V8 (Rehabilitation Director) confirmed R1's bone stimulator had not been obtained and initiated after the 8/1/19 appointment. V8 stated she was not aware of R1's bone stimulator order until after the last appointment with V9 on 9/17/19. V8 stated if the bone stimulator was ordered 8/1/19 it should have been initiated shortly after the initial order. On 10/1/19 at 9:33 AM, V9 confirmed R1 has a 2nd cervical vertebrae fracture after a fall. V9 stated on R1's visits 6/25/19 and 8/1/19 R1's neck collar was misapplied and loose. V9 stated the neck collar only works if it is applied correctly - tight and chin touching the collar. V9 stated if the resident can move their head with the collar on it delays healing of the fracture. V9 stated the facilities inability to apply the collar correctly has delayed healing. V9 further stated a bone stimulator was recommended to assist with healing and the facilities failure to secure the bone stimulator has caused even further delays. V9 stated the brace is not comfortable and R1 does not like wearing the collar. R1's Physician order [REDACTED]. Another physician order [REDACTED].

Based on interview and record review the facility failed to assess and treat a pressure related wound for one resident (R2) for 1 month after it was discovered. This failure caused R2's wound to worsen and required hospitalization for treatment. This applies to 1 of 4 residents (R2) reviewed for wounds in the sample of 4. The findings include: R2 was admitted to the facility (MONTH) 1, (YEAR) per the admission face sheet. R2 was discharged to the hospital (MONTH) 12, 2019 for treatment of [REDACTED]. The physician orders [REDACTED]. Nursing notes dated (MONTH) 22, 2019 showed that at 2:42 pm it was brought to the attention of the nurse that R2 had a wound on his left heel. The nursing assessment documents a stage 2-3 wound that measured 3 centimeter by 3 centimeter with a dark center to the left heel. The note showed that the physician was notified, and orders were received. Treatment Administration record showed that 1 treatment was administered on (MONTH) 25, 2019 by nursing staff. The physician orders [REDACTED]. The clinical record showed no reason or information as to why the treatment was discontinued. The clinical record had no wound care note from the Treatment Nurse for the wound on the left heel until (MONTH) 24, 2019. There were no notes from the wound care doctor for the wound on the left ankle in R2's clinical record until (MONTH) 24, 2019. The note showed the wound was pressure related and was a stage 4. There were no new physician orders [REDACTED]. Nursing notes dated (MONTH) 12. 2019 showed that R2's physician gave orders to send R2 to the hospital at the daughter's request. R2 was sent to the hospital and admitted with a [DIAGNOSES REDACTED]. The records from the community hospital showed that R2 had become resistant to many antibiotics used to treat the wound and the bone in the foot was also probably infected. The hospital records showed that R2's wound had become a stage 4 wound with probable infection of the bone. On (MONTH) 15, 2019 at 12:40 pm, in the conference room V2 DON(Director of Nursing) said that after reviewing R2's clinical record R2's wound was discovered (MONTH) 22, 2019. V2 said that When V3 Wound care nurse came back on Monday Morning (MONTH) 24, 2019 she thought the new order was an error and discontinued the order. V2 said R2 received no further treatment on the wound on the left heel until (MONTH) 24, 2019. V2 stated, I don't know why other staff did not see this and report it to the nurse. R2 did not receive treatment on the left heel wound from (MONTH) 23, 2019 through (MONTH) 24, 2019. On (MONTH) 15, 2019 at 3:45 pm, in the conference room V3 Wound Treatment Nurse said that she had never been notified of the wound on the left heel. V3 stated, I discontinued the order because I thought it was an error. R2 had wounds to right leg. No one told me of the wound on the left heel. V3 said that staff told her about the wound on (MONTH) 24, 2019. On (MONTH) 16 at 8:55 am via telephone V5 (Wound Care Physician) said that she was not aware of the wound on the left heel until (MONTH) 24, 2019. V5 stated, The wound would worsen if left untreated for [REDACTED].

Based on interview and record review the facility failed to monitor the use of anti-coagulant medication. This applies to 1 of 3 residents (R1) reviewed for anti-coagulant medication monitoring in a sample of 10. This failure resulted in R1 being hospitalized and treated for [REDACTED]. Findings include: R1's hospital Palliative Care Consultation report dated 2/4/19 documents R1 with [DIAGNOSES REDACTED]. R1's Hospital Discharge Instructions dated 2/7/19 documents initiate a new medication, [MEDICATION NAME] 5 milligrams (mg) every day. R1's hospital Laboratory Report dated 2/7/19 documents R1 with an INR of 3.0 seconds with a recommended target INR levels documented as 2.0-3.0 seconds for treatment of [REDACTED]. R1's Facility Order Summary Report dated (MONTH) 3, 2019 documents R1 with an order for [REDACTED]. R1's Progress Notes dated 3/5/19 document R1 as having a large amount of blood on bed linen with large clots and R1 sent to the hospital for evaluation. R1's hospital Emergency Department Physician Report dated 3/5/19 documents R1 with an elevated INR greater than 11 seconds and receiving treatment including fresh frozen plasma (blood product) and vitamin K. This report documents R1 being admitted to intensive care due to a high risk for decompensation due to gastric intestinal bleeding and elevated INR. On 4/3/19 at 12:25 PM, V2 (Director of Nursing) confirmed there should be orders to monitor R1's INR due to receipt of [MEDICATION NAME] and there were none completed. V2 stated facility protocol is to complete a baseline INR the next weekday (Monday through Friday) and then contact the physician for further monitoring orders. On 4/9/19 at 2:15 PM, V8 (Physician) stated V8 has standing orders the facility is to follow which include monitoring INR for newly initiated [MEDICATION NAME] on Monday and Thursdays and to call V8 with those results for further instructions/orders. V8 stated once the INR is stable, the INR is to be monitored every week, then twice a month and then monthly but these orders are initiated by V8 and individualized for each resident based on their INR results. V8 stated the facility should have been monitoring R1's INR levels or called if they needed further orders. V8 stated R1's INR level should have been maintained between 2.5-3.0 seconds. V8 stated R1's elevated INR and lack of monitoring contributed to R1's hospitalization .

Based on observation, interview and record review the facility failed to implement treatment interventions and make timely identification of the development of a pressure ulcer. This applies to 2 of 3 residents (R1, R2) reviewed for pressure ulcers in a sample of 6. This failure resulted in R1's sacral pressure ulcer worsening and R2 developing an infected unstageable pressure ulcer to the right outer ankle. Findings include: 1. On (MONTH) 5, (YEAR) at 1:30 PM, R2 had a pressure ulcer to the right lateral malleolus (ankle) which was open and the wound bed was covered with yellow dead skin measuring 3.0 centimeters (cm) by 4.0 cm by 0.1 cm. V3 (Wound Nurse) stated the wound was caused when R2 refused to remove compression stockings. A Progress Note dated (MONTH) 7, (YEAR), completed by V4 (Nurse Practitioner), documents R2 seen and examined per family request for a wound to the right lateral ankle. V4 documented as entering the room a malodorous odor noted and R2 sat with bilateral compressing stocking in place which had dried brown drainage to the right lateral foot region. V4 removed the compression stockings and a newly acquired wound was noted to the right outer ankle with drainage. V4 documented under assessment and plan the right lateral malleolus wound was of an unknown duration with [MEDICAL CONDITION] present. An antibiotic was initiated and a dressing was ordered. A Skin/Wound Progress Note dated (MONTH) 7, (YEAR), completed by V3 (Wound Nurse) documents R2 with a facility acquired unstageable pressure ulcer to the right lateral malleolus measuring 4.0 cm by 4.7 cm by 0.3 cm. R2's (MONTH) (YEAR) Treatment Administration Record (TAR) documents R2 receiving A and D ointment to the bilateral lower extremities twice a day. On (MONTH) 5, (YEAR) V3 (Wound Nurse) documented on the TAR R2's A and D ointment was applied. On (MONTH) 11, (YEAR) at 2:50 PM, V3 stated R2 would allow staff