Every finding on record at Arc at Hickory Point

Based on observation, interview and record review, the facility failed to ensure a resident received timely antibiotic therapy for a wound infection, failed to notify the physician of new wounds and obtain treatment orders, and failed to follow Enhanced Barrier Precautions, complete wound assessments and update wound care plans for two of four (R4 and R6) residents reviewed for pressure sores on the sample list of 20. Failing to ensure R4 received timely antibiotic therapy resulted in R4's pressure sore continuing to deteriorate and R4 experiencing severe pain. Findings Include:The facility's Risk Call Procedure, revised January 2022, documents that the Risk Call process is designed to review facility-acquired pressure ulcers, identify the root cause of the facility-acquired pressure ulcer, determine whether the care plan was updated with new interventions, and determine whether the pressure ulcer was unavoidable.The facility's Physician-Family Notification - Change in Condition Policy, revised November 2018, documents the facility will notify the resident, physician, and resident representative when there is a significant change in the resident's condition, including the development of Stage II pressure ulcers.The facility's Comprehensive Care Plan policy, revised August of 2017, documents the facility will develop and implement a comprehensive person-centered care plan for each resident. The care plan must describe services that are to be furnished to attain the resident's highest practicable physical, mental, and psychosocial well-being.The facility's Skin Condition Assessment & Monitoring - Pressure and Non-Pressure Policy, revised June 2018, documents that its purpose is to establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown and ensuring interventions are implemented. The policy documents that pressure and other ulcers will be assessed and measured weekly by the licensed nurse and documented in the resident's clinical record. The policy further documents that when weekly changes requiring physician or responsible party notification occur, those individuals will be notified and the notification will be documented in the clinical record. These changes include new onset of purulent drainage, new onset of odor, increased wound-related pain, and the onset of new ulcers. The resident's care plan will be revised, as appropriate, to reflect changes in skin integrity, interventions, and goals of care.The facility's Enhanced Barrier Precautions Policy, revised December 2025, documents that Standard Precautions must be followed with all care. Additionally, gown and gloves must be worn when assisting a resident with incontinence care, dressing, and providing hygiene.The facility's Certified Nursing Assistant Policy, revised July 2023, documents Certified Nursing Assistants are to reposition bedridden residents at least every two hours, or more frequently if clinically indicated.1. R4's admission Assessment, dated 3/25/26, documents excoriation to the coccyx.R4's Nurse Practitioner Note, dated 3/27/26, documents R4 was recently hospitalized following a mechanical fall resulting in a vertebral fracture. R4 had a thoracolumbosacral orthosis (TLSO) brace (back brace) applied and R4's past medical history includes, Dementia, Hypertension, Anxiety, Depression, and Spinal Stenosis.R4's Treatment Administration Record, dated March 2026, documents an order for Miconazole Nitrate Powder 2% to be applied to a rash every 12 hours as needed.R4's Nursing Note, dated 5/5/26, documents a 2 centimeter (cm) length by 2.5 cm width abrasion to R4's left buttock and that the physician was notified.On 7/29/26 at 12:44 PM, V9 Assistant Director of Nursing (ADON), stated the facility was not completing Risk Management Assessments for skin conditions and that these were instead being documented under a Skin-Other Assessment. V9 confirmed there was neither a Risk Management Assessment nor a Skin-Other Assessment completed for R4's left buttock wound identified on 5/5/26. V9 stated a Skin-Other Assessment should have been completed but acknowledged it was not completed because V9 was unaware one was required.R4's Weekly Skin Observation Note, dated 5/26/26, documents an abnormal, discolored area on the right heel measuring 3.0 cm length x 4.2 cm width. The note documents that treatment was initiated, appropriate notifications were completed, and R4's Care Plan was updated.R4's Care Plan, dated 6/10/26, documents skin impairment of the left buttock and right heel related to fragile skin. R4's interventions, all dated 6/10/26, included encouraging adequate nutrition and hydration to promote skin integrity, monitoring the wound sites for signs and symptoms of infection, completing treatments as ordered, and having the wound care provider assess and treat the wounds as needed.On 7/29/26 at 9:19 AM, V9 ADON confirmed no new or individualized care plan interventions were implemented after R4's wounds were identified on 5/5/26 and 5/26/26. V9 stated individualized interventions should have been added to the care plan.R4's Nursing Note, dated 6/9/26, documents the wound care provider debrided R4's left buttock wound. The note further documents the wound had an odor, moderate purulent drainage, and signs and symptoms of infection. A wound culture was obtained.R4's Wound Assessment Details Report, dated 6/9/26, documents the left buttock wound measures 4.5 cm length by 4.0 cm width by 0.6 cm depth.R4's Administration Record, dated June 2026, documents a physician's order for Ciprofloxacin 500 milligrams (mg) to be administered by mouth twice daily for 10 days to treat R4's wound infection. The order was scheduled to begin on 6/12/26 and end on 6/22/26.R4's Nursing Note, dated 6/16/26, documents the left buttock wound had moderate serosanguineous drainage and a slight odor. The note also documents a wound culture was obtained and sent to the laboratory by the wound care provider.R4's Final Results, reported 6/22/26, document the wound culture results, including the identified pathogens and recommended antibiotic susceptibilities.On 7/30/26 at 3:15 PM, V42 Chief Executive Officer of the laboratory company stated R4's wound culture results were collected on 6/16/26 and transmitted to V27 Nurse Practitioner on 6/22/26.R4's Wound Assessment Details Report, dated 6/23/26, documents the left buttock pressure ulcer has moderate purulent drainage and signs of infection. The report documents the wound measures 5.0 cm length by 3.0 cm width by 2.0 cm depth.R4's Visit Report, dated 6/23/26, documents signs and symptoms of infection were present in the left buttock pressure ulcer and antibiotics were prescribed.R4's Nursing Note, dated 6/23/26, documents wound rounds were completed with the wound care provider and no new orders were received.On 7/31/26 at 10:04 AM, V27 Nurse Practitioner stated V27 recalled providing wound care for R4. V27 stated that by R4's third wound care visit, the wound had declined. V27 stated V27 became concerned because, although V27 was performing debridement, ordering treatment, and managing the wound, V27 questioned whether R4 was being repositioned every two hours. V27 stated V27 asked facility staff whether R4 was being repositioned every two hours and was informed that repositioning was being completed.On 7/31/26 at 11:47 AM, V27 stated V27 received R4's wound culture results via email on 6/22/26 but did not recall reviewing the results until 6/29/26, when V27 prescribed a different antibiotic. V27 stated that when V27 evaluated R4 on 6/23/26, V27 believed R4 remained on antibiotic therapy for the wound. V27 stated the wound nurse did not notify V27 that R4's antibiotic course had been completed while the wound continued to exhibit signs and symptoms of infection. V27 stated V27 expects the wound nurse to monitor residents' wounds and notify V27 if a wound continues to exhibit signs or symptoms of infection or demonstrates clinical deterioration so appropriate treatment can be initiated or modified. V27 stated failure to notify V27 of changes in the wound could result in further wound deterioration. V27 further stated because V27 evaluates residents weekly, V27 relies on the wound nurse to actively monitor wounds between visits and communicate significant changes requiring provider intervention. On 7/29/26 at 3:54 PM, V41 Medical Director stated V41 would expect facility staff to notify the physician if R4's antibiotic course was completed and R4 continued to exhibit signs and symptoms of infection, especially if R4 experienced increased wound pain. V41 stated V41 would have evaluated R4 based on the reported clinical findings and considered continuing the current antibiotic, changing the antibiotic or route of administration, or transferring R4 to the hospital for further evaluation and treatment.R4's Nursing Note, dated 6/26/26, documents R4 reported significant pain during wound care treatment. The note documents V9 Assistant Director of Nurses (ADON) was notified.On 7/30/26 at 1:52 PM, V6 Licensed Practical Nurse (LPN) stated V6 notified V9, ADON, on 6/26/26 because R4's wound was worsening and R4 experienced pain during the dressing change. V6 was unable to recall the specific appearance of the wound but stated that, around that time, R4's left buttock wound began tunneling.R4's Administration Record, dated June 2026, documents a physician order for Doxycycline Hyclate 100 mg with instructions to administer one tablet by mouth twice daily for 10 days for wound treatment. The order had a start date of 6/29/26. R4's Medication Administration Record does not document an antibiotic order for R4's wound from 6/23/26 through 6/28/26.On 7/28/26 at 10:20 AM, V9 ADON stated R4's initial wound culture was obtained and sent to the laboratory on 6/9/26, and R4 was started on antibiotic therapy while awaiting the culture results. V9 stated a second wound culture was obtained on 6/16/26 because the previous specimen was either insufficient or inconclusive. V9 stated R4 did not receive antibiotic therapy from 6/23/26 through 6/28/26 because the wound culture results were pending. V9 stated V9 did not receive an order from V27 on 6/23/26 to continue or initiate a different antibiotic. V9 further stated the wound culture results were received on 6/29/26 and indicated the previous antibiotic regimen, administered from 6/12/26 through 6/22/26, was not effective against the identified bacteria. R4 was then started on a different antibiotic.R4's Skin-Other Skin Condition Report - Version 2, dated 6/29/26, documents new excoriation below the open wound on R4's coccyx.R4's Wound Assessment Details Report, dated 6/30/26, documents R4's left buttock wound had moderate purulent drainage, an odor, and signs of infection. The wound measured 5.0 cm length by 3.0 cm width by 1.0 cm depth.R4's Nursing Note, dated 7/1/26, documents R4 was seen by the wound care provider. The note documents R4 had a new wound to the coccyx and was started on a new antibiotic based on the wound culture results from the previous week.R4's Wound Assessment Details, dated 6/30/26, documents R4 had a Stage III pressure ulcer to the coccyx. The wound had moderate bloody exudate, odor, and signs and symptoms of infection. The wound measured 3.5 cm length by 2.5 cm width by 0.5 cm depth.R4's Antibiotic Time Out, dated 7/1/26, documents the coccyx wound had moderate purulent drainage with odor. The document further notes R4 had a decreased appetite and a decline in Activities of Daily Living (ADLs).R4's Nursing Note, dated 7/2/26, documents the physician was contacted regarding R4's pain management regimen. The note documents R4 received scheduled Tramadol at 8:00 AM and 12:00 PM and requested additional pain medication before the next scheduled 12:00 PM dose. The note further documents R4 had an as-needed order for Norco 5 mg/325 mg; however, only four hours elapsed between the scheduled Tramadol doses. The note documents facility staff requested an adjustment to R4's pain management regimen and were awaiting the physician's response.R4's eInteract Transfer Form, dated 7/4/26, documents R4 has a Stage IV pressure ulcer to the coccyx with necrotic tissue present. The form further documents R4 was transferred to the hospital on 7/2/26.R4's History and Physical, dated 7/3/26, documents R4 was transferred from the facility to the local emergency department for wound tunneling and a possible infection involving the right heel and buttock. The record documents R4 reported buttock pain. The physician recommended intravenous (IV) antibiotics and wound debridement.R4's Discharge summary, dated [DATE], documents R4 was discharged to the facility with hospice services and diagnosed with osteomyelitis associated with a Stage IV sacral pressure ulcer. It documents Infectious Disease and Wound Care consultations were completed. R4 had a Stage IV pressure ulcer to the sacrum with significant undermining and tunneling. It also documents Infectious Disease determined the role of antibiotic therapy was limited and there was no plan for surgical intervention or debridement because of R4's bedbound status. It further documents R4 would require a diverting ostomy; however, V34 (R4's Power of Attorney) declined the procedure.On 7/29/26 at 9:19 AM, V9 ADON stated there were movement limitations associated with R4's TLSO brace that made repositioning difficult and R4 experienced back and buttock pain related to the brace. V9 stated V9 was unable to locate documentation identifying the specific movement limitations or spinal precautions in R4's Electronic Health Record. V9 stated facility staff placed R4 on spinal precautions; however, documentation of those precautions could not be located. V9 stated R4 could be repositioned slightly with placement of a portion of a pillow beneath R4 to assist with pressure relief. V9 stated R4's pain was addressed with scheduled pain medication. V9 further stated facility policy requires residents to be checked and repositioned at least every two hours.On 7/27/26 at 12:27 PM, V34 R4's Power of Attorney (POA) stated R4 developed the wound while residing at the facility. V34 stated R4 was admitted to the facility for rehabilitation following a fall that resulted in a vertebral fracture. V34 stated after residing at the facility for a period of time, R4 developed a pressure ulcer on the buttocks. V34 reported R4 has severe arthritis, is unable to reposition independently in bed, and relies on staff for repositioning. V34 stated facility staff were expected to reposition R4 every two hours; however, V34 believed repositioning was not consistently completed because repositioning caused R4 pain. V34 stated that in July, a nurse contacted V34 and reported concerns regarding R4's coccyx wound, stating the wound appeared to require debridement and intravenous (IV) antibiotics and that R4 was being transferred to the hospital for evaluation. V34 stated V34 was not formally notified regarding changes in R4's wound but obtained updates by asking staff during visits. V34 stated staff reported the coccyx wound was worsening. V34 stated the first time V34 observed the wound was after R4 was transferred to the hospital and V34 was shocked by the severity of the wound. V34 reported the wound tunneled from one side of R4's buttocks to the other. R4 stated the pain in the buttocks felt like a grilled pancake on a hot skillet. V34 stated following R4's hospitalization and diagnosis of osteomyelitis associated with the coccyx wound, R4 was no longer able to sit in a chair because of pain. V34 stated R4 stated the prescribed pain medication made the pain more tolerable; however, sitting in the wheelchair remained torture because of the wound pain. V34 stated V34 never anticipated this outcome and remained shocked that R4 was now receiving hospice services because R4 was not a surgical candidate and the family did not want R4 repeatedly hospitalized for intravenous antibiotic therapy and recurrent wound infections.On 7/28/26 at 12:30 PM, V9 ADON, V26 Medical Assistant, and V27 Nurse Practitioner performed a dressing change to R4's coccyx and right heel wounds. V9 informed R4 that pain medication had been administered before the dressing change but discomfort could still occur during the procedure. V9 removed the existing dressing, performed hand hygiene, changed gloves, and cleansed the wound. During cleansing of the left buttock wound, R4 winced and moaned in pain. The wound bed contained approximately 60% red granulation tissue and 40% necrotic tissue. A small amount of serosanguineous drainage was observed on the removed dressing, which was dated 7/27/26. V26 photographed the wound. V27 explained the left buttock wound would be debrided. V27 applied lidocaine spray, debrided the wound, and obtained wound measurements. After additional lidocaine was applied and allowed to take effect for several minutes, the debridement resumed. Minimal bleeding was observed. V9 performed hand hygiene and applied the ordered dressing in accordance with the physician's order. R4's right heel dressing was completed using the same technique. 2. R6's Minimum Data Set, dated [DATE], documents R6 is moderately cognitively impaired.R6's admission Assessment, dated 12/30/25, documents R6 has excoriation and redness to the coccyx.R6's Physician Order, dated 1/1/26, documents a treatment order for a skin tear located on the coccyx.R6's Care Plan, dated 1/2/26, documents R6 is at risk for impaired skin integrity related to diabetes, impaired mobility, incontinence, fragile skin, and aging/disease process with interventions including, assessing and documenting changes in skin status, reporting pertinent changes in skin status to the physician, using a pressure-relieving cushion while R6 is up in a chair, and completing weekly treatment documentation including measurements of each area of skin breakdown, including width, length, depth, type of tissue, exudate, and other notable changes or observations.R6's Nursing Note, dated 1/24/26, documents R6 was sent to the hospital for evaluation of a kidney stone obstruction.R6's Other Progress Notes from the local hospital, dated 1/29/26, document R6 has an unstageable pressure injury to the coccyx measuring 2 centimeters (cm) length by 1.5 cm width. The notes further document R6 has an unstageable pressure injury to the left sacrum measuring 3 cm length by 2 cm depth and a deep tissue pressure injury to the right sacrum measuring 1 cm length by 1 cm width. The documentation indicates all wounds were present on admission to the hospital.R6's admission Assessment, dated 2/7/26, documents R6 has open areas to the right and left buttocks.R6's Nursing Note, dated 2/17/26, documents R6's second skin assessment was completed, and redness was noted to R6's right back area with one open area containing eschar and another open area containing slough.R6's Electronic Medical Record does not contain documentation of wound measurements, wound assessments, or physician notification regarding R6's wounds until 2/20/26.R6's Wound Assessment Details Report, dated 2/20/26, documents R6 has an unstageable pressure ulcer to the left buttock, identified on 2/8/26, measuring 1.2 cm length by 1 cm width by 0 cm depth.R6's Wound Assessment Details Report, dated 2/20/26, documents R6 has a Stage III pressure ulcer to the coccyx, identified on 2/8/26, measuring 2 cm length by 1.5 cm width by 0.3 cm depth. R6's Treatment Administration Record, dated February 2026, documents a physician order for treatment to R6's coccyx with a start date of 2/20/26. The record also documents a physician order for treatment to R6's left buttock with a start date of 2/20/26. The record does not document treatment orders for R6's wounds identified upon readmission on [DATE] until 2/20/26.R6's Care Plan, dated 3/15/26, documents R6 has a pressure ulcer located on the coccyx and left buttock with interventions including monitoring the site for signs and symptoms of infection. R6's Care Plan does not include additional individualized interventions for the treatment or prevention of pressure ulcers after the wounds were identified on 2/8/26.R6's Care Plan, dated 4/14/26, documents R6 was placed on Enhanced Barrier Precautions (EBP) due to chronic wounds and documents staff must wear a gown and gloves when providing the following care: dressing, bathing/showering, providing hygiene, changing linens, incontinence care, medical device care, and wound care for R6.R6's Wound Assessment Details Report, dated 7/21/26, documents R6 has a Stage III pressure ulcer to the coccyx measuring 4 cm x 1.8 cm x 0.3 cm depth.On 7/27/26 at 9:46 AM, R6 was seated in a wheelchair. R6 stated R6 was admitted to the facility around Christmas for therapy after undergoing right hip surgery. R6 was unable to recall when the wound to the coccyx started. R6 stated staff changed R6's wound dressing as ordered. R6 stated staff repositioned R6; however, R6 was unable to confirm that repositioning occurred frequently or every two hours.On 7/27/26 at 9:28 AM, R6 had an Enhanced Barrier Precautions sign posted on the door, and a container of gowns and gloves was available near the doorway. V43 Certified Nursing Assistant (CNA) entered R6's room with a brief and asked R6 if R6 was ready to get dressed for the day. V43 was not wearing a gown or gloves. V43 then provided care to R6.On 7/27/26 at 9:42 AM, V43 CNA exited the room and performed hand hygiene. V43 stated V43 provided perineal care to R6. V43 confirmed V43 was not wearing Personal Protective Equipment (PPE) while providing care to R6. V43 stated V43 was unaware R6 was on EBP and checked the door after providing care to determine whether signage was posted. V43 confirmed R6 had a wound and the wound dressing was intact. V43 confirmed PPE should have been worn while providing care to R6.On 7/31/26 at 10:18 AM, V9 ADON (Assistant Director of Nurses), stated staff are expected to follow Enhanced Barrier Precautions when providing care to residents requiring those precautions.On 7/29/26 at 11:00 AM, V9 ADON stated there was no documentation of wound measurements or assessments for R6's coccyx wound until 2/20/26. V9 stated these assessments should have been completed by the facility wound nurse; however, the wound nurse who would have completed the assessments is no longer employed by the facility.On 7/31/26 at 12:05 PM, V9 ADON stated staff are expected to contact the Medical Director for treatment orders when a wound is present on admission and there is not an existing treatment order.On 7/29/26 at 2:00 PM, V9 ADON confirmed there were no new or individualized interventions added to R6's Care Plan after R6's wound was identified on 2/7/26 until 3/15/26. V9 stated individualized interventions should have been added.