to lower the compression stocking down to the ankle but not entirely remove them off of his feet. V3 stated she would have been able to see R2's ankle to identify any wounds to the ankles. On (MONTH) 6, (YEAR), V12 (Nurse) documented on the TAR R2's A and D ointment was applied. On (MONTH) 11, (YEAR) at 2:56 PM, V12 stated R2 did not refuse at any time to remove compression stockings and A and D ointment was applied as ordered. On (MONTH) 5, (YEAR), V14 (Nurse) documented on the TAR that R2's A and D ointment was applied. On (MONTH) 11, (YEAR) at 3:04 PM, V14 stated there was never any refusal by R2 to remove compression stockings and there was no issues applying R2's A and D ointment. On (MONTH) 6, (YEAR), V13 (Nurse) documented on the TAR R2's A and D ointment was applied. On (MONTH) 11, (YEAR) at 3:00 PM, V13 stated R2 would allow staff to lower the compression stocking to apply the A and D ointment. The (MONTH) (YEAR) Progress Notes do not document R2 refusing to remove compression stockings. R2's (MONTH) 26, (YEAR) Care Plan does not document R2 with behaviors of refusing to remove compression stockings. On (MONTH) 7, (YEAR) at 1:00 PM, V4 stated R2's pressure ulcer to the outer right ankle should have been identified quicker and was large and infected when it was discovered by the facility. V4 further stated, It should not have happened If (R2) refused to remove compression stockings I would have discontinued them because they will cause more issues if not removed. (The wound) definitely wasn't acquired overnight. 2. (MONTH) 7, (YEAR) at 11:08 AM, V3 (Wound Nurse) changed the [DEVICE] dressing on R1's stage 4 sacral pressure ulcer which measured 8.0 centimeters (cm) by 11.0 cm by 1.0 cm. R1's Order Recap Report dated (MONTH) 7, (YEAR) documents R1 with current orders, beginning on (MONTH) 21, (YEAR), to change the sacral dressing on Mondays, Wednesdays and Fridays and as needed if loose, soiled or removed and apply the [DEVICE] at a setting of 125 millimeters of mercury (mmhg). R1's Progress Notes dated (MONTH) 22, (YEAR) at 8 PM documents R1's [DEVICE] off and the nurse was unable to re-apply the [DEVICE] as ordered. A wet to dry dressing was applied. R1's Progress note (MONTH) 23, (YEAR) at 7:46 am V4 (Nurse Practitioner) documented that R1 was seen and examined for a weekly wound assessment. V4 documents the prior evening R1's [DEVICE] became dislodged and staff was unable to reapply. V4 documents the wound appears to have slightly worsened and to reapply the vacuum. R1's Wound Care History Report documents R1's stage 4 sacral pressure ulcer measuring 9.0 cm by 13 cm by 1.5 cm on (MONTH) 16, (YEAR). R1's Skin/Wound Progress Note dated (MONTH) 23, (YEAR) documents R1's sacral pressure ulcer as a stage 4 measuring 9.5 cm by 11.5 cm by 2 cm. On (MONTH) 7, (YEAR) at 1:00 PM, V4 stated R1's [DEVICE] is to be on R1's sacral pressure ulcer at all times with a dressing change 3 times a week. V4 stated R1's [DEVICE] did come off once and it regressed while it was off. V4 stated once the vacuum is reapplied it takes a day or two for the wound to recover back to the healing state it was prior to the vacuum being off. V4 stated when it is off a wet to dry dressing is applied and it is not as effective as the [DEVICE]. The (MONTH) Treatment Administration Record entry to use a [DEVICE] for sacral pressure ulcer on (MONTH) 27-28, (YEAR) does not document R1's [DEVICE] in place and being utilized. A Progress Note dated (MONTH) 27, (YEAR) at 5:30 PM documents R1's [DEVICE] was removed for an appointment. These progress notes at 11:23 PM document R1 returned at 8:55 PM and a wet to dry dressing was applied. On (MONTH) 7, (YEAR) at 12:00 PM, V3 stated V3 is the only person who can apply the [DEVICE]. V3 stated when R1's [DEVICE] was off and there wasn't any staff present who knew how to reapply it correctly on (MONTH) 22, (YEAR). V3 confirmed when R1 returned from the appointment on (MONTH) 27, (YEAR), R1's [DEVICE] was not reapplied to R1's sacral wound until (MONTH) 29, (YEAR). The facility policy Pressure Ulcers/Skin Breakdown dated (MONTH) (YEAR) documents the physician will provide pertinent orders related to treatment of [REDACTED].

Based on observation, interview and record review the facility failed to notify the physician of changes in a foot wound and failed to follow physicians orders for wound care. This failure resulted in R21 with wound decline, hospitalization and [DIAGNOSES REDACTED]. This failure applies to one resident (R21) of three residents reviewed for wound management. Findings include: physician's orders [REDACTED]. Quarterly MDS/BIMS (Minimum Data Set/Brief Interview for Mental Status) dated 6/15/18 indicates R21 scored 14/15 and is cognitively intact. Physician Note dated 6/19/18 indicates wound on left great toe and Wound Physician to see on 6/20/18. Physician Wound Care Note dated 6/20/18 indicates R21 with left foot traumatic hematoma (4cm x 4cm x1cm/centimeter), left great toe wound 1.5cm x 1.3cm) and left 4th toe ulcer (0.3cm x 6.3cm x 0.1cm). No facility skin/wound assessments were documented until 7/6/18 nursing note and 7/12/18 Body Skin assessment. Care Plan/Alteration in Skin Integrity was initiated on 6/18/18 and only included left great toe as problem. Care plan was not updated to include dorsal or left 4th toe wounds. POS indicates R21 has orders: 7/19/18 for [MEDICATION NAME] Ointment 2% (topical antibacterial) to left 3rd toe every day shift for wound care; cleanse with Dakins 0.5% (antiseptic solution), apply [MEDICATION NAME] and cover with non-adherent dressing - change Daily. 7/19/18 for Santyl Ointment (topical chemical [MEDICATION NAME] agent) to left dorsal foot topically every day shift for wound care; cleanse with [MEDICATION NAME] (antiseptic solution), apply Santyl to wound base, cover with foam and wrap with gauze dressing - change Daily. 7/19/18 for Santyl Ointment to left Great toe topically every day shift for toe ulcer; cleanse with [MEDICATION NAME], apply santyl, cover with foam, wrap with gauze dressing - change Daily. On 7/24/18 at 2:35pm R21 stated The nurse yesterday said my foot was worse and the wound doctor said if my foot doesn't get taken care of I may lose my foot. R21 stated sometimes staff skip her treatment. At that time R21 was noted to have a wrapped gauze dressing on left foot dated 7/23/18. R21 stated that her dressing had not yet been changed (on 7/24/18). On 7/25/18 at 5:55pm R21 was eating dinner in her room after returning from [MEDICAL TREATMENT]. At that time it was noted that R21 had the same dressing dated 7/23/18 on the left foot. Dressing was dingy and dirty on the bottom as R21 had no shoes or protective covering over foot. R21 stated that the dressing was not changed (on 7/24/18) and still had not been changed (on 7/25/18). On 7/25/18 at 6:20pm V2, RN (Registered Nurse)/Treatment Nurse and V22, Wound Care Physician were in R21's room. V2, RN stated that the floor nurses are supposed to do the dressing changes and (R21's) dressing should have been changed yesterday. At that time R21's dressing was removed from left foot. R21's left foot was dark red, painful, with wounds on dorsal (top of foot), great toe and 3rd toe. Wounds all appeared with partial brown/black/gray areas. At that time V22, Physician stated that the wounds are significantly worse than last time (7/18/18) he saw the them. V22 stated areas weren't black before and dorsal skin was intact. V22 stated that R2 needs immediate hospitalization due to R21's impaired circulation and infection in the foot. V22 stated that staff should always follow physician's orders [REDACTED]. V22 stated I would hate to think what this foot would look like if I didn't see it every week. On 7/26/18 at 11:00am V38, Agency LPN (Licensed Practical Nurse) stated he was R21's assigned nurse on 7/24/18 and that the last time he saw R21's wounds (7/22/18) her foot was kinda red great toe and dorsal had slough and dorsal had blacked around edges. V38 stated that it is very hard to know if there are changes to a residents wounds being an agency nurse unless you've actually seen the wound a few times. V38 stated he really didn't know if it was worse or not. V38 stated that he must have got too busy and forgot to change R21's dressing on 7/24/18 even though he charted it was done. Nursing Note dated 7/25/18 at 11:35pm indicates orders were received from V22, Wound Care Physician to send R21 to local hospital for evaluation left foot. Nursing Note date 7/26/18 at 2:08am indicates R21 admitted to hospital with [DIAGNOSES REDACTED].

Based on observation, interview and record review the facility failed to provide timely incontinent care for one resident with an uncovered pressure sore, exposing the wound to urinary excrement. Based on interview and record review, the facility failed to notify the physician of one residents' abnormal lab report. As a result R22 was hospitalized and treated with antibiotics for a urinary tract infection 3 weeks after the abnormal lab report. This applies to one (R9) of 4 residents reviewed for incontinence and 1(R22) of 3 residents reviewed for indwelling urinary catheters in the sample of 23. The Findings Include: 1). R9's Face Sheet documents the following Diagnosis: [REDACTED]. On Saturday (MONTH) 14, (YEAR) upon arrival R9 was up in a wheelchair with a mechanical lift sling underneath her bottom while seated in a wheelchair. On (MONTH) 14, (YEAR) at 8:11PM, V7(CNA) and V9(CNA) wheeled R9 to the room and placed R9 in bed utilizing a mechanical lifting device. The seat cushion that R9 was sitting on had a puddle of wetness on top of it and R9's light beige pants contained wet areas in the genital and peri-anal area. It was confirmed by V9 that it was urine. Upon removal of the incontinent brief, it was heavily soiled. R9 said I have not been toileted since 8AM this morning when the day shift got me up. Upon cleaning R9's genital area there was a heavy build-up of thick white creamy substance and a stage 3 pressure ulcer to the bottom region with no dressing on it. At this time V9 said residents should be changed every 2 hours. There was no response as to why incontinent care was not provided for R9 from 8AM to 8PM. V9 confirmed that R9 had a wound on her bottom and there was no dressing on it. On Saturday (MONTH) 14, (YEAR) at 8:34AM, V5(Nurse) said she was not aware of any sacral wound for R9. V5 said sitting in urine from this morning to this evening could cause a wound . Care Plan for bowel and bladder incontinence initiated on [DATE] says the residents uses disposable briefs, change/check every 2 hours and as needed. On (MONTH) 25, (YEAR) at 8:51AM, V2(Nurse) said she coordinates the bowel and bladder program. V2 said it is standard care to provide incontinent care for residents every 2 hours. 2). Face Sheet documents R22 was admitted on [DATE] with a pertinent [DIAGNOSES REDACTED]. Skin Wound Note dated [DATE] documents, urinary catheter will be placed for urine diversion related to numerous pressure injuries and their unique locations to promote better wound healing. Nursing Progress Note dated [DATE] documents urinary catheter patent draining dark colored urine. Nursing Progress Note dated [DATE] documents urinary catheter patent draining dark colored urine. Nursing Progress Noted dated [DATE] documents resident urinary catheter patent. Urine yellow and very cloudy. Resident does not appear confused or altered for baseline. V34(Medical Doctor) updated of cloudy urine, Urinalysis and Culture and Sensitivity orders obtained . Lab Report dated [DATE] documents, the results of the urine culture [DIAGNOSES REDACTED] Pneumoniae and an abnormal urinalysis. Medication Administration Records and Physician order [REDACTED]. There was no documentation of the V34(Medical Doctor) being notified of the lab results Nursing Progress Note dated [DATE] documents urinary catheter patent, draining thick cloudy urine with mild amount of sediment noted . Nursing Progress Note dated [DATE] documents removed current urinary catheter and replaced with a new catheter related to signs of infection and Urinalysis, urine slightly hazy after insertion . Nursing Progress Note dated [DATE] documents urinary catheter patent and draining dark amber urine . Nursing Progress Note dated [DATE] documents .poor appetitive this evening Nursing Progress Note dated [DATE] states, 5:45PM, family here with concern. Family states R22 is more aggressive/agitated, confused. Appetite/ fluid intake poor. Family requesting R22 to be sent to the emergency room for evaluation. R22 was sent to the emergency room and admitted with a [DIAGNOSES REDACTED]. Nursing Progress Note dated [DATE] documents R22 returned from the hospital on 4 additional days of oral antibiotics for pneumonia. Nursing Progress Notes were reviewed from [DATE] until [DATE]. R22 continued to decline in eating and was sent out to the hospital on [DATE]. Hospital Record dated (MONTH) 28, (YEAR) through (MONTH) 29, (YEAR) was reviewed. R22 was diagnosed with [REDACTED]. R22 was treated with antibiotics but continued to deteriorate and the family decided to make R22 a DNR(do not resuscitate). R22 expired on (MONTH) 29, (YEAR). On [DATE] at 2:27PM, V2(Nurse) said the physician should have been notified about the abnormal labs on [DATE]. V2 said she did not find any documentation on physician notification/physician instruction. Care Plan for urinary catheter dated [DATE] states monitor/record/ report to Medical Doctor for sign/symptoms of Urinary tract infection: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, fouls smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. On [DATE] at 8:49AM, V34(Medical Doctor) was interviewed and said he did not recall R22 and was not informed of a abnormal lab but if he were informed he would have made a decision based on the labs and other test that he could have ordered on what to do.

Based on observation, interview and record review the facility failed to complete weekly pressure ulcer assessments and implement physician ordered treatments and interventions to promote the healing of pressure ulcers. This applies to 2 of 5 residents (R9, R62) reviewed for pressure ulcers in a sample of 26. This failure resulted in R9 and R62 pressure ulcer to worsen. R62's wound progressed from a Stage II wound to a Stage III wound and R62 developed a new wound. R9's wound increased in size and failed to heal. Findings include: 1. R62 was admitted to the facility April 29, 2017 per the admission face sheet. The physician orders [REDACTED]. R62 was able to talk with small words and at times was difficult to understand. R62 had dressings to the sacrum, the left buttock and the right leg stump. On June 12, 2018 at 10:00am R62 was lying in bed. Staff removed the bed covers. R62 had pillows under the right buttock and lower back. Both stumps to the legs were sitting directly on pillows applying pressure to the areas that had wounds. R62's wound was assessed by V4 (Wound Care Physician) on June 6, 2018 as new wound and a Stage II pressure partial thickness. R62 has an order dated June 11, 2018 to elevate legs. V4 (Wound Care Physician) stated during observation of R62's wounds on June 13, 2018 that R62 needs to have the stumps elevated. During this time, V4 demonstrated to the staff specifically how R62's stumps should be elevated to prevent further skin breakdown. A review of R62's plan of care last updated May 21, 2018 does not include interventions for elevation of R62's stumps. V4's documentation dated June 13, 2018 described R62's right leg stump as a Stage III full thickness wound measuring 3.0 cm (centimeters) by 2.0 cm by 0.1 cm indicating a decline in the wound. R62's sacrum wound was measured by V4 on June 13, 2018 and was noted to measure 4.5 cm by 3.4 cm by 1.0 cm and was coded as a full thickness Stage III pressure ulcers with 60% slough. V4 measured this same wound on May 16, 2018 and it measured 1.4 cm by 2.0 cm by 0.2 Stage III full thicknesses with 50% granulation, however on May 9, 2018 the wound measured 2.0 cm by 2.7 cm by 0.1 cm Stage II partial thickness wound. Physician orders [REDACTED]. The Medication Administration Record [REDACTED]. V4 assessed R62's left buttock wound on June 13, 2018 and described this wound as a full thickness Stage III wound with 70% slough and yellow drainage and measured 4.5 cm by 3.5 cm. V2 then proceeded to order a [DEVICE] for this wound to treat the drainage. Facility documentation dated May 25, 2018 codes this wound as a Stage II in house acquired pressure ulcer with no slough and measuring 3.7 cm by 2.5 cm by 2.4 cm. On May 29, 2018 nursing notes code R62's left buttock as 5.5 cm by 4.0 cm with unknown deapth due to slough, no further measurements of R62's left buttock wound was noted in the clinical record as of June 14, 2018. The physician order [REDACTED]. The Treatment administration sheet showed that this was not done on multiple occasions (18 doses) from May 25th through June10, 2018. The treatment of [REDACTED]. On June 13, 2018 at 3:00pm V4 (Wound Care Physician) was changing the dressings to R62's wounds. V4 said that the sacral wound had worsened to a stage three and was down to the bone. V4 said that the wound to the right leg stump had progressively worsened to a new pressure ulcer. V4 said that when he saw the stump last week it was only a blister. On further exam V4 said that the wound to the left buttock had also worsened to a stage 3 from a stage 2. V4 said that offloading these areas with position changes as ordered were important to follow as well as treatments and medications orders. V4 stated, If everyone just followed the treatment orders there would be progress. On June 14, 2018 at 11:20am, via telephone interview,V4 said that medications, dressings, wound care orders and positioning are all important factors in wound healing. V4 stated, If all of these factors are not followed wound healing is impeded. It won't happen if treatment orders are not followed. A nursing note dated June 5, 2018 at 3:18pm showed that R62's family had called nursing staff to the room to look at R62's dressing. The note showed that the dressing was loose and had a moderate amount of drainage with odor. The note documented that the family insisted that R62 be sent out to the local hospital for treatment. R62 was sent to the community hospital emergency room and returned to the facility June 6, 2018 with orders for treatment. The physician order [REDACTED]. The medication administration sheet showed that no doses were given on June 7, 8 and 11, 2018. 2. On June 13, 2018 at 9:30 AM, V9 (Nursing Assistant) performed incontinence care on R9. R9 had a pressure ulcer to the right ischium area which did not have a dressing covering the wound nor was R9 on an air mattress. R9 stated dressing changes were not being completed as they were supposed to occur. R9's May 2018 Treatment Administration Record (TAR) documents to cleanse the right ischium with [MEDICATION NAME] solution, apply Calcium Alginate and a [MEDICATION NAME] dressing three times a week on Monday, Wednesday and Friday. The TAR on Monday May 28 and Wednesday May 30, 2018 do not document this treatment as completed. V4's (Wound Care Physician) Physician Wound Care assessment dated [DATE] documents R9 with a stage 3 pressure ulcer to the right ischium measuring 2.0 by 0.8 by 0.2 centimeters (cm) with a stable wound bed per goal. V4's treatment plan is to cleanse the wound with [MEDICATION NAME] and apply [MEDICATION NAME] Powder and Calcium Alginate and [MEDICATION NAME] dressings three times a week. V4's preventative measures include use of an air mattress. The additional note section completed by V4 document this Pressure Ulcer as healing slowly. This report also documents R9 with a stage 1 Pressure Ulcer to the right heel. R9's May and June 2018 Treatment Administration Record documents to cleanse the right ischium with [MEDICATION NAME] solution, apply Calcium Alginate and a [MEDICATION NAME] dressing three times a week on Monday, Wednesday and Friday with a start date of May 18, 2018. There no change in R9's treatment per V4's orders after the May 23, 2018 assessment. After V4's Wound Care assessment dated [DATE] the electronic clinical record includes one Wound assessment dated [DATE] which is not fully completed and there is no other comprehensive wound assessments which include measurements and wound characteristics of R9's right Ischium pressure ulcer until V4's next assessment on June 13, 2018. On June 13, 2018 at 3:30pm, R9 laid in a bed with a regular mattress (not an air mattress). V4 performed an assessment of R9's right ischium. V4 measured R9's right ischium pressure ulcer as 4.0 by 2.0 by 0.1 cm. During an interview on June 13, 2018 at 3:30pm, V4 described R9's wound bed to the right ischium as moist and stated that was why [MEDICATION NAME] Powder was ordered at the time of his last assessment. In addition, V4 stated R9 is supposed to be on an air mattress as ordered. V4 stated R9's measurements are worse and V4 expected R9's right ischium pressure ulcer to be healed at this point. V4 stated he expects R9's treatments to be implemented as ordered ad if done as ordered R9's wound would likely be healed, not worse. In addition, while performing R9's dressing changes V4 removed R9's foam boots and the [MEDICATION NAME] dressing on R9's right heel was dated June 5, 2018. V4's Wound Care assessment dated [DATE] documents R9's ischium pressure ulcer as full thickness stage 3 with stalled healing but healing is expected to occur. R9's Brief Interview of Mental Status dated March 15, 2018 documents R9 as cognitively intact. A Healthcare Equipment Order form dated June 13, 2018 documents an order for [REDACTED]. On June 13, 2018 at 3:52 PM V2 (Director of Nursing) confirmed the facility is to complete wound assessments weekly which describe wound characteristics and measurements. V2 stated wound treatments are to be completed as ordered and documented on the TAR when completed. Pressure Ulcers/Skin Breakdown- Clinical Protocol dated April 2013 documents the physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, cleansing, dressings and topical agents. Information to be documented in the clinical record includes the date and type of wound care given, and all assessment data such as wound bed color, size and drainage obtained when inspecting the wound. The facility policy for Administering medications dated November 2013 showed that nursing staff are to initial the residents medication and treatment administration sheets on the appropriate line after giving each medication or treatment

Based on observation interview and record review the facility failed to implement measures to promote the healing of pressure ulcers. This applies to 2 of 4 residents (R2 and R4) reviewed for pressure ulcers in a sample of 17. Findings include: 1. On (MONTH) 22, (YEAR) at 10:05 am, R4 laid on a bed with a regular mattress and received incontinence care by V7 and V8 (Nursing Assistants). R4 had a small open pressure ulcer to the right ischial area present and without a dressing covering the pressure ulcer. V7 and V8 completed care and placed a new incontinence brief on R4 without notifying V6 (Wound Nurse) R4's dressing was not present. On (MONTH) 22, (YEAR) at 2:02 pm, V6 performed wound care treatment to the right ischial pressure ulcer. V6 confirmed R4 should have a dressing in place at all times and stated she was not aware R4's dressing had come off. V6 stated staff are to inform a nurse if a dressing comes off so it can be replaced. R4's Physician Wound Report, completed by V19 (Wound Physician), dated (MONTH) 16, (YEAR) documents R4 with a right ischial pressure ulcer which is to be covered with silver alginate and [MEDICATION NAME]. This report also documents R4 is to be on a alternating pressure mattress (air mattress). 2. On (MONTH) 22, (YEAR) at 10:01 am, 11:21 am, 11:45 am, and 1:00 pm R2 laid in bed on a regular mattress. R2's Care Plan dated (MONTH) 11, (YEAR) documents R2 at risk for alterations in skin integrity related to incontinence and fracture history. This care plan documents R2 to utilize a alternating pressure air mattress mattress overlay with an initiation date of (MONTH) 15, (YEAR). On (MONTH) 24, (YEAR) at 12:58 pm, V6 confirmed if R2's care plan documents an alternating pressure mattress R2 should have one in place. V6 also confirmed if V19 recommended an alternating pressure mattress for R4 it should have been implemented.

Based on observation, interview and record review the facility failed to safely transfer a resident and failed to implement preventative measures to prevent repeated falls. This applies to 2 of 3 residents (R1, R2) reviewed for falls in a sample of 17. This failure resulted in R1 incurring a facial laceration requiring sutures and a right 9th rib fracture and R2 obtaining a fracture to the distal shaft of the left femur. Findings include: 1. R2's Clinical Resident Profile dated (MONTH) 24, (YEAR) documents R2 as a [AGE] year old resident with [DIAGNOSES REDACTED]. On (MONTH) 22, (YEAR) at 11:45 am, R2 laid in bed with a large amount of swelling to the left knee and upper left leg. R2 stated, It hurts. A facility Incident Report dated (MONTH) 20, (YEAR) at 7:07 pm, documents when the nursing assistants were transferring R2 from the wheelchair to the toilet, R2's knees buckled and R2 was lowered to the floor. When R2 was lowered the nursing assistants heard a distinct cracking sound from the left leg. On (MONTH) 22, (YEAR) at 2:59 pm, V13 (Nursing Assistant) stated on (MONTH) 20, (YEAR) V13 and V12 (Nursing Assistants) transferred R2 from the wheelchair to the toilet by standing and pivoting R2. V13 stated while pivoting R2 her knees buckled and R2 was lowered to the floor. After placing R2 onto the floor V13 extended R2's legs and V13 reported hearing cracking noises. V13 stated, So later in the shift I found out (R2) had been changed to a sit to stand (mechanical lift) with 2 assists on (MONTH) 7th, (YEAR). R2's Progress Note dated (MONTH) 21, (YEAR) documents R2 with a fracture above the knee per X-Ray. R2's Radiology Results Report dated (MONTH) 22, (YEAR) (latest version) documents R2 with an oblique and slightly comminuted [MEDICAL CONDITION] shaft of the left femur. R2's Lift assessment dated (MONTH) 7, (YEAR) documents R2 to use a sit to stand lift for transfers. On (MONTH) 25, (YEAR) at 10:39 am, V30 (Medical Director) confirmed the facility should have used a mechanical sit to stand lift to transfer R2 as assessed by the facility to prevent R2's injury. 2. R1's Admission Record dated (MONTH) 2, (YEAR) documents R1 as an [AGE] year old resident with [DIAGNOSES REDACTED]. R1's Brief Interview of Mental Status dated (MONTH) 13, (YEAR) documents R1 with severe cognitive impairments. A facility Incident Report dated (MONTH) 2, (YEAR) at 4:40 am documents R1 was found sitting on the floor on buttocks at the end of the bed. R1 stated she was trying to get into the chair. R1's Progress Notes dated (MONTH) 2, (YEAR) document R1 with a laceration to the left outer eye. The hospital emergency room visit report dated (MONTH) 2, (YEAR) documents R1 with small laceration which required 3 sutures. A facility Incident Report dated (MONTH) 3, (YEAR) at 1:15pm, documents R1 was found on the floor in the common area without injuries. A facility Incident Report dated (MONTH) 6, (YEAR) at 4:25 PM documents R1 was found on the floor in the common area without injuries. A facility Incident Report dated (MONTH) 16, (YEAR) at 8:34 am, documents R1 as being found on the floor in a common area. A Progress Note dated (MONTH) 16, (YEAR) documents R1 had just been repositioned due to leaning forward in her reclining chair and when the staff went to assist another resident R1 got out of the reclining chair and was found on the floor with a skin tear to the right outer forearm. These notes also document an X-Ray was completed due to R1 complaints of pain which revealed a fracture to the 9th rib. The Radiology Result Report dated (MONTH) 18, (YEAR) (latest version) documents R1 with a right 9th rib fracture. R1's Care Plan for fall risk dated (MONTH) 17, (YEAR) documents on (MONTH) 26, (YEAR) an intervention was initiated to keep R1 in the common areas when awake; there were no further revisions after R1's falls (MONTH) 2, 3, or 6, (YEAR). On (MONTH) 23, (YEAR) at 11:15 am, V17 (Restorative Nurse) stated the root cause of R1's falls is due to R1 not remembering she cannot walk and anxiety which causes R1 to fidget and be busy all the time. V17 stated after a fall the interdisciplinary team meets and implements interventions to prevent further falls which are documented in the care plan. V17 confirmed no interventions were initiated after R1's falls on (MONTH) 2, 3, or 6, (YEAR). On (MONTH) 25, (YEAR) at 8:10 am, V29 (Physician) stated due to R1's impulsivity the only way to prevent 100% of her falls would be to place R1 on one to one but confirmed the facility should be evaluating falls to determine if there is preventative measures which can be placed in an attempt to keep residents safe and prevent further falls. The facility policy Safe Lifting and Movement of Residents dated (MONTH) 2013 documents the facility will assess assess individual residents' needs for transfer assistance on an ongoing basis and the facility will use the appropriate techniques and devices to lift and move residents.