Based on observation, interview, and record review, the facility failed to designate a Registered Nurse as a full time Director of Nursing. This failure has the potential to affect all fifty-five residents residing in the facility. Findings include: During the survey period on 7/22/26, 7/23/26, 7/27/26, 7/28/26, 7/29/26, and 7/31/26, there was not a designated Director of Nursing working in the facility. On 7/28/26 at 9:40 AM, V15, Registered Nurse, stated the facility did not currently have a Director of Nursing. On 7/28/26 at 9:48 AM, V18, Licensed Practical Nurse, stated the facility did not currently have a Director of Nursing but had a Regional Nurse checking on things. On 7/28/26 at 12:37 PM, V4, Regional Nurse, stated V4 was not at the facility full time due to being responsible for multiple facilities. V4 stated another Regional Nurse, V2, was likewise not at the facility full time due to also being responsible for multiple facilities. On 7/28/26 at 12:55 PM, V9, Assistant Director of Nursing, stated there was not a designated Director of Nursing at the facility and neither V2 nor V4 was at the facility full time. On 7/29/26 at 3:22 PM, R16 stated R16 had missed one dose of an intravenous antibiotic due to the medication being stored in a room on a different hall of the facility from where R16 resided. R16 stated the nursing staff needed to be more organized. R16 stated R16 could not ever speak to a Director of Nursing, only being able to speak with the nurses on duty. R16 stated the nursing staff needed to take their direction from a Director of Nursing. On 7/31/26 at 9:20 AM, V1, Administrator, stated the facility did not have a designated Director of Nursing. V1 stated V1 had worked at the facility approximately forty-five days and there had not been a designated Director of Nursing during his time worked. V1 stated the Regional Nurses were not at the facility full time. The facility's Illinois Department of Public Health License, Permit, Certification, Registration effective 5/27/26, issued as conditional status, expiration date of 11/22/26, documents the facility has a licensed bed capacity of 64 beds, and all 64 beds are categorized as skilled nursing. The facility's Resident Roster dated for 7/22/26 documents fifty-five residents reside in the facility, all of whom require skilled nursing services.