Based on interview and record review, the facility failed to identify, assess, notify the physician, obtain treatment orders and document relevant data regarding 1 resident's (R1) pressure sore. These failures affected 1 resident out of 3 (R1) reviewed for pressure ulcers. Findings include: Nursing notes for R1 reflect that she was readmitted to the facility 1/4/18 from the hospital after falling at home and sustaining a fractured knee. She was admitted for short term rehab. R1 had just been discharged from the facility on 12/30/17 with home health services. There is no mention of R1 having any skin breakdown on her 1/4/18 admission, either in her admission nursing note of 1/4/18 at 10:24 PM or her admission nursing assessment of that same date. Nursing note of 1/19/18 timed at 4:30 PM indicates that R1 stated that her physician had told her she was at risk for infection from an indwelling catheter, but that he had wanted it placed on 1/10/18 due to wound care to her buttock. There is no mention of any buttock wound on 1/10/18 in nursing notes. There had been no mention in any progress notes of any buttock wound until this point, and no further mention until nursing note of 1/30/18 timed at 6:36 PM. This note indicates that R1 had requested removal of her indwelling catheter, which had been ordered upon the resident's request when she saw her physician in the office on 1/10/18. The catheter had been placed due to the resident's returning to the facility with a small superficial area to her left intergluteal cleft. R1 had wanted the catheter so she would not have to keep using the bedpan for urination. Other than these two notes, there is no assessment, description or measurement contained in R1's electronic clinical record. It cannot be determined when this wound developed due to the lack of documentation and assessment. Nursing note of 2/9/18 at 1:20 AM notes that R1 called the EMTs (Emergency Medical Technicians) at approximately 12:45 AM. Earlier she had complained of pain in her buttock. The note indicates that R1 had been repositioned. She had received [MEDICATION NAME] at 1:00 AM (after calling 911). She was transported to a local hospital. Nursing notes timed at 2:32 AM on that same date indicates R1 returned to the facility with instructions to keep her dry, to reposition her and to apply creme. These were completed On 3/1/18 at 3:20 PM, V22 (LPN) stated that she was the nurse caring for R1 on the night R1 called the ambulance herself due to butt pain. V22 stated that R1 had complained of discomfort in her butttock area and V22 explained to R2 that it was too soon to give her any further pain medication. R1 had frequent complaints of pain and required much pain medication. After R1 called 911, V22 medicated her because enough time had passed to allow for another dose of medication. At the time R1 complained, she did not look at R1's buttock area, but did reposition her. It was not unusual for R1 to complain of pain, including in her buttock area. She assumed R1 had a decubitus ulcer. V22 states she thinks she spoke to the emergency room and was given instructions for R1 but not given any information on a wound. V22 also did not look at R1's buttock area when R1 returned to the facility because she was very busy. She assumed that the hospital had not found any wound on R1 based on their instructions of keeping her dry, repositioning her and applying creme to the area. R1 made no further complaints that shift. Shower sheet for R1 dated 2/6/18 reflects an anatomical drawing of a person. which staff are to use to indicate any skin impairments on. On 2/6/18, there is a circle around the buttock area of the picture and written in that circle is the word sore. This shower sheet was signed by V4. (CNA). On 3/1/18 at 2:50 PM, V4 (CNA) stated that she recalled R1 and recalled that R1 told multiple people about her butt pain. She believes this was on the day she documented on the shower sheet, 2/6/18. V4 described a small wound about the size of a dime, which she describes as hard to see, between the cheeks of R1's butt. She recalls R1 asking for creme to be applied, which she did. V4 stated she applied creme and went to get a nurse, but can't recall who she told. V4 recalls the nurse going in to look at it. V4 recalled seeing the wound nurse in with R1 one day, but can't recall when. On 3/2/28 at 12:10 PM, V16 (Treatment Nurse) stated that one day R1 asked V16 to look at her buttock, but she can't recall when that was. She recalls seeing a superficial opening which was very small. At the time she did not feel any treatment was required; the staff was using barrier creme on it. V16 did not notify R1's doctor or make any note; she may have discussed it with a staff nurse but can't recall. She was not asked to assess R1's wound again. When there is a minor wound such as R1's. typically the staff nurse handles physician notification and gets initial treatment orders.She was not aware of the [DIAGNOSES REDACTED]. emergency room record for R1 dated 2/9/18 states that R1 presents from rehab with a painful decubitus ulcer. Physical findings included a small, dime-sized sacral ulceration, Grade 3. Primary Impression was decubitus ulcer, Stage 3. On 3/2/18 V12 (RN) stated that she recalls R1 having a superficial opening to her intergluteal cleft. The CNA (V4) informed her of it. She does not know when R1 got the wound. She thinks V4 had told someone a few days prior to her but it didn't look like anything had been done, such as there were no wound care orders. V12 stated that she applied barrier creme to the area; she doesn't recall if she got any other treatment orders. Typically, if there was a change in a residents skin condition, she would do a skin alteration report. She could not recall if she did one or not. According to V2 (ADON) on the same day, there were no skin alteration reports for R1. Review of physician orders [REDACTED]. On 3/2/18 at 1:35 PM, V2 confirmed not finding any wound care orders for R1's sacral wound as well as no order for any wound care evaluation. On 3/1/18 at 1:40 PM, V5 (LPN) stated that typically,skin checks are done upon admission and then the CNAs perform them during showers and complete a shower sheet for the resident. The CNA is to notify the nurse if a skin abnormality is found, and the nurse is to then go and assess the area and sign the shower sheet. The shower sheet for R1 dated 2/6/18 only contains the signature of V4 (CNA); no nurse signed this sheet. According to V5, no one ever asked her to check R1's buttock area. V5 also stated that they are to do a skin assessment when residents come back from the hospital. There is no skin assessment for R1 upon her arrival back in the facility on 2/9/18. If a resident complains of buttock pain, as a nurse, she would assess the area. Review of all of R1's nursing progress notes from her 1/4/18 admission through her discharge on 2/11/18 does not reflect any notification of V23 (MD for R1) regarding R1's Stage 3 pressure ulcer. On 3/2/18 at 3:50 PM, V23 (R1's MD) stated that he is familiar with R1. He recalled that she had a sacral wound but is not sure how he became aware of it. He might have seen it during an office visit. He could not recall if staff ever notified him about the wound and did not recall if he ever gave treatment orders for it. R1's clinical record contains no documentation of physician notification or any treatments done to R1's Stage 3 sacral wound except for the application of barrier creme. Facility policy on Pressure Ulcers/Skin Breakdown-Clinical Protocol states, in part, 2. In addition, the nurse shall describe and document the following: a. full assessment of pressure sore including location, stage, length, width and depth, presence of exudate or necrotic tissue; b. pain assessment; c. resident's mobility status; d. current treatments, including support surfaces; and e. all active diagnoses. This was not done.

Based on interview and record review, the facility failed to follow physician orders for the removal of one resident's peripherally inserted central catheter (PICC). The facility also failed to consistently monitor/assess a PICC-line site, perform dressing changes and document flushes. These failures resulted in R2 being sent to the hospital with a swollen arm 4 days after removal of the PICC line was ordered. R2 was diagnosed with [REDACTED]. These failures affected 1 of 2 residents (R2) reviewed for PICC/Midline catheters out of a sample of 7. Findings include: Nursing note of 2/5/18 timed at 9:40 PM states that R2 was readmitted to the facility from a local hospital, and she was on IV (intravenous) antibiotics and was in isolation for a stool infection. R2 had no complaints of pain. There is no mention of a PICC line catheter. On 2/6/18 nursing note timed at 11:46 PM indicates that R2 received her IV antibiotics, but does not indicate the presence of a PICC line. This note was authored by V12 (RN). On 3/2/18 at 1:40pm, V12 stated that she recalled giving R2 her antibiotic through her PICC line. R2's admission note of 2/5/18 was authored by V5 (LPN). On 3/2/18 at 2:55 PM, V5 stated via telephone that there is no specific place on the nursing admission form to note a PICC line, and so she would normally note it in her narrative nursing note. V5 stated that she believed that R2 did return from the hospital with the PICC line in place, but she must have overlooked documenting it. She was not aware of any problem with R2's PICC line until the day she transferred R2 to the hospital with a swollen arm (2/18/18). On 2/27/18 at 3:05 PM, V5 stated that on 2/18/18, a CNA (certified nursing aide) reported that R2's arm was swollen and painful. Upon assessment, R2's arm was swollen from the PICC site down to her fingers, and her arm was red. Her arm was swollen twice the size of normal. It was red and warm to touch. V5 stated the PICC line site had also drained some yellowish/brown material which she could see through the transparent dressing. V5 stated that she had not seen R2 since the morning of 2/14/18 and was not aware of the 2/14/18 order for the PICC line to be removed. According to V5, LPNs can do dressing changes, but RNs must do the flushes and removal of the line. Dressing changes can be documented in the TAR (treatment administration record) or in nursing notes. She never did a dressing change on R2. PICC line dressings are to be changed every 7 days after the initial change or as needed. Review of Physician orders reflects an order dated 2/14/18 to remove R2's PICC. There is no documentation in nursing progress notes from her 2/5/18 admission that R2's PICC line was removed. Nursing progress note of 2/18/18 timed at 1:38 PM documents that R2 was sent to the hospital via ambulance. R2 had complained of a swollen hand and upon assessment, her arm was swollen from the elbow down, and was warm to touch. The PICC line was also noted to be draining. R2's physician was notified of the symptoms and ordered R2 sent to the hospital. Hospital records dated 2/18/18 provides a [DIAGNOSES REDACTED]. emergency room notes of 2/18/18 timed at 11:40 AM note that R2 presented for evaluation of her PICC line. Staff reported R2's left upper arm had been swollen and warm to touch since the day prior. R2 was noted to have a single lumen PICC line present to her left upper arm. Her left hand and forearm were swollen, but she had a good radial pulse. Discharge summary of 2/19/18 states that R2 had recently been hospitalized for [REDACTED]. It was noted that R2 had completed her course of antibiotics and the PICC line was ordered to be removed, but this had not been done. The PICC line was removed in the hospital. She was given a dose of [MEDICATION NAME] (blood thinning medication) and was to continue on [MEDICATION NAME] and [MEDICATION NAME] for 3 months. R2 returned to the facility on [DATE]. On 3/1/18 at 1:20 PM, V9 (MD for R2) stated that R2 was sent back to the facility from an office appointment on 2/14/18 with a written order for her PICC line to be removed, as she had completed her course of IV antibiotics. It was not done and she was sent to the hospital 4 days later with a swollen hand and arm. It should have been removed. He expected his order to be carried out as soon as possible, but definitely within 24 hours. Waiting 4 days was a long time to wait for it to be removed. Without the PICC line catheter, she would not have gotten the [MEDICAL CONDITION]. A [MEDICAL CONDITION] is a known complication of a PICC line and that is one reason timely removal is important. On 2/27/18 at 3:40 PM, V24 (LPN) stated that she recalled R2 returning from a doctor's appointment on 2/14/18. R2 came back with a written order for the rmoval of the PICC line. She entered the order into the electronic medical record system, but she could not remove it herself because only a Registered Nurse (RN) can remove a PICC line. She can't recall if she passed on the information during report that R2 needed her PICC line removed. She does not recall asking anyone else to remove the PICC line.According to V24, her role as an LPN in the care of a PICC line is to monitor the site for any sign of infection. Only RNs can do the dressing changes and flushes. Monitoring of the site should be documented in the nursing notes. On 3/2/18 at 10:45 AM, V2 (ADON) stated that the presence of a PICC or mid-line catheter should be indicated on admission, either in the skin assessment or in an admission note. She reviewed the admission assessment for R2 of 2/5/18 and did not see any mention of R2's PICC line. V2 also read R2's admission note of the same date and did not see any mention or assessment of R2's PICC line. On 2/27/18 at 2:05 PM, V2 stated that she expects the nursing staff to monitor the site of the PICC for infection every shift and to flush the PICC every shift. This can be documented in the progress notes, or if an order is in the system, it can be documented on the TAR (treatment administration record) but you don't need an order for [REDACTED]. V2 stated she was aware that the PICC line was to be removed and cautioned her nurse to be sure they had an order for [REDACTED]. On 2/27/18 at 2:30 PM, V12 (RN) stated that care of a PICC or mid-line catheter includes a dressing change every 7 days after the initial dressing change, or as needed and flushing the catheter every shift with either normal saline or [MEDICATION NAME] if that is ordered. Documentation of dressing change is done in the progress notes. The site is to be monitored every shift and she would document that the site was dry and intact and any abnormal findings. As nurses, they are to document care and monitoring when it is done. On 2/27/18 at 2:25 PM, V3 (Clinical Operations Nurse) stated that she was not aware of the order for the removal of R2's PICC line and that it was not removed until R2 went to the hospital 4 days later. V3 stated that she expects the nursing staff to monitor the site every shift and to follow their policy. The standard for monitoring the PICC line is to monitor it every shift. Staff should document monitoring and orders should be followed timely. From the time of R2's admission on 2/5/18 the following documentation is the only documentation/nursing note about R2's PICC line until 2/18/18 when she went to the hospital: 2/8/18 at 9:06 AM-remains on IV antibiotics-no redness or [MEDICAL CONDITION] to site; 2/11/18 at 10:39 PM-IV mid-line secure and IV given without difficulty; 2/12/18 at 8:00 PM-IV antibiotics adminstered to PICC line to left upper arm, excellent blood return presnt. Dressing to PICC line dry and intact; 2/13/18 at 6:44 AM-PICC line in place, need orders to remove; 2/16/18 at 11;08 PM-Midline catheter remains in place. The next mention of R2's PICC line is the 2/18/18 nursing note when her arm was discovered red and swollen.The only actual assessments were the notes of 2/12/18 and 2/8/18; the other notes merely mention that it is in place or that medication was given without difficulty. This documentation does not reflect monitoring every shift. Policy entitled Central Venous and Midline Catheter flushing states that no physician's order is required for flushing. The purpose of flushing is to maintain the patency of the catheter, in part, and to ensure medication administration. It states that insertion site assessment should be done as part of the flushing process. It states to flush catheters at regular intervals to maintain patency as well as before and after medication administration. Policy entitled Central Venous Catheter Dressing Changes states that a physician's order is not needed for the procedure. Under the section titled Assessment, it states to observe the insertion site and surrounding area for compliactions. Under general guidelines, it states that catheter site care allows for the observation and evaluation of the catheter-skin junction and surrounding tissue. The initial dressing change is to be done within 24 hours of the insertion, and after that, is to be done at least every 7 days, and as needed, such as if contaminated or wet. The Documentation requirement for both of these policies states that the following information is to be documented in the resident's medical record: date and time medication administered and flush done and dressing was changed; amount of flush administered; condition of IV site before and after administration (for flush); signature of person either doing the flush or the dressing change; condition of sutures if present, type of dressing placed, any complications. R2's MAR from her (MONTH) (YEAR) admission contains no documentation of any flushes or dressing changes; R2's nursing notes also contain no documentation of flushes or dressing changes to the PICC dressing. On 2/28/18 at 1:35 V2 stated that there was no TAR for R2 for (MONTH) (YEAR). On 3/7/18 at 12:00 PM, V2 stated that typically the admitting nurse would obtain any orders needed for care of the PICC line if one was in place on admission. If the resident did not come in with orders from the hospital, they should obtain orders from the attending physician. If hospital orders for the care of thr PICC line are included in the discharge paperwork, the admission nurse should confirm these orders with the attending physician. Review of physician orders from R2's 2/5/18 admission reflects no orders for the care and maitenance of R2's PICC line. On 2/28/18 at 11:48 AM, R2 stated that the day prior to her going out to the hospital with her swollen arm, the therapist had noted some swelling of her arm. The following day, the nurse checked it and sent her to the hospital where a [MEDICAL CONDITION] was diagnosed . The PICC line was removed in the hospital. R2 did not recall staff ever changing the dressing on the PICC line but recalls the nursing staff cleaning the port of the tubing before giving her IV medication. R2 stated that the clear dressing was never removed in the facility.

Based on interview and record review the facility failed to make timely notifications to the physician of the development of an area of black tissue to a resident's posterior heel. This applies to one of three residents (R4) reviewed for wounds in a sample of six. This failure resulted in R4 developing an infected pressure ulcer to the right heel requiring a hospital admission for surgical debridement and antibiotic treatment. Findings include: The Order Summary Report dated August 2, 2017 documents R4 with [DIAGNOSES REDACTED]. On August 2, 2017 at 10:42am, E8 RN (Registerd Nurse) confirmed E8 was first made aware of the black area to R4's right heel around July 14, 2017, which E8 stated was possibly the last day before E8 went on vacation. E8 stated R4's heel had a black half dollar sized area of tissue. E8 stated, I didn't call the physician. E8 stated on July 26, 2017 E8 returned from vacation on that date and saw R4's heel wound again and it was slightly bigger. E8 stated on July 30, 2017 a Nursing Assistant (E7) reported E8 needed to look at R4's wound to the right heel which E8 assessed and was now open. E8 stated Z2 (Physician) was notified and instructed E8 to send R4 to the hospital. E8 confirmed E8 never contacted the physician prior to July 30, 2017 and should have. On August 2, 2017 at 10:27am, E6 (Day Nursing Assistant) stated, On July 26, 2017 I got (R4) up and took off her socks. (R4) had a black area to the right heel about the size of a small plum. E6 stated this was reported to E21 (Midnight Nurse) who said she would pass it onto E8 (Day Nurse) to evaluate since it was change of shift. E6 stated later in the shift, while E8 was passing medications, E6 asked E8 if she had seen R4's heel and E8 said she had not seen it yet. R4's Body Check form dated July 26, 2017, completed by E6 documents R4 with a black area to the posterior right heel. All July 2017 Body Check forms prior to this do not document any evidence of the presence of a Pressure Ulcer. On August 3, 2017 at 1:12pm, E3 (Director of Nursing) stated E8 was on vacation July 18, 2017 and returned on July 26, 2017. The Progress Note dated July 30, 2017 at 7:41am, documents R4 with a foul odor and drainage to a black area on the heel; physician contacted and R4 was sent to the hospital. On August 2, 2017 at 2:46pm, Z2 (Physician) stated, I was first called July 30, 2017-message was heel wound with drainage. I sent (R4) out for an evaluation. I was not aware prior. Z2 stated, If I had been made aware of a black area to the foot, even closed, I would send to the ER (emergency room ) for evaluation. In my experience wound assessments are not always accurate. I couldn't see her; it would be most appropriate way to get an accurate assessment and treatment .If evaluated when first observed the outcome possibly could have been better .They should have called sooner so it could be treated. The emergency room Provider Note dated July 30, 2017 documents R4's Physical Exam as large eschar (dead skin) over right heel and the area is foul smelling. The hospital Admission History and Physical dated July 30 2017 documents R4 with a 2-3 inch non-healing ulcer to the right heel. Areas of exposed tissue with overlying necrotic tissue and purulent discharge. [DIAGNOSES REDACTED]. On August 3, 2017 at 8:50am, Z3 (Podiatrist) stated R4 is being treated in the hospital and had eschar (dead skin) to the right posterior heel which Z3 surgically debrided. Z3 stated antibiotics were started for [MEDICAL CONDITION] because the wound was infected. Z3 stated R4 has limited movement due to [MEDICAL CONDITION] and is at risk to develop pressure wounds which progress quickly in residents in R4's condition. Z3 stated R4's wound is a full thickness Stage IV Pressure Ulcer. Z3 stated R4 is now at an increased risk to develop a life threatening infection now that the wound has been debrided. The policy Change in Resident's Condition or Status dated December 2016 documents the nurse will notify the resident's physician when there has been a significant change in the residents' physical condition. A significant change of condition is a major decline in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. The Pressure Ulcer/Skin Breakdown Clinical Protocol dated March 2014 documents the physician will authorize pertinent orders related to wound treatments, identify medical interventions related to wound management; for example treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, etc.

Based on interview and record review the facility failed to protect a resident from neglect by failing to make timely notifications to the physician of the development of a black area of tissue to the right heel, monitor this wound and implement interventions to prevent further deterioration of the wound. This applies to one of three residents (R4) reviewed for wounds in a sample of six. This failure resulted in R4 developing an infected Pressure Ulcer to the right heel requiring a hospital admission for surgical debridement and antibiotic treatment. Findings include: The Order Summary Report dated August 2, 2017 documents R4 with [DIAGNOSES REDACTED]. On August 2, 2017 at 10:42am, E8 RN (Registered Nurse) stated E8 was first made aware of the black area to R4's right heel around July 14, 2017, which E8 stated was possibly the last day before E8 went on vacation. E8 stated R4's heel had a black half dollar sized area of tissue. E8 stated, I elevated her legs. I attempted to notify the Treatment Nurse (E11) and was unable to reach her. E8 stated, I didn't call the physician. E8 stated on July 26, 2017 E8 returned from vacation on that date and saw R4's heel wound again and it was slightly bigger. E8 stated on July 30, 2017 a Nursing Assistant (E7) reported to E8 to come and look at R4's wound to the right heel which E8 assessed and was now open. E8 stated Z2 (Physician) was notified and instructed E8 to send R4 to the hospital. E8 confirmed E8 never contacted the physician prior to July 30, 2017 and should have. E8 stated, I do not recall any treatment or intervention being done for her after the day it was discovered. On August 2, 2017 at 10:27am, E6 (Day Nursing Assistant) stated, On July 26, 2017 I got (R4) up and took off her socks. (R4) had a black area to the right heel about the size of a small plum. E6 stated this was reported to E21 (Midnight Nurse) who said she would pass it onto E8 (Day Nurse) to evaluate since it was change of shift. E6 stated later in the shift, while E8 was passing medications, E6 asked E8 if she had seen R4's heel and E8 said she had not seen it yet. R4's Body Check form dated July 26, 2017, completed by E6 documents R4 with a black area to the posterior right heel. All July 2017 Body Check forms prior to this do not document any evidence of the presence of a Pressure Ulcer. On August 3, 2017 at 1:12pm, E3 (Director of Nursing) stated E8 was on vacation July 18, 2017 and returned on July 26, 2017. On August 3, 2017 at 11:47am, E11 (Treatment Nurse) stated E11 is generally notified of a wound or pressure ulcer by the floor nurse. At the time a wound is identified the physician and family are notified and treatment orders are obtained. E11 stated E11's first observation of a wound includes measurements, assessment of wound characteristics and assessment for additional individualized interventions. E11 stated after the initial assessment the wound is then monitored and weekly assessments are documented and in between the wound is monitored and physician is notified of any changes. E11 stated black tissue is considered an unstageable wound and the wound needs to be offloaded. On August 3, 2017 at 12:27pm, E11 confirmed no offloading interventions were added because E11 was not notified to assess R4. E11 confirmed if E11 had assessed R4, interventions to offload the right heel would be initiated. On August 2, 2017 at 3:03pm, E3 (Director of Nursing) stated the process for Pressure Ulcer Treatment was not followed: not contacting the physician, getting treatment orders promptly, monitoring and assessing the wound and implementation of interventions to prevent the further deterioration of the wound. On August 2, 2017 at 2:46pm, Z2 (Physician) stated, I was first called July 30, 2017, the message was heel wound with drainage. I sent (R4) out for an evaluation. I was not aware prior Z2 stated, If I had been made aware of a black area to the foot, even closed, I would send to the ER (emergency room ) for evaluation. In my experience wound assessments are not always accurate. I couldn't see her; it would be most appropriate way to get an accurate assessment and treatment .If evaluated when first observed the outcome possibly could have been better .They should have called sooner so it could be treated. On August 3, 2017 at 8:50am, Z3 (Podiatrist) stated R4 is being treated in the hospital and had eschar (dead skin) to the right posterior heel upon admission which Z3 surgically debrided. Z3 stated antibiotics were started for [MEDICAL CONDITION] because the wound was infected. Z3 stated R4 has limited movement due to [MEDICAL CONDITION] and is at risk to develop pressure wounds which progress quickly. Z3 stated R3's heel definitely had pressure to the posterior heel area too long and probably started as a blister. Z3 stated if the pressure ulcer had been identified sooner it could have been offloaded quicker. Z3 stated R4's wound is a full thickness Stage IV Pressure Ulcer. Z3 stated R4 is now at an increased risk to develop a life threatening infection now that the wound has been debrided. The hospital Admission History and Physical dated July 30 2017 documents R4 with a 2-3 inch non-healing ulcer to the right heel. Areas of exposed tissue with overlying necrotic tissue and purulent discharge. [DIAGNOSES REDACTED]. The Care Plan dated June 7, 2017 documents R4 at risk for skin alteration related to decreased mobility and does not include interventions to offload heels. The Order Summary Report dated August 2, 2017 and the July Medication Administration and Treatment Records do not include treatment orders or interventions for the care of R4's wound. The Progress Notes dated July 2017 do not include any assessments or documentation of the characteristics, monitoring or physician notification of the wound until July 30, 2017 when R4 was sent to the hospital for evaluation. On August 3, 2017 at 9:23am, E1 (Administrator) stated the facility has investigated R4's care and has substantiated neglect. The facility Abuse Policy dated September 2016 documents the facility affirms the right of our residents to be free from neglect. Residents must not be abused by anyone, including facility staff. Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness, or results in the deterioration of a resident's physical or mental condition. The Pressure Ulcer/Skin Breakdown Clinical Protocol dated March 2014 documents the physician will authorize pertinent orders related to wound treatments and identify medical interventions related to wound management; for example treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, etc. The policy Change in Resident's Condition or Status dated December 2016 documents the nurse will notify the resident's physician when there has been a significant change in the residents' physical condition. A significant change of condition is a major decline in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions.

Based on interview and record review the facility failed to assess and monitor the development of a black area of tissue to a heel, implement interventions to prevent further deterioration of the wound and promptly notify the physician of the development of a wound. This applies to one of three residents (R4) reviewed for wounds in a sample of six. This failure resulted in R4 developing an infected pressure ulcer to the right heel requiring a hospital admission for surgical debridement and antibiotic treatment. Findings include: The Order Summary Report dated August 2, 2017 documents R4 with [DIAGNOSES REDACTED]. On August 2, 2017 at 10:42am, E8 RN (Registered Nurse) stated E8 was first made aware of the black area to R4's right heel around July 14, 2017, which E8 stated was possibly the last day before E8 went on vacation. E8 stated R4's heel had a black half dollar sized area of tissue. E8 stated, I elevated her legs. I attempted to notify the Treatment Nurse (E11) and was unable to reach her. E8 stated, I didn't call the physician. E8 stated on July 26, 2017 E8 returned from vacation on that date and saw R4's heel wound again and it was slightly bigger. E8 stated on July 30, 2017 a Nursing Assistant (E7) reported to E8 to come and look at R4's wound to the right heel which E8 assessed and was now open. E8 stated Z2 (Physician) was notified and instructed E8 to send R4 to the hospital. E8 confirmed E8 never contacted the physician prior to July 30, 2017 and should have. E8 stated, I do not recall any treatment or intervention being done for her after the day it was discovered. On August 2, 2017 at 10:27am, E6 (Day Nursing Assistant) stated, On July 26, 2017 I got (R4) up and took off her socks. (R4) had a black area to the right heel about the size of a small plum. E6 stated this was reported to E21 (Midnight Nurse) who said she would pass it onto E8 (Day Nurse) to evaluate since it was change of shift. E6 stated later in the shift, while E8 was passing medications, E6 asked E8 if she had seen R4's heel and E8 said she had not seen it yet. R4's Body Check form dated July 26, 2017, completed by E6 documents R4 with a black area to the posterior right heel. All July 2017 Body Check forms prior to this do not document any evidence of the presence of a Pressure Ulcer. On August 3, 2017 at 1:12pm, E3 (Director of Nursing) stated E8 was on vacation July 18, 2017 and returned on July 26, 2017. On August 3, 2017 at 11:47am, E11 stated E11 is generally notified of a wound or pressure ulcer by the floor nurse. At the time a wound is identified the physician and family are notified and treatment orders are obtained. E11 stated E11's first observation of a wound includes measurements, assessment of wound characteristics and assessment for additional individualized interventions. E11 stated after the initial assessment the wound is then monitored and weekly assessments are documented and in between the wound is monitored and physician is notified of any changes. E11 stated black tissue is considered an unstageable wound and the wound needs to be offloaded. On August 3, 2017 at 12:27pm, E11 confirmed no offloading interventions were added because E11 was not notified. E11 confirmed if E11 had assessed R4 interventions to offload the right heel would be initiated. On August 2, 2017 at 2:46pm, Z2 (Physician) stated, I was first called July 30, 2017 the message was heel wound with drainage. I sent (R4) out for an evaluation. I was not aware prior Z2 stated, If I had been made aware of a black area to the foot, even closed, I would send to the ER (emergency room ) for evaluation. In my experience wound assessments are not always accurate. I couldn't see her it would be most appropriate way to get an accurate assessment and treatment .If evaluated when first observed the outcome possibly could have been better .They should have called sooner so it could be treated. On August 2, 2017 at 3:03pm, E3 (Director of Nursing) stated the process for Pressure Ulcer Treatment was not followed: not contacting the physician, getting treatment orders promptly, monitoring and assessing the wound and implementation of interventions to prevent the further deterioration of the wound. The hospital Admission History and Physical dated July 30 2017 documents R4 with a 2-3 inch non-healing ulcer to the right heel. Areas of exposed tissue with overlying necrotic tissue and purulent discharge. [DIAGNOSES REDACTED]. On August 3, 2017 at 8:50am, Z3 (Podiatrist) stated R4 is being treated in the hospital and had eschar (dead skin) to the right posterior heel upon admission which Z3 surgically debrided. Z3 stated antibiotics were started for [MEDICAL CONDITION] because the wound was infected. Z3 stated R4 has limited movement due to [MEDICAL CONDITION] and is at risk to develop pressure wounds which progress quickly. Z3 stated R3's heel definitely had pressure to the posterior heel area too long and probably started as a blister. Z3 stated if the pressure ulcer had been identified sooner it could have been offloaded quicker. Z3 stated R4's wound is a full thickness Stage IV Pressure Ulcer. Z3 stated R4 is now at an increased risk to develop a life threatening infection now that the wound has been debrided. R4's Braden dated June 29, 2017 documents R4 at risk for skin breakdown related to being chairfast, makes slight changes in position independently and potential problem with friction and sheer due to skin sliding to some extent on sheets, chair, etc. during positioning. The Care Plan dated June 7, 2017 documents R4 at risk for skin alteration related to decreased mobility and does not include interventions to offload heels. The Order Summary Report dated August 2, 2017 and the July Medication Administration and Treatment Records do not include treatment orders or interventions for the care of R4's wound. The Progress Notes dated July 2017 do not include any assessments or documentation of the characteristics, monitoring or physician notification of the wound until July 30, 2017 when R4 was sent to the hospital for evaluation. The Minimum Data Set, dated dated dated [DATE] documents R4 requiring extensive assistance of two staff persons for bed mobility and transfers and mobile with a wheelchair with one staff person's assistance. The Pressure Ulcer/Skin Breakdown Clinical Protocol dated March 2014 documents the physician will authorize pertinent orders related to wound treatments and identify medical interventions related to wound management; for example treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, etc. The policy Change in Resident's Condition or Status dated December 2016 documents the nurse will notify the resident's physician when there has been a significant change in the residents' physical condition. A significant change of condition is a major decline in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions.

Based on observation, interview and record review the facility failed to provide necessary supervision and re-evaluate, update and implement effective interventions to prevent continued falls for 1 of 7 sampled residents (R9), assessed as high risk for falls. These failures resulted in a fall in which R9 sustained a fracture to the right hip. Findings include: According to the medical record R9 is a [AGE] year old female with [DIAGNOSES REDACTED]. R9's medical record also indicates that she is a high risk for falls. R9's care plan was reviewed on 04/13/11 and it was noted that she is a high risk for falls and accidents. Interventions currently in place include the use of a low bed, wheelchair alarm and bed alarm. Incident reports with attached investigations were reviewed and the following information was noted: On 09/04/10 R9 took off her body alarm (wheelchair alarm) and stood facing her wheelchair, lost her balance and fell backward hitting her head on the closet door. R9 sustained a 2 cm (centimeter) laceration to the back of her head. After the incident the facility incorporated the use of an alarmed self-releasing lap device. On 10/31/10 R9 was found on the floor in the lobby by the receptionist's desk. Resident apparently took her body alarm off and stood up and fell . (The lap device was not mentioned in the report.) A skin tear was noted to the left lower leg. There were no documented witnesses to the fall. The facility's action plan after this fall was to "continue with the present plan." R9's R.A.P. (Resident Assessment Instrument ) dated 10/31/10 in the medical record was completed by E5, CNA. In the summary E5 wrote in part, "Attempts at keeping close monitoring of resident with alarms did not succeed. Resident would be upset by alarm and become almost hysterical in attempting to shut off alarm causing much more unsafe situation. Staff & family understand that she may have some falls". During 4/14/11 interview E5 confirmed that R9 was not utilizing alarms at the time of the 10/31/10 fall. On 11/01/10 R9 was found on the floor between her bed and the closet. She was found with blood coming from the right brow and rug burns below the eye. The facility's investigation included a plan to "increase activity level, will check for urine and CBC as diagnostic eval." An incident report of 01/19/11documented the following: R9 was observed by E6 and E7 (housekeepers) to stand up from her wheelchair and fell to the floor while in the dining room. No other staff were present in the dining room at the time of this fall. She was lying on her right side with the right temple on the floor and her right arm extended out to the side. R9 was transferred to the hospital an x -ray revealed a fracture of the right femoral neck. The facility's investigation report dated 01/25/11 did not include an action plan to address R9's fall of 01/19/11. R9 was observed on the morning of 04/12/11. She was being pushed in a wheelchair by a staff member. R9 was also observed on 04/13/11 and 04/14/11 in her wheelchair propelling herself around the facility by using her feet. A wheelchair alarm was in place. A lap device was not observed in place. However, the current use of alarms contradicts the assessment of 10/31/11 that the use of alarms did not succeed. E5 and E2, D.O.N. (Director of Nursing) were interviewed on 04/14/11 at approximately 2 PM. Both staff were asked about R9's care plan that notes the following; "1/28/11, using wheelchair for mobility, wheelchair and bed alarms reinstated. Neither E2 nor E5 were able to provide any documentation that the facility has tried any new interventions to prevent further falls after R9's fall with hip fracture on 01/19/11.