Based on observation, interview and record review, the facility failed to implement fall interventions for one (R4) of three residents reviewed for falls in a sample list of three. Findings include: R4's Fall Risk assessment dated [DATE] documents R4 is a high fall risk. R4's Care Plan initiated 6/12/2026 documents R4 required assistance from staff for Activities of Daily Living (ADL's), toileting and transferring. R4's Care Plan initiated 6/12/2026 documents R4 is at risk for falls related to Confusion, Deconditioning, Gait/Balance problems, and History of Falls. R4's Electronic Health Record (EHR) documents an admission date of 6/11/2026 and diagnosed with Left Femur Fracture, Fall, Dementia, and Right Artificial Hip Joint. On 6/16/2026 at 9:15 AM, V6 (Family for R4) was at the bedside with R4. V6 stated they never leave R4 alone since they were worried R4 would fall. V6 stated R4 was to have an alarm but the one that was brought in was broken and was to be replaced. Since admission V6 stated R4 has not had a working alarm. V6 stated the family has verbally alerted various staff members with concerns about the broken alarm and absence of a functioning alarm. V6 stated they have addressed concerns regarding R4 not having any fall precautions in place and have not had anyone provide any answers. V6 stated they were very concerned since R4 is confused, has hearing difficulties, and has had falls with injuries in the past and recently. R4's broken alarm was located in R4's armoire. V6 stated they do not feel R4 is safe in the facility unless they are there to watch R4. V6 stated they have requested for R4 to be discharged home. At this time, V6 activated R4's call light which was answered by V8 within five minutes. R4 then activated the bathroom call light at 9:50 AM and the call light was answered again by V8 at 9:55 AM. R4 had no alarm in R4's recliner chair or bed. No alarm had been put in place. On 6/16/2026 at 10:00 AM, V5 (Licensed Practical Nurse, LPN) was the nurse for the 300-400 hall. V5 was unable to identify who was a fall risk on the 300 or 400 hall and was unable to identify what fall prevention interventions were care-planned for R2, R3, or R4. V5 stated they did not know how to identify a residents' fall risk. On 6/16/2026 at 10:45 AM, V12 (Medical Director) stated R4 is a high fall risk. V12 stated they were made aware of R4's family request to discharge home. R4 is to be discharged to home. On 6/16/2026 at 11:00 AM, V8 (Certified Nurses Aid, CNA) could not demonstrate how the alarm functioned because the alarm was not in place. V8 confirmed the alarm was not in R4's room and stated they did not know why. V8 cannot recall when the last time the alarm was used. V8 did not retrieved a new alarm. On 6/16/2026 at 11:10 AM, V9 (Certified Nurses Aid, CNA) could not demonstrate how the alarm functioned because it was not present. V9 confirmed the alarm was not in R4's room and stated they did not know where to get one. On 6/16/2026 at 1:00 PM, V2 (Director of Nursing, DON) stated the facility is bedrail-free and the facility does not use alarms. V2 confirmed R4 is identified as a high fall risk by the Fall Risk Assessment completed upon admission. R4's Fall Risk Assessment scores R4 at 13. The facility's Fall Scale determines any resident that scores over 9 is at high risk for falls. V2 stated there should not be an alarm in R4's room. V2 confirmed R4's Care Plan initiated 6/12/2026 documents R4 is to have a call light connect visual alarm per family request. V2 confirmed the alarm intervention was on the Care Plan. V2 confirmed the alarm was not present in R4's room. V2 stated V7 (Former Administrator) had added the alarm intervention to R4's Care Plan and stated they did not know why.R4's Care Plan dated 6/12/2026 documents R4 is to have a call light connect visual alarm.

Based on observation, interview and record review, the facility failed to ensure an oxygen cylinder was secured and stored properly for two residents (R71 and R1) in a sample list of 37 residents. Findings Include: On 3/01/2026 at 8:35AM, R71 had a portable oxygen cylinder located on the left side of R71's bed, not secured and not in use by the resident. R71 stated R71 does not use oxygen. On 03/01/2026 at 9:05AM, R1 had a portable oxygen cylinder located by the entry door inside R1's room. R1 stated R1 use to use oxygen and a BiPAP (Bilevel Positive Airway Pressure) machine but no longer uses either. R71's Physician Orders documented on 2/21/26, R71 receives two liters of Oxygen via Nasal Cannula every shift for Shortness of Breath. R1's Physician Orders dated on 1/27/26 Documents R1 is to receive Oxygen at three liters via nasal canula and Continuous Positive Airway Pressure (CPAP) machine. On 3/1/2026 at 1:25PM, V7 (Maintenance Director) stated there shouldn't be portable oxygen cylinders in the room as the oxygen cylinders are only for going out of the building for appointments.

Based on interview and record review, the facility failed to treat residents with respect and dignity for one (R76) of three residents (R75, R60, R76) reviewed for respect and dignity in the sample list of 37 residents. This failure resulted in R76 feeling embarrassed and degraded with a low self-esteem after staff continued the incontinence check after R76 stated R76 had notified staff that R76 was continent of urine.Findings Include:R76's Medical Record reviewed documents R76 was admitted to the facility on [DATE] from a local hospital with Diagnoses of Seasonal Allergic Rhinitis, Polyneuropathy, Long Term (Current) Use Of Oral Hypoglycemic Drugs, Presence Of Right Artificial Knee Joint, Aftercare Following Joint Replacement Surgery, Chronic Obstructive Pulmonary Disease, Autoimmune Hepatitis, Presence of Left Artificial Shoulder Joint, Asthma, Hypoxemia, Type 2 Diabetes Mellitus Without Complications, and Parkinsonism.R76's assessment record reviewed V6 admission Nurse/License Practical Nurse, documents on the admission assessment dated [DATE] at 09:57AM under subsection K; bowel and bladder that R76 is always continent of bowel and bladder.The same admission assessment under F, the neurological section, documents Neuro: R76 is alert to person, place, time, situation, and is verbally appropriate. On 03/03/26 at 09:50AM, V27 Certified Nursing Assistant (CNA) stated that the staff should read the care plan and if a resident is continent staff should ask the resident if the resident needs assistance to the restroom but should not insist that the bed/resident be checked for incontinence if alert resident states they are dry.On 03/03/26 at 11:40AM, V30 (R76's) Family Member, stated that R76 was feeling embarrassed and degraded with a low self-esteem after staff continued an incontinence urine bed check at 04:00AM on 2/25/26 after R76 stated R76 told staff that R76 was continent of urine and did not need the bed checked for urine incontinence.On 3/4/26 at 10:16AM, V6 admission Nurse/License Practical Nurse (LPN), stated the staff should follow the care plan and check/change the residents who are incontinent of urine and ask continent residents if they need assistance in getting to the bathroom. V6 stated the staff should be following the residents wants and needs.On 3/4/26 at 10:16AM, V1 Administrator and V23 Corporate Nurse stated a resident has the right to be treated with dignity and make the choice if the resident needs to be checked and changed or if they need assistance to the restroom. The Resident Rights policy dated 12/2025 documents the Purpose is to promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her abilities. The same policy documents under the guidelines documents Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. The facility will not hamper, compel, treat differentially, or retaliate against a resident for exercising his/her rights. Facility practices designed to support and encourage resident participation in meeting care planning goals as documented in the resident assessment and care plan are not interference or coercion.The Bowel & Bladder- Assessment & Toileting Programs dated 01 /2026 documents Purpose: Based on the resident's comprehensive assessment the facility will ensure that each resident with bowel or bladder incontinence will receive appropriate treatment and services to restore as much normal bowel or bladder functioning as possible. The same program documents under Guidelines: Subsection 3. If the resident is identified as continent, the voiding diary, Restorative Incontinence Observation, and toileting program will not be completed.

Based on observation, interview, and record review the facility failed to ensure state survey results were accessible and contained all surveys which were completed in the last year. This failure had the potential to affect all 59 residents residing in the facility.On 3/1/2026 at 10:58 AM, R4, R22, R26 and R27 were interviewed for resident council meetings. On 3/1/2026 at 11:50 AM, during the resident council meeting, R4, R22, R26, R27 stated they were unaware of where the state survey inspection results were located. On 3/1/2026 at 12:00 PM, V12 (Receptionist) stated the survey book is located in the foyer in a drawer. V12 pointed to a four-drawer dresser in the foyer. A picture frame propped up on the dresser contained a sign that stated, Survey Results. At that time, the survey book was not located on top of or in the dresser. V1 (Administrator) confirmed it was not accessible to the residents as it was located in her office. V1 and V2 (Regional Director of Operations) stated that the book was missing surveys and needed to be updated. On 3/1/2026 at 12:20 PM, V2 stated the survey book was missing the 5/1/2025 annual survey, 5/8/2025 complaint, 6/6/2025 certification revisit, 6/24/2025 complaint follow-up, 6/30/2025 annual prep certification, 8/1/2025 follow up complaint, 8/17/2025 licensure survey, 8/25/2025 licensure follow up, 9/16/2025 Facility reported incident times two, 9/18/2025 complaint, 10/14/2025 complaint, 11/18/2025 follow up to 9/23/2025, 12/15/2025 follow up complaint, 1/15/2026 complaints times four, and the 2/17/2026 complaint. The facility's Long Term Care Application for Medicaid and Medicare signed by V1 Administrator documents there are 59 residents residing in the facility.

Based on observation, interview, and record review the facility failed to complete wound assessments/measurements at least weekly and implement interventions to prevent wounds for three residents (R1, R6, R36) of five residents reviewed for wounds in a sample list of 37 residents.Findings Include: Facility Skin Condition Assessment & Monitoring – Pressure and Non – Pressure revised on 12/2025 documents a skin condition assessment and pressure ulcer risk assessment (Braden) will be completed at the time of admission/readmission. The pressure ulcer risk assessment will be updated quarterly and is necessary. This also documents that residents identified will have a weekly skin assessment by a licensed nurse. Also, a wound assessment will be initiated and documented in the resident chart when a pressure and/or other non-pressure skin conditions are identified by licensed nurse. This document also states that wound assessment and monitoring that a licensed nurse shall observe condition of wound incision daily, or with dressing changes as ordered. Observations such as drainage, dehiscence, redness, swelling, or pain will be documented in the nurse's notes if Observations are acute, physician and responsible party will be notified by charge nurse. Notifications will be documented in the residents' clinical record. 1.) On 03/01/2026 at 9:05AM, R1 was observed lying in bed eating breakfast. R1 stated R1 had a wound on admission, and it had healed and then reopened almost a month ago. Wound Notes Documented on 1/15/26 documents Wound Comments: Writer to room for skin reassessment and perform wound care. Patient (R1) has stage 3 pressure injury to sacrum, and IAD/MASD (Incontinence-Associated Dermatitis/Moisture-Associated Skin Damage) noted to peri-rectal area. Recommend zinc paste as needed. No other open areas or skin concerns noted. Patient remains on low air loss mattress. Nursing Progress Note documented on 2/5/2026 states Guest (R1) has open area to coccyx. NP (Nurse Practitioner) made aware and new orders to cleanse coccyx with generic wound cleanser, pack wound with calcium alginate, cover with boarder foam daily PRN (as needed) until healed. Wound nurse aware. Wound Notes Documented on a stage three pressure ulcer on coccyx measuring in centimeters 0.60 Long x 0.40 Wide x 0.10 Deep, with orders dated on 2/26/26 Coccyx: Cleanse area with NS (Normal Saline), apply collagen powder cover with bordered gauze, there is also an order dated on 2/5/2026 to Cleanse coccyx with generic wound cleanser, pat dry, pack with calcium alginate, cover with foam dressing daily PRN until healed with a discontinued date of 3/2/2026. The Minimum Data Set (MDS) dated [DATE] Documents R1 does not have a pressure ulcer. On 3/2/2026 at 8:50AM, V8 (Licensed Practical Nurse) stated that R1 has a pressure ulcer to the coccyx area and daily treatments are completed at bedtime. On 3/2/2026 at 9:35AM, V6 (Licensed Practical Nurse) stated that R1 had a wound on R1's coccyx area and completed wound rounds with the wound doctor. V6 stated that the pressure ulcer developed on 2/5/2026 and new orders were received. 2.) On 3/01/26 at 8:36AM, R6 was observed sitting in R6's wheelchair in R6's room. A sign was posted on the wall above R6's bed that reads, Heels must be floated while in bed. R6 stated R6 has sores that developed from lying in bed too much when R6 was first admitted to the facility. R6 also stated that R6 does not wear anything on R6's feet at night and only uses a Santa pillow between R6's legs. R6's electronic medical record (EMR) documents that R6 was admitted to the facility on [DATE]. R6's Minimum Data Set (MDS) dated [DATE] documents that R6's cognition is intact. The quarterly review of R6's MDS dated [DATE], Section M, documents that R6 has unhealed pressure ulcers, including two Stage 2 pressure ulcers and two Stage 3 pressure ulcers, which were not present on admission. R6's Care Plan dated 12/9/25 documents that R6 has actual skin impairment, including pressure injuries to R6's inner left and right ankles, outer left ankle, and the inside of the right foot. Care Plan interventions dated 11/11/25 document that staff are to encourage R6 to wear heel protectors while in bed and encourage R6 to float R6's heels while in bed. V24 Family Nurse Practitioners (FNP) wound care notes dated 2/18/26 document an off loading recommendation for R6 to wear heel protectors to the lower legs to prevent further pressure on the affected areas. On 3/4/26 at 10:44AM, V1 Administrator stated staff should have been following provider recommendations for R6 to wear heel protectors while R6 is in bed or documenting R6's refusal. 3.) R36's Minimum Data set completed 2/18/26 documents R36 was admitted on [DATE]. R36's Wound Clinic Consult dated 2/12/26 documents R36 was admitted with wounds to her bilateral lower extremities and left heel. R36's Medication Administration Record (MAR) for March 2026 includes treatment orders initiated 2/12/26 for treatments to her left heel, bilateral groin, and abdominal fold. On 3/1/26 at 8:45AM R36 was seated in a recliner in her room. R36's left heel was covered by a gauze wrap with yellow staining to the heel area. The dressing was not dated and appeared soiled. There is no documentation included in R36's medical record to indicate weekly wound assessments or measurements. On 3/4/26 V6, Licensed Practical Nurse (LPN) Wound Nurse verified R36 was admitted with multiple wounds and continues to have active treatments in place. V6 also verified the MDS documentation was not accurate. V6 stated we only document weekly if there are any new open areas. If there are no new open areas, we just initial the MAR (Medication Administration Record) as skin check completed. If the wound doctor sees the resident, then the full assessment is done. It looks like (R36) has not seen the wound doctor. I think (R36) was missed.

Based on observation, interview, and record review the facility failed to administer oxygen as ordered by the physician, change oxygen tubing and humidification weekly, and prevent possible cross contamination for four (R19, R36, R51, R58) of six residents reviewed for oxygen on a sample list of 37 residents. Findings:Findings Include: 1. R58's Care Plan revised 2/12/26 documents (R58) has altered respiratory status/difficulty breathing related to Pulmonary Hypertension, Obstructive Sleep Apnea, and Disorders of the Diaphragm. R58 has a current physician's order initiated 2/28/26 for continuous oxygen per nasal cannula at 3 liters per minute. On 3/1/26 at 9:30AM, R58 was observed resting in bed. The oxygen concentrator was set at 3 liters per minute, but the cannula and tubing in place to R58 was not attached to the concentrator. R58 stated R58 felt short of breath. V8 Licensed Practical Nurse (LPN) was notified. V8 went to R58's room and connected the tubing to the concentrator. V8 stated They must have forgotten to hook up the tubing when they put (R58) to bed. On 3/3/26 at 2:00PM. V58 was resting in bed. R58 complained of feeling short of breath. R58 stated part of my diaphragm is paralyzed and I get short of breath The oxygen concentrator was off, and the tubing and cannula were coiled up on top of the concentrator. V4 Certified Nurse's Aide (CNA) was notified. V4 replaced the cannula to R58's nose. V4 stated (R58) is supposed to have oxygen all the time at 3 (liters per minute). V4 turned on the concentrator to 3 liters per minute. 2. R36 has a current physician's order for Oxygen 2 liters per minute per nasal cannula while sleeping due to Sleep Apnea. R36 stated I wear oxygen at night, but I don't need it during the day. On 3/1/26 at 9:30AM, R36 was observed sitting in R36's room in a recliner. The oxygen concentrator was in the room tubing was attached and the nasal cannula was on the floor. The tubing and the empty humidifier bottle were not dated, and the cannula was covered in a crusty dry white matter. On 3/4/26 at 9:00AM, V6 Licensed Practical Nurse (LPN) verified (R58) has an order for continuous oxygen and should have it in place at all times and the cannula should not be on the floor and it is the facility's policy to date oxygen tubing and change it at least weekly. 3.) On 3/01/26 at 8:51AM, a sign reading Oxygen in Use was posted on R19's door and R19 was observed lying on R19's back in bed watching television. R19's oxygen tubing was on the floor, and R19's oxygen concentrator was running in the bathroom. R19 stated R19 has only been wearing R19's oxygen at night and that staff sometimes assist him with the tubing and concentrator, but not often. R19's Minimum Data Set (MDS) dated [DATE] documents R19 has the following active medical conditions, Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia and dependence on supplemental Oxygen. Section J of this MDS indicates that R19 experiences shortness breath with exertion, when sitting at rest, and when lying flat. Section O of this same MDS documents that R19 requires respirator treatment with continuous Oxygen therapy. R19's physician's order dated 1/27/26 documents, Oxygen at 2 liters per minute via nasal cannula every shift. R19's Care Plan dated 1/30/26 documents that R19 has COPD and Chronic Respiratory Failure with Hypoxia with an intervention of Oxygen at 2 liters per minute via nasal cannula continuously. R19's Medication Administration Record (MAR) for January, February, and March 2026 documents staff signatures indicating administration of oxygen at 2 liters per minute via nasal cannula continuously; the order is dated 1/27/26. On 3/02/26 at 11:35AM, V6 Licensed Practical Nurse (LPN) stated R19 has a physician's order for oxygen at 2 liters per minute via nasal cannula to be worn continuously. V6 confirmed that R19 should be wearing oxygen at all times. 4. R51's Care Plan with a revision date of 12/17/25 documents, R51 has altered respiratory status and difficulty breathing related to Shortness of Breath and Atelectasis. This care plan includes an intervention to apply oxygen at two liters via nasal cannula continuously. R51's Physician Order dated 12/8/25 documents an order to administer two liters of oxygen continuously. On 3/01/2026 at 9:01 AM, R51 was sitting in a wheelchair in R51's room. R51 was not wearing oxygen. An oxygen concentrator was plugged into an outlet against the wall. Oxygen tubing was connected to a humidification water bottle; this bottle was dated 12/8. The humidification bottle was empty. The nasal cannula attached to concentrator was not dated. On 3/02/2026 at 9:35 AM, R51 was sitting in a wheelchair in R51's room. R51 was not wearing oxygen. An oxygen concentrator was plugged into an outlet against the wall. Oxygen tubing was connected to a humidification water bottle; this bottle was dated 12/8. The humidification bottle was empty. The nasal cannula attached to concentrator was not dated. On 3/02/2026 at 11:40 AM, R51 was sitting at a dining table. R51 was not wearing oxygen from 11:40 AM to 11:55 AM. On 3/02/2026 at 12:55 PM, V6 Licensed Practical Nurse walked into R51's room and confirmed the date on the empty humidification bottle was 12/8. At that time, V6 looked up R51's orders and stated R51 had an order for two liters of oxygen to be administered continuously. V6 checked R51's pulse oximetry and it read 96 percent. V6 did not apply oxygen to R51 after looking at the order and checking R51's pulse oximetry. On 3/03/2026 at 9:33 AM, R51 was sitting in a wheelchair in R51's room. R51 was not wearing oxygen. On 03/02/2026 at 1:05 PM, V1 Administrator stated V1 would expect R51 to be wearing oxygen as ordered by the physician.

Based on interview and record review the facility failed to ensure medications were available by the pharmacy for two (R10, R150) of 16 residents reviewed for medications on the sample list of 37 residents. Findings Include: 1.) On 3/02/2026 at 8:15 AM, R10 stated when R10 was admitted (1/30/26) and readmitted (2/15/26) to the facility, R10's pain medication was not given because the facility did not have it. R10's physician orders dated 1/30/26 documents an order for Oxycodone Hydrochloride 30 milligrams (mg) one tablet by mouth every morning and at bedtime. R10's Medication Administration Record (MAR) for January 2026 documents R10's Oxycodone was not administered and to see progress note on 1/30/2026 and 1/31/2026. R10's progress notes for 1/30/26 at 7:56 PM does not document why the Oxycodone was not administered. R10's progress note dated 1/31/26 at 6:38 PM documents the Oxycodone was not available. R10's Medical Record does not document an attempt to call the backup pharmacy to obtain R10's Oxycodone. R10's MAR for February of 2026 documents R10's Oxycodone was not administered on 2/15/26 at 8:00 AM or 8:00 PM and documents to see progress notes. R10's progress notes dated 2/15/26 at 10:17 AM documents the Oxycodone was not administered due to being unavailable. On 3/2/26 at 1:04 PM, V1 Administrator stated R10 did not get the Oxycodone as ordered by the physician on 1/30/26, 1/31/26, or 2/15/26. V1 stated the nurse on duty should have called the backup pharmacy to obtain R10's Oxycodone. 2. R150's Medication Administration Record (MAR) for March 2026 includes a current order for Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT (Fluticasone-Umeclidinium-Vilanterol)1 puff inhale orally one time a day for SOB (Shortness of Breath)/wheezing. This same MAR documents on 3/2/26 this medication was not given. R150's progress note dated 3/2/26 at 11:36AM documents Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT 1 puff inhale orally one time a day for SOB/wheezing Unavailable will arrive tonight. R150's Minimum Data Set (MDS) dated [DATE] documents R150 is cognitively intact. On 3/3/26 R150 stated They didn't have my Trelegy for three days. I really need that for my breathing. V22 Licensed Practical Nurse (LPN) stated I work here quite a bit from agency. There is a problem having all the medication available sometimes. It just takes one click on the computer to reorder. I'm not sure why it gets missed.

A. Based on Observation, Interview and Record Review, the facility failed to implement enhanced barrier precautions and Contact Precautions in accordance with facility policy for two residents (R71 and R61) on a sample list of 37 residents reviewed for transmission-based precautions. This deficient practice had the potential to increase the risk of transmission of multidrug-resistant organisms and communicable infections to other residents and staff. B. Based on observation, interview, and record review the facility failed to appropriately sanitize a glucometer between use on multiple residents for one resident (R33) of one resident reviewed for glucometer sanitization in a sample list of 37 residents. Findings Include: A. Facility Enhanced Barrier and Contact Precautions revised on 12/25 with chronic wounds or indwelling medical devices during high-contact resident care activities. This policy also documents Standard Precautions must be followed with all cares including gown and gloves must worn when providing the following cares: Dresing, Bathing/Showing, Providing Hygiene, Changing Linens, Incontinence Care, Medical Device Care, and Wound Care. On 3/01/2026 at 8:35AM, R71 had no signage on the door for enhanced barrier precautions for R71's Blister from a diagnosis of Cellulitis and Congestive Heart Failure. On 3/01/2026 at 8:44AM, R61 had no Contact Precautions signage on the door. R1 has a Right Above the knee amputation, a Peripherally Inserted Central Catheter (PICC Line) and an eye infection that R1 was getting antibiotics for. On 3/01/2026 at 8:45AM, R61 had no enhanced barrier precautions signage on the door. R61 has a below the knee amputation which is wrapped. V4 was assisting residents with breakfast in gown, mask with no gloves. There was no enhanced barrier precautions signage on the door. On 3/01/2026 at 8:45 AM, V4 (Certified Nursing Assistant) stated yes she should be wearing gloves and that she believes that R4 has an eye infection but stated maybe it was from the wound. On 3/1/2026 at 1:30PM, V1 (Administrator) Confirmed the staff should be following Enhanced Barrier Precautions for any open area on any residents. B. R33's Medication Administration Sheet (MAR) for March 2006 includes a physician's order initiated 2/27/26 for blood sugars BID (Twice Daily) every morning and at bedtime for diabetes. On 3/3/26 at 9:52AM, V22 Licensed Practical Nurse (LPN) was observed cleaning a glucometer on the medication cart. V22 stated V22 had just finished checking a blood sugar on another resident and was cleaning the glucometer to use it to check R33's blood sugar. V22 stated V22 was using alcohol wipes, but she knew it should be bleach wipes. V22 also stated I specifically asked the housekeeping supervisor for bleach wipes for this cart this morning and was told we are not allowed to have bleach wipes on the medication cart. On 3/3/26 at 11:00AM, V1 Administrator verified the medication cart should be stocked with bleach wipes and the glucometer should be cleaned with bleach wipes. V1 stated V1 would take care of it. The facility's Glucometer Cleaning Policy revised January of 2026 documents Purpose: To prevent the growth and spread of microorganisms and bloodborne pathogens. Guidelines: The blood glucose monitor should be cleaned and disinfected between each resident test. Procedure: 1. Put on nonsterile gloves. 2. Inspect for blood, debris, dust, or lint anywhere on the meter. 3. To clean and disinfect the meter, use appropriate bleach wipe disinfectant. 4. Wipe meter with bleach wipe/towel until all surfaces of the glucometer are visibly wet and note kill time of the product. Do not wipe inside battery compartment, code chip port, or test strip port. 5. Discard the bleach wipe/towel. 6. Place the glucometer on a clean surface such as a paper towel and allow it to dry for no less than 3 minutes, according to manufacturer's instructions.

Based on interview and record review, the facility failed to answer call lights in a timely manner for one (R76) of three residents (R75, R60, R76) reviewed for call lights in the sample list of 37 residents.Findings Include:Grievance forms dated December 8 and 28, 2025 and February 3 and 26, 2026, all document residents having to wait extended times for help with various activities.Resident Council Minutes dated February 6, 2026, document six residents attended the meeting and documented staff need to answer call lights quicker.R76's Medical Record reviewed 2/24/26 documents R76 admitted to the facility on [DATE] from a local hospital with Diagnoses of Seasonal Allergic Rhinitis, Polyneuropathy, Long Term (Current) Use Of Oral Hypoglycemic Drugs, Presence Of Right Artificial Knee Joint, Aftercare Following Joint Replacement Surgery, Chronic Obstructive Pulmonary Disease, Autoimmune Hepatitis, Presence Of Left Artificial Shoulder Joint, Asthma, Hypoxemia, Type 2 Diabetes Mellitus Without Complications, and Parkinsonism.On 03/03/26 at 09:50AM, V27 Certified Nursing Assistant (CNA) stated that the staff should answer the call lights in a timely manner but that does not always happen.On 03/03/26 at 11:40AM, V30 (R76's) Family Member stated that R76 did not have a call light answered in a timely manner. V30 stated R76 had to wait for over 30 minutes for a call light to be answered on 02/25/26. V30 stated upon approaching the nurse's station multiple staff members were going on break, while multiple call lights were activated. V30 stated the call lights above the door were lit as well as sounding an alarm at the nurse's station.On 3/4/26 at 10:16AM, V6 admission Nurse/License Practical Nurse (LPN), stated staff should answer the call light in under 10 minutes and should not be exiting the unit if call lights are activated. V6 stated V6 is not aware of any staff not responding to call lights before going to break.On 3/4/26 at 10:16AM, V1 Administrator, and V23 Corporate Nurse stated staff should answer a call light in under 10-15 minutes to meet resident needs and should not be going to break or exiting the unit until the call lights are answered and needs have been met for the residents. V1 stated V1 is not aware of staff not responding to call lights before going to break off the unit.The Call Light policy dated 01/2026 documents: The purpose of this policy is to respond to residents' requests and needs in a timely and courteous manner. The same policy documents Guidelines: Resident call lights will be answered in timely manner. Subsection 2 documents: All staff should assist in answering call lights. Nursing staff members shall go to resident rooms to respond to call system and promptly cancel the call light when the room is entered. 3. Bathroom lights should be viewed as emergencies and immediate attention will be given.

Based on observation, interview, and record review the facility failed to assess the ability to self-administer medications for one of one resident (R10) on the sample list of 37 residents. Findings include: The Facility's Self Administration of Medication policy dated 4/2025 documents residents who request to self-administer drugs will be assessed using the Self Administration of Medications tool at the time of admission to determine if the practice is safe. 0n 3/1/2026 at 9:10 AM, a bottle of liquid Mucinex containing dextromethorphan 20 milligrams (mg), guaifenesin 400 mg, and phenylephrine 10 mg, a roller-ball tube of Aspercream (4% lidocaine), and a can of 4% lidocaine was sitting on R10's over the bed table. On 3/2/2026 at 9:05 AM, a bottle of liquid Mucinex, a roller tube of Aspercream, and a can of 4% lidocaine was sitting on R10's over the bed table. On 3/2/2026 at 1:32 PM, R10 stated R10 self-administers the Mucinex for congestion. R10 stated R10 self-administers the lidocaine and Aspercream which are used for pain management. R10's Electronic Health Record did not contain an assessment to determine R10's ability to self-administer medications. This medical record did not contain a Self-Administration of Medications tool. On 3/2/2026 1:50 PM, V1 Administrator stated R10 did not have an assessment to self-administer medications and R10 should not be self-administering medications.

Based on observation, interview and record review, the facility failed to provide clean bedding for one (R43) of 43 residents reviewed for environment on the sample list of 37 residents.Findings include: R43's admission Minimum Data Set assessment dated [DATE] documents R43 is cognitively intact. This assessment documents R43 requires partial to moderate assistance with activities of daily living. On 3/03/2026 at 9:28 AM, R43 was lying in bed. R43's pillowcase had brown smearing across the top of the pillowcase by R43's face. R43 was lying between the top sheet and the bottom sheet. Scattered brown crumbs were scattered along R43's upper body on top of the bottom sheet. R43 stated R43 eats in the bed and R43 would like to have clean bedding. R43 stated R43's bedding has not been changed since her room move on 2/21/26. R43's Daily Census in R43's Electronic Medical Record documents R43 moved rooms on 2/21/26. On 3/03/2026 at 9:33 AM, R43 was sitting in R43's wheelchair in R43's room. R43 stated R43's bedding had not been changed. R43's pillowcase had the same brown smearing across the top and the scattered brown crumbs remained scattered on top of the bottom sheet. On 3/03/2026 at 10:52 AM, V20 Certified Nurse's Assistant (CNA) stated bedding is supposed to be changed when soiled. On 3/4/26 at 10:35AM, V23 Corporate Registered Nurse/RN stated, I believe we change the bed linens daily when the resident gets up, but they certainly should be changed any time they are soiled particularly with feces.

Based on interview and record review the facility failed to ensure the right to be free from chemical restraints by failing to assess the need for a psychotropic medication, failing to develop a plan of care for an antidepressant used for insomnia and failing to implement non-pharmacological interventions for insomnia for one (R10) of five residents reviewed for unnecessary medications on the sample list of 37 residents. Findings include: R10's Medication Administration Record (MAR) shows an order for mirtazapine (antidepressant) oral tablet 7.5 mg (milligrams) give 7.5 mg at bedtime for depression and insomnia start on 2/19/2026 at 8:00 PM. R10's Physician Progress Note dated 2/19/2026 written by V18 (Physician's Assistant) documents R10 was seen by V18 that day. V18 documented that R10 reported R10, can't sleep. This note documents V18 prescribed mirtazapine 7.5 mg at bedtime for Insomnia. On 3/3/2026 at 10:30 AM, R10 stated R10 has had a problem with sleeping R10's whole life from working swing shifts. R10 stated R10 preferred to fall asleep with the television on or R10 will read to help with falling asleep. R10's Electronic Medical Record does not contain an assessment for R10's Remeron or that nonpharmacological interventions were attempted for Insomnia. R10's Antidepressant Care Plan dated 2/24/26 does not document R10's diagnosis of Insomnia or interventions for the Insomnia. On 3/3/2026 at 12:45 PM, V1 (Administrator) confirmed R10 was not assessed for the use of psychotropic medications used for insomnia, R10 is not monitored for Insomnia, a plan of care was not developed for Insomnia, and nonpharmacological interventions were not put into place. The Facility's Behavior Service Program policy dated 3/2025 documents a plan of care will be developed for behaviors, the behaviors will be monitored, and interventions will be implemented.

Based on observation, interview, and record review the facility failed to accurately assess wounds in the Minimum Data Set for two residents (R36, R1) of 33 residents reviewed for MDS accuracy in a sample list of 37 residents.Findings Include: R36's Minimum Data Set (MDS) completed 2/18/26 documents R36 was admitted on [DATE]. R36's Wound Clinic Consult dated 2/12/26 documents R36 was admitted with wounds to her bilateral lower extremities and left heel. R36's Medication Administration Record (MAR) for March 2026 includes treatment orders initiated 2/12/26 for treatments to her left heel, bilateral groin, and abdominal fold. On 3/1/26 at 8:45AM, R36 was seated in a recliner in R36's room. R36's left heel was covered by a gauze wrap with yellow staining to the heel area. The dressing was not dated and appeared soiled. R36's MDS dated [DATE] documents R36 was admitted without wounds of any kind. On 3/4/26, V6 Licensed Practical Nurse (LPN)/ Wound Nurse verified R36 was admitted with multiple wounds and continues to have active treatments in place. V6 also verified the MDS documentation was not accurate. Wound Notes Documented on 1/15/26 documents Wound Comments: Writer to room for skin reassessment and perform wound care. Patient (R1) has stage 3 pressure injury to sacrum, and IAD/MASD (Incontinence-Associated Dermatitis/Moisture-Associated Skin Damage) noted to peri-rectal area. Recommend zinc paste as needed. No other open areas or skin concerns noted. Patient remains on low air loss mattress. Nursing Progress Note documented on 2/5/2026 states Guest (R1) has open area to coccyx. NP (Nurse Practitioner) made aware and new orders to cleanse coccyx with generic wound cleanser, pack wound with calcium alginate, cover with boarder foam daily PRN (as needed) until healed. Wound nurse aware. Wound Notes Documented on a stage 3 pressure ulcer on coccyx measuring 0.60 Long x 0.40 Wide x 0.10 Deep, with orders dated on 2/26/26. Coccyx: Cleanse area with NS (Normal Saline), apply collagen powder cover with bordered gauze, there is also an order dated on 2/5/2026 to Cleanse coccyx with generic wound cleanser, pat dry, pack with calcium alginate, cover with foam dressing daily PRN until healed with a discontinued date of 3/2/2026. MDS dated [DATE] Documents R1 does not have a pressure ulcer. On 3/2/2026 at 8:50AM, V8 (Licensed Practical Nurse) stated R1 has a pressure ulcer to the coccyx area and daily treatments are completed at bedtime. On 3/2/2026 at 9:35AM, V6 (Licensed Practical Nurse) stated R1 had a wound on R1's coccyx area and completed wound rounds with the wound doctor. V6 stated that the pressure ulcer developed on 2/5/2026 and new orders were received. V6 stated while completing wound rounds on R1. Facility Skin Condition Assessment & Monitoring – Pressure and Non – Pressure revised on 12/2025 documents a skin condition assessment and pressure ulcer risk assessment (Braden) will be completed at the time of admission/readmission. The pressure ulcer risk assessment will be updated quarterly and is necessary. This also documents that residents identified will have a weekly skin assessment by a licensed nurse. Also, a wound assessment will be initiated and documented in the resident chart when a pressure and/or other non-pressure skin conditions are identified by licensed nurse. This document also states that wound assessment and monitoring that a licensed nurse shall observe condition of wound incision daily, or with dressing changes as ordered. Observations such as drainage, dehiscence, redness, swelling, or pain will be documented in the nurse's notes if Observations are acute, physician and responsible party will be notified by charge nurse. Notifications will be documented in the resident's clinical record.

Based on observation, interview, and record review the facility failed to provide shaving assistance for one resident desiring to be shaved (R58) of three residents reviewed for shaving in a sample list of 37 residents. Findings Include:R58's Minimum Data Set (MDS) dated [DATE] documents R58 is cognitively intact and dependent on staff for personal hygiene including shaving.On 3/1/26 at 9:40AM, R58 was observed resting in R58's bed. R58 had coarse gray facial hair approximately 1/4 inch long on R58's face and chin. When asked if R58 preferred to be unshaven R58 stated no I like to shave every day. I like to be clean shaven. I've never been one to wear a beard, but I can't do it myself and they tell me they can't do that for me.On 3/2/26, V23 Corporate Registered Nurse (RN) verified it is the facility's policy to offer a shave as often as the resident prefers to be shaved. V23 also confirmed the CNA staff are expected to shave each resident as per their preference.

Based on observation, interview, and record review the facility failed to provide pain medication when pain was present and as ordered by the physician for one (R10) of two residents reviewed for pain on the sample list of 37 residents. R10's Pain Care Plan dated 2/2/26 documents R10 has low back pain, migraines, and pain due to a left femur fracture. This care plan includes an intervention to provide pain medication as ordered by the physician. R10's physician orders dated 1/30/26 documents an order for Oxycodone Hydrochloride 30 milligrams (mg) one tablet by mouth every morning and at bedtime for pain and an order for Norco 5-325 mg one tablet every six hours as needed for pain. On 03/02/2026 at 8:15 AM, R10 stated when admitted and readmitted to the facility pain medication was not given because the facility did not have it. R10 stated when R10 receives the pain medication R10's would rate pain as a three on a one to ten scale but when R10 doesn't receive the pain medication the pain rating is an eight on a one to ten scale. R10's Medication Administration Record (MAR) for January 2026 documents R10's Oxycodone was not administered and documents to see progress note on 1/30/2026 and 1/31/2026. This MAR documents R10's pain rating as a nine on a one to ten scale on 1/30/26 and on 1/31/26. R10's progress notes for 1/30/26 at 7:56 PM does not document why the oxycodone was not administered. R10's progress note dated 1/31/26 at 6:38 PM documents the Oxycodone was not available. R10's MAR for February of 2026 documents R10's Oxycodone was not administered on 2/15/26 at 8:00 AM or 8:00 PM and documents to see progress notes. R10's progress note dated 2/15/26 at 10:17 AM documents the Oxycodone was not administered due to being unavailable. On 3/2/26 at 1:04 PM, V1 Administrator stated R10 did not get the Oxycodone as ordered by the physician on 1/30/26, 1/31/26, or 2/15/26. On 3/3/26 at 10:30 AM, R10's call light was activated outside of the room. R10 was lying in bed and stated R10 was having pain and rated the pain as an eight out of ten on a one to ten scale. At 10:35 AM, V20 Certified Nurse's Assistant (CNA) entered the room. R10 told V20 CNA that R10 was in pain and V20 CNA responded to R10 and stated V20 CNA was going to go and report the pain to the nurse (V19, Licensed Practical Nurse). On 3/3/26 at 10:43 AM, R10 stated R10 was going to activate the call light since no one has brought pain medication to R10. R10 then activated the call light. On 3/3/26 at 10:45 AM, V20 CNA answered the call light and stated V19 LPN said it was too early to receive any pain medications. R10 then asked to speak to V19 LPN. On 3/3/26 at 11:00 AM, V6 Licensed Practical Nurse entered R10's room to talk to R10 about an X-ray. R10 told V6 LPN that R10 was having pain. V6 told R10 LPN that V6 would let her nurse (V19) know R10 was having pain. R10's Medication Administration Record (MAR) dated 3/3/26 documents Oxycodone 30 milligrams was last given at 8:00 AM. This MAR documents R10's Norco 5-325 mg was last given on 3/2/26 at 1:17 PM. On 3/3/26 at 11:10 AM, V6 LPN and V19 LPN were discussing R10's pain medication and V6 stated V6 was going to call to clarify R10's pain medication orders. V19 stated V19 was going on break. On 3/3/26 at 11:40 AM, V6 LPN stated V6 after calling the physician V6 let V19 know that R10 could have one tablet of Norco 5-325 mg as ordered for pain. On 3/3/26 at 11:55 AM, V19 LPN walked to the desk at the nurse's station and when asked stated V19 has not given R10 the pain medication yet. R10's MAR documented R10 received one tablet of Norco 5-325 mg on 3/3/26 at 11:59 AM. On 3/4/26 at 1:35 PM, V1 Administrator stated R10's pain medication should have been given as soon as possible when R10's pain was reported.

Based on observation, interview, and record review, the facility failed to properly store medications for two (R10, R51) of 24 residents reviewed for environment on the sample list of 37 residents. Findings include: 1.) On 3/1/2026 at 9:10 AM and on 3/2/26 at 9:05 AM, a bottle of liquid Mucinex containing dextromethorphan 20 milligrams (mg), guaifenesin 400 mg, and phenylephrine 10 mg, a roller-ball tube of Aspercream (4% lidocaine), and a can of 4% lidocaine was sitting on R10's over the bed table. On 3/2/2026 at 1:32 PM, R10 stated the Mucinex, Aspercream, and Lidocaine are kept on the over the bed table and the staff does not take them out of the room. On 3/2/2026 at 1:40 PM, V6 Licensed Practical Nurse stated the Mucinex, Aspercream, and Lidocaine should not be stored on R10's over the bed table and they should be locked in the medication cart. 2.) On 3/1/2026 at 9:01 AM a medicine cup with a pill inside was sitting in the windowsill of R51's room. V6 stated that medications should not be stored in resident's rooms.

Based on observation, interview, and record review, the facility failed to identify a newly admitted resident as a potential elopement risk and failed to provide supervision and interventions to prevent elopement for one of four (R1) residents reviewed for elopement on a sample list of four. These failures resulted in R1, a severely cognitively impaired resident at risk for falls with impaired safety awareness, leaving the facility unsupervised on foot with no coat or shoes on with outside temperatures below freezing. R1 was found by family members six tenths of a mile from the facility in a restaurant parking lot near two interstates/highways eight hours after the resident was last observed in the facility. R1 suffered frostbite to bilateral feet great toes due to environmental exposure, hypothermia, a fracture to the proximal phalanx of left great toe, and a hematoma with laceration to the right frontal forehead requiring hospitalization.The immediate jeopardy began on 2/7/26 at approximately 11:00 pm when R1 was last seen in the facility. R1 left the facility unnoticed and traveled six tenths of a mile away from the facility on foot with no coat or shoes on with outside temperatures below freezing. V1, Administrator, was notified of the Immediate Jeopardy on 2/11/26 at 3:55 p.m. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 2/8/26, but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.R1's face sheet documents R1 is 99-years old and admitted to the facility on [DATE].R1's Minimum Data Sheet (MDS) section C with print date of 2/10/26 documents R1 has severe cognitive impairment.R1's initial elopement evaluation assessment dated [DATE] was not completed in full before V12 Social Service Director (SSD) locked assessment as completed which then indicated R1 was not an elopement risk.R1's Care Plan, undated, documents R1's diagnoses as Gastrointestinal Hemorrhage, Hypertensive Urgency, Anemia, Atherosclerotic Heart Disease, Presence of Aortocoronary Bypass Graft, Abdominal Aortic Aneurysm, Chronic Obstructive Pulmonary Disease, Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Delirium, Gout, Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms, and Personal History of Malignant Neoplasm of Prostate.R1's Care Plan, undated, documents current skin impairment, increased risk for falls related to gait imbalance requiring walker and gait belt, impaired cognitive function, impaired communication, impaired hearing requiring hearing aids, and impaired visual function requiring the use of glasses.R1's community survival skills assessment completed on 2/8/26 by V12 Social Service Director (SSD), documents R1 has no safety awareness and survival skills if outside the facility on R1's own and recommends R1 not be unsupervised outside. R1's Undated Care Plan documents a new intervention dated 2/8/26 for increased risk of elopement.Progress Notes dated 2/2/26 at 7:56PM document R1 had an unwitnessed fall in his room with neuro checks to be completed through 2/5/26.The Facility Investigation Notes dated 2/7 to 2/8/2026 document on 2/8/26 at 6:09AM, V8 Nurse Supervisor Licensed Practical Nurse (LPN) notified V9 Director of Nursing (DON), that R1 was missing from the facility. At 6:11 AM V9 DON notified V1 Administrator of the incident. At 7:06AM, V14 Certified Nurse Assistant (CNA) located R1 in a restaurant parking lot and at 7:07AM, V14 CNA called 911. On 2/8/26 at 7:16AM, EMS arrived on scene and transported R1 to the local hospital for evaluation.R1's Hospital Records dated 2/10/26 document R1 arrived at the Emergency Department at 7:23AM on 2/8/26. The Hospital Records document R1 was hypothermic with a temperature of 94.8 degrees Fahrenheit (F), with frostbite to bilateral great toes and additional digits related to environmental exposure, discoloration of bilateral hands, abrasions to bilateral knees, a hematoma to the forehead, a comminuted fracture through the distal neck and head of the proximal phalanx of the left great toe extending to the articular surface, and that R1 was disoriented and complaining of back pain. The Records document R1 was found with no coat and no shoes on.V14 Certified Nurses Aide's (CNA) statement dated 2/8/26 documents on 2/8/26 at 5:40AM V14 entered through the front entrance of the facility for her shift and noticed a bedside table sitting by the door. While completing morning vital signs, V14 noted that R1 was not in his room and alerted V8 Licensed Practical Nurse at that time. V14 found R1 at a local restaurant and placed her coat over his shoulders and called 911. The statement documents that R1's family arrived around the same time as V14 at the restaurant parking lot.The Facility Investigation File documents on 2/8/26, time unknown, V8 Licensed Practical Nurse (LPN) stated she last saw R1 at 11:00PM in his room in bed. The File documents V8 denied hearing any door alarms throughout the night and stated she was alerted to a missing resident around 5:30AM.R1's Progress Notes dated 2/9/26 document the Interdisciplinary Team (IDT) met following R1's unauthorized leave and the root cause was determined to be confusion/wandering behavior.The Facility Final Report dated 2/13/26 documents R1 was hospitalized with frostbite to toes and bilateral feet, hypothermia, Urinary Tract Infection (UTI), and fracture to the left great toe. The Report documents R1 was reassessed for risk of elopement and community survival skills and R1's Plan of Care was updated to reflect current risk of elopement and associated behavioral needs.The Google Map Application dated 2/17/26 documents the distance from the facility to the location R1 was found is 0.6 miles.The World Weather Forecast Temperature Charts dated 2/7/26 and 2/8/26 for the facility location document the temperature at 11:00PM on 2/7/26 was 25 degrees F with a real feel of 16 degrees F and the temperature at 7:00AM on 2/8/26 was 27 degrees F with a real feel of 15 degrees F.The Facility Daily Assignment Sheet dated 2/7/26 third shift, documents V8 LPN and V15 LPN were the nurses on shift between the hours of 10:00PM and 6:00AM. The Daily Assignment Sheet documents V16 CNA, V17 CNA, V18 CNA, and V19 CNA were the Certified Nursing Assistants for the third shift on 2/7/26 between the hours of 10:00PM and 6:00AM. The Facility Daily Assignment Sheet dated 2/8/26 first shift, documents V14 CNA worked from 6:00AM to 2:00PM.On 2/11/26 at 12:55 PM V14 CNA confirmed V14's statement dated 2/8/26. V14 stated V14 noted R1 missing the morning of 2/8/26 after arriving for the day shift and V14 alerted V8 LPN that R1 was not in his room.On 2/8/26 at 8:00AM, V15 Licensed Practical Nurse (LPN) stated that he was the overnight nurse for the other wing and stated he was completing wound rounds at end of the shift when he was alerted there was a Code Pink (Missing Resident).Attempts were made during the survey to contact V8 LPN, V16 CNA, V17 CNA, V18 CNA and V19 CNA night shift staff.On 2/10/26 at 1:15PM V10 Hospital Registered Nurse stated that R1 sustained a hematoma with skin tear to the right forehead area, bilateral foot frostbite involving great toes and additional digits due to environmental exposure, and fracture to left proximal phalanx great toes requiring a surgical shoe. V10 stated R1 was currently being treated for a Urinary Tract Infection with Intravenous Antibiotics. On 2/10/26 at 2:05 PM V6, Facility Nurse Practitioner, stated that R1 could have suffered kidney failure, hypothermia, loss of limbs, falls, fractures, heart attack, and ultimately death from being unattended outside of facility. V6 stated R1 has poor cognition, is extremely hard of hearing, has poor vision, and has no safety awareness.At 11:50AM on 2/10/26, V1 Administrator, and V2 Regional Operations Director, stated that the facility does not have cameras and that through interviews and witness statements, R1 was identified as last seen around 11:00PM on 2/7/26 and was not identified as missing until 6:05 AM the following morning on 2/8/26. V1 and V2 stated R1's family was notified and family found R1 at approximately 7:00AM.On 2/10/26 at 9:55AM, V4, R1's Family Member, stated on 2/8/26 at 6:55AM she was notified by facility staff that R1 was missing. V4 stated at 7:00AM, V4 and V4's spouse found R1 crouched down by a wall at a restaurant on the way to the facility wearing a T-shirt, sweatshirt, jeans and socks. V4 stated R1 did not have a coat, hat or shoes on. V4 stated R1, complained he was cold, and the wind was very bad. V4 stated R1 had a visible knot on his forehead and R1's left-hand fingers were blue. R1 stated he had been a bad boy and that he had wandered into the hallway looking for help when he wandered out. V4 stated R1 stated that he fell several times that night. V4 stated that R1 required a walker to walk, but the facility did not have one for R1, so he did not have any walking aid when found at the restaurant that morning. V4 stated upon admission to local emergency room, R1 was found to have frostbite to the left index finger and right and left great toes, and R1's left great toe was broken and at this time, amputation of frostbit extremities is still a possibility. V4 stated R1 was also found to have a urinary tract infection at the hospital that R1 did not have at the time of admission to the facility five days prior. V4 also stated that R1 was found in clothing from the day prior, and R1's hearing aides were in R1's ears but not charged, R1's dentures were in place, and R1 did not have his glasses on. V4 stated V4 believes R1 was never assisted to bed that evening prior. V4 also stated that after admission to facility on 2/2/26, R1 had fallen in the facility. On 2/10/26 at 11:30 AM, V5 Receptionist stated there is an elopement alert binder at the front desk that identifies residents who are at risk of elopement. V5 stated there is always someone at the front desk from 8AM to 8PM seven days a week and prior to leaving shift, the outside front door is locked so no one can enter, and the inside exit door is alarmed a with code.On 2/10/26 at 9:00AM the restaurant parking lot where R1 was found, 0.6miles from the facility, was noted to be located at the intersection of two major highways. The policy titled Code Pink-Missing Resident/ Elopement, dated 11/2017, documents the facility maintains a process to assess all residents for risk for elopement, implement risk reduction strategies for those identified as an elopement risk, and institute measure for resident identification at the time of admission.The Immediate Jeopardy that began on 2/7/26 was removed on 2/8/26 when the facility took the following actions to remove the immediacy:1.) R1 was reassessed for risk of elopement and community survival skills and R1's Plan of Care was updated to include R1's current risk of elopement and associated behavioral needs by V12 SSD on 2/8/2026. The facility has a plan to have R1 on one to one observation when R1 returns.2.) On 2/8/26, V11 Maintenance Director reviewed the incident and confirmed door alarms/system functional status.3.) The elopement binder was reviewed and updated on 2/8/2026, completed by V12 SSD, V13 SSD, V21 MDS, V9 DON and V1 Administrator.4.) Code Pink Education and Rounding Expectations were provided to 100% of staff on 2/8/2026, completed by V22 Human Resource Director, V20 CNA Scheduler, V9 DON, V3 ADON, & V1 Administrator.5.) All residents were assessed for risk of elopement and community survival by V12 SSD, V13 SSD, V21 MDS, and V8 admission Nurse on 2/8/2026.6.) All residents will be reevaluated for elopement risk at admission, readmission, quarterly, annually, and significant change or incidentally if at risk behaviors are identified. This will be on-going. SSDs assigned this responsibility as of 2/8/26. Audit will be reviewed by the administrator or designee for six weeks.7.) On 2/8/2026 100% of staff were in serviced regarding wandering/exit seeking behavior, and when to provide/implement increased supervision to a resident exhibiting these behaviors by V3 ADON, V9 DON, V20 CNA Scheduler, V1 Administrator, and V22 Human Resources Director (HRD).8.) On 2/8/2026 100% of staff were in serviced regarding door alarms as required safety measure and must never be turned off, silenced, or disabled. These alarms help prevent unauthorized leave. Any alarm issues must be reported immediately to the charge nurse and maintenance, and staff are expected to respond promptly when alarms sound. The front door entrance door alarm may be disabled from approximate times of 8 am to 8 pm only when the door is being monitored by staff. Staff in-serviced by V9 DON, V22 HRD, V3 ADON, and V1 Administrator.9.) An Elopement drill was conducted on 2/8/2026 at 2:25 PM by V9 DON & V1 Administrator.10.) A plan for in-servicing was implemented which includes elopement policy, wandering/exit seeking behavior and door alarms to occur upon hire and remain ongoing by V22 HRD.11.) On 2/8/2026 Agency staff were in-serviced by the agency platform regarding Code Pink and Rounding Expectations prior to working at the facility. 12.) An ADHOC Quality Assurance (QA) meeting was completed with the IDT regarding the Elopement Policy and Procedure on 2/8/2026.13.) The QA committee will review policy and procedure as part of the Quality Assurance Process on 2/11/26.14.) Elopement will be reviewed during each quarterly meeting for four meetings.The facility presented an abatement plan to remove the immediacy on 2/11/26 at 3:59 p.m. The survey team reviewed the abatement plan and was able to accept the plan to remove the immediacy. The abatement plan was approved on 2/13/26 at 10:10 a.m.

Based on observation, interview and record review the facility failed to complete thorough fall investigations, failed to implement fall interventions and failed to supervise high fall risk residents for one (R7) resident out of three residents reviewed for Accidents in a sample list of twelve residents. Failing to provide supervision and implement fall interventions resulted in R7 falling and experiencing pain due to injury from an unwitnessed fall that required emergency services. Findings include:R7's medical record documents medical diagnoses as Encephalopathy, Falls, Vascular Dementia with Behavioral Disturbance, Abnormal findings on diagnostic imaging of other parts of musculoskeletal system, Anemia, Weakness and Pacemaker.R7's Minimum Data Set (MDS) dated [DATE] documents R7 as moderately cognitively impaired. This same MDS documents R7 requires supervision with toileting, bathing, dressing, bed mobility and transfers.R7's Fall Care Plan initiated on 11/10/25 documents R7 as being at risk for falls.R7's Incident Fall assessment dated [DATE] documents R7 has had 1-2 previous falls in the past three months and has intermittent confusion.R7's Care Plan intervention dated 11/17/25 documents R7 requires gait belt and assist to transfer between surfaces. This same care plan documents an intervention dated 11/10/25 for staff to ensure that the R7 is wearing appropriate footwear and to anticipate and meet the resident's needs.R7's Nurse Progress Note dated 1/1/26 at 8:34 AM documents R7 was found by V10 CNA on his bathroom floor at 5:56 AM. This same note documents R7 was ambulating without assistance, call light was not used, barefoot using walker and fall was unwitnessed. This same note documents R7 obtained a laceration to his Right Forehead, abrasion to Right Knee and abrasion to his Left Foot. This same note documents R7 who is on blood thinners was walking to his toilet as he lost his balance. R7's Fall Incident assessment dated [DATE] documents R7 had a unwitnessed fall in his bathroom. This same assessment documents R7 has intermittent confusion and was barefoot using his walker when he lost balance and fell resulting in a Forehead laceration and Right Knee and Left Foot abrasion. This same assessment documents R7 was sent to the emergency room for evaluation. R7's Hospital Record dated 1/1/26 documents R7 was seen in the emergency room following a fall at the facility resulting in Left Ankle swelling, foreign body of Left Fifth finger and a closed head injury of Hematoma to R7's Right Forehead. This same record documents R7 has Dementia and is a poor historian. This same hospital record documents R7's Left fifth finger was diffusely swollen with a laceration on the pad of the distal finger tip. R7's Radiology Report dated 1/1/26 documents Impression: Small radiopaque foreign body within the palmar aspect of the distal fifth finger. This same report documents R7's fifth finger injury was Post trip and ground level fall. On 1/13/26 at 2:00 PM R7 was sitting in his chair in his room. R7's urinal was sitting in his bathroom, not within his reach. R7's left fifth finger at the proximal joint showed a black line across the entire width. R7 showed his left fifth finger saying I got that when I fell. It did hurt but not now.On 1/13/26 at 2:05 pm R7 stated he did not know where his urinal was located. R7 stated if he needed to use the bathroom, he would just get up and go. R7's call light was laying across his bed not within reach of R7.On 1/14/26 at 3:00 PM R7 was sitting in his chair in his room. R7's urinal was sitting in his bathroom, not within his reach. On 1/15/26 at 10:45 AM R7 was sitting in his chair in his room. R7's urinal was sitting in his bathroom, not within his reach. On 1/14/26 at 1:50 PM V10 Certified Nurse Aide (CNA) stated she was in the room next door to R7's when she heard him fall. V10 CNA stated she was not assigned to R7 that day but went to his room to check on R7 after hearing the thud noise. V10 CNA stated R7 was laying on his right side on the floor, barefooted with his walker laying on its side next to R7. V10 CNA stated there was blood on the floor due to R7's finger was bleeding.On 1/14/26 at 1:55 PM V6 Certified Nurse Aide (CNA) stated she was instructed by other staff that R7 does not need any assistance walking. V6 CNA stated R7 walks independently with his walker all the time to his bathroom. V6 CNA stated she does not try to assist R7 when he is walking independently. V6 CNA stated R7 is not a fall risk. V6 CNA searched R7's room and confirmed R7's urinal was in his bathroom, out of his reach. On 1/14/26 at 4:30 PM V32 CNA stated she was assigned to R7 the morning of his fall on 1/1/26. V32 CNA stated she was assisting the nurse with wound care at the time of R7's fall. V32 CNA stated she had not checked on R7 for a few hours. V32 CNA stated the last time she saw R7, he was in bed sleeping. V32 CNA stated R7 gets up independently and does not need staff assistance for toileting. On 1/16/26 at 1:15 PM V2 Director of Nurses (DON) stated R7 should have had on the appropriate footwear to help prevent his fall. V2 DON stated the intervention for R7's fall was to place a urinal at his bedside. V2 DON stated R7's urinal should always be within his reach. V2 DON stated she reviewed the hospital record and read where R7 had a foreign body in his left fifth finger but is unaware of what that might be. V2 DON stated R7 does not have a medical history of any procedure in which hardware might have been placed. V2 DON stated during her investigation of R7's fall, she read the nurses progress note but did not interview staff. V2 DON stated she did not ask if R7's call light was within reach or where R7's footwear might have been. V2 DON confirmed R7's fall investigation could have been more thorough.

Based on interview and record review the facility failed to identify and report an alteration in skin integrity to prevent a pressure ulcer for one (R1) of four residents reviewed for quality of care. This failure resulted in R1 developing a Stage 2 pressure ulcer to the middle of R1's tailbone.Findings include:The facility's Skin Condition Assessment & Monitoring - Pressure and Non-Pressure Policy, dated 04/2025, documents that the purpose of the policy is to establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries, and other non-pressure skin conditions, and ensuring interventions are implemented.R1's Care Plan, initiated on 05/22/2019, documents that R1 is at risk for developing pressure ulcers and other impairments to skin integrity related to decreased mobility, pain, and weakness. This Care Plan includes an intervention dated 05/23/2019 for monitoring, reminding, and assisting to turn/reposition R1 at least every two hours, more often as needed or requested, and to notify R1's nurse immediately of any new areas of skin breakdown noted during bathing or daily care.R1's CNA (Certified Nurse Assistant) Skin Attention Form (completed by CNA during resident bath) from 09/01/2025 through 10/01/2025 does not document any skin issues.R1's Comprehensive Incident Fall assessment dated [DATE] documents a skin tear on R1's tailbone measuring 4.2 centimeters (cm) by 3.1 cm.R1's Hospice Plan of Care Update Report dated 10/04/2025 documents that R1 had a pressure ulcer/pressure injury to the tailbone area.On 10/09/2025 at 9:52 AM, V14, Assistant Director of Nursing (ADON), stated she was not aware that R1 had a sore on her tailbone until it was found the morning of R1's fall on 09/27/2025, and that the area on R1's tailbone did not have the appearance of a skin tear.On 10/09/2025 at 12:36 PM, V5, Licensed Practical Nurse (LPN), stated the CNAs are responsible for checking on residents every two hours and repositioning them. She stated R1 preferred to be up in her geriatric chair and that she sits in it most of the day. She also stated that she did not know how one would be expected to reposition a resident who sits in a geriatric chair.On 10/09/2025 at 1:51 PM, V23, Registered Nurse (RN - Hospice), stated that during R1's initial Hospice assessment on 10/04/2025, she discovered a pressure ulcer on R1's tailbone area that was the size of an egg, 0.1 cm in depth, deeper than skin, and pale in color.R1's Wound Care visit report dated 10/07/2025 documents that R1 had a Stage 2 pressure ulcer in the middle of R1's tailbone measuring 6.5 cm by 5.5 cm by 0.1 cm in depth.On 10/09/2025 at 2:39 PM, V24, Doctor of Nursing Practice (DNP - Wound Care), stated he saw R1 on 10/07/2025 and that the area on R1's tailbone was a pressure ulcer, not a skin tear. By the appearance of the wound, it had developed three to four weeks prior and was not caused by R1's fall on 09/27/2025.

Based on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent a fall for two (R1, R4) of four residents reviewed for accidents. This failure resulted in localized swelling of clotted blood on R1's forehead and a displaced break to R4's left collarbone and localized swelling of clotted blood on R4's forehead.Findings include: The facility's Fall Prevention Program Policy dated 10/2024 documents that the purpose of this policy is to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. This policy documents that residents will be observed approximately every two hours to ensure the resident is safely positioned in the bed or chair and provided care as assigned in accordance with the plan of care.On 10/09/2025 at 5:30 AM, R1 was lying bed and noted to have a yellowish-purple discoloration to R1's entire forehead.On 10/09/2025 at 5:33 AM, R4 was lying in bed and noted to have a yellowish-purple discoloration on R4's forehead. On 10/09/2025 at 7:00 AM, R4 was sleeping in a geriatric chair in Hall 1B with a sling supporting her left arm. R1's Care Plan initiated on 5/22/2019 documents that R1 has a history of falls as evidenced by physical limitations, weakness, and cognition. R1's electronic medical record contains a nursing note dated 9/29/2025 that documents the interdisciplinary team met to review R1's recent fall and R1 sustained a fall with injury of skin tear to tailbone and noted swelling to forehead. R4's Care Plan initiated on 12/13/2024 documents that R4 is at risk for falls related to Parkinson's. R4's incident investigation report documents that R4 was observed on the floor on 9/27/25 at 4:30 AM with redness to left shoulder, a cut to forehead and complaints of head pain.On 10/08/2025 at 1:28 PM, V4 Licensed Practical Nurse (LPN) stated V11 Certified Nurse Assistant (CNA) was the CNA assigned to Hall 1B the night of R1 and R4 had unwitnessed falls. V4 LPN stated that twice between 10:00 PM and 4:30 AM she found V11 CNA asleep in a chair. V4 LPN stated she found V11 CNA also lying on the couch in the nook with the lights off, and several other times throughout that night V4 LPN stated she could not locate V11 CNA anywhere on Hall 1B. V4 LPN stated she found R4 at 4:30 AM on 9/27/25 lying on the floor in a puddle of urine next to R4's bed with a cut and dried blood on her forehead. V4 LPN stated V11 CNA was nowhere to be found. V4 LPN stated she never saw V11 CNA doing rounds on Hall 1B on the night R1 and R4 had unwitnessed falls.On 10/08/2025 at 1:21 PM, V11 CNA stated she is no longer an employee at the (Facility Name). V11 CNA stated she gave the facility a statement regarding the incident with R1 and R4. V11 CNA declined to answer any further questions.On 10/08/2025 at 12:39 PM, V9 CNA stated V10 CNA called V9 CNA into the room because V10 CNA had found R1 on the floor next to R1's bed. V9 CNA stated R1's incontinence underwear was saturated with urine and R1 had a lump on the right side of her forehead.On 10/08/2025 at 12:53 PM, V10 CNA stated she found R1 lying on her stomach with a large lump noted on the right side of R1's forehead. V10 CNA stated R1's incontinence underwear was fully saturated so much that there was a wet mark left on the floor. V10 CNA stated R1's bed was four feet off the ground and should have been in the low position. On 10/14/2025 at 9:40 AM, V28 Human Resources Manager stated that V11 CNA was terminated for failure to follow (Facility Name) conduct of standards policy. V28 HR stated V4 LPN was working with V11 CNA the night R1 and R4 fell, and V4 LPN reported that V11 CNA could not be located several times throughout the night, and that V4 LPN reported that V11 CNA was found with her eyes shut. V28 stated it was the expectation of the company that staff remain on the hall they are assigned to, and that V11 CNA should have remained on the Hall 1B. X-Ray results of R1's head dated 9/27/2025 documents that R1 sustained localized swelling of clotted blood to R1's left forehead.X-Ray results of R4's head and arms dated 9/27/2025 documents that R4 sustained localized swelling of clotted blood to R4's right forehead and a displaced break to R4's collarbone.

Based on interview and record review, the facility failed to ensure fall interventions were in place for one (R1) of three residents reviewed for falls on a sample list of seven. This failure resulted in R1 falling and sustaining multiple left-sided rib fractures, a collection of blood in the chest cavity, and a left sided collapsed lung. Findings include: The facility's Fall Prevention Program policy provided by V1, Administrator, does not contain a date. This documents the purpose of this policy is to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Guidelines for the Fall Prevention Program included the following components: methods to identify risk factors, methods to identify residents at risk, educate resident and resident representative to fall prevention program at time of admission, throughout residents stay, and when changes occur, assessment time frames, use and implementation of professional standards of practice, immediate change in interventions that were successful, notification of physician, family/legal representative, communication with direct care staff members, documentation requirements, adherence to manufacturer's recommendation in us of alarm and medical devices and special care equipment. The policy documents the resident's Care Plan will incorporate the following: identification of all risk/issue, addresses each fall, interventions are changed with each fall, as appropriate, and preventative measures. This policy documents the following standards: a Fall Risk Assessment will be performed by a licensed nurse at the time of admission. The assessment tool will incorporate current clinical practice guidelines, safety interventions will be implemented for each resident identified at risk, the admitting nurse and assigned CNA are responsible for initiating safety precautions at the time of admission, all assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained, and the Director of Nursing or Designee is responsible for monitoring the Fall Prevention Program, including further staff educations programs, purchase of additional equipment, or other appropriate environmental alterations.R1's profile sheet, dated 6/30/25, documents a medical diagnosis of repeated falls.R1's Fall Risk Assessment, dated 06/29/25, documents R1's assessment score was 13.0 on a scale of zero (low risk) to fourteen (high risk). R1's Care Plan, dated 7/01/25, documents R1 is at risk for falls related to weakness and partial paralysis on one side of R1's body following a stroke that affected R1's left non-dominant side.R1's MDS (Minimum Data Set) admission Assessment, dated 7/08/25, documents R1 requires partial to moderate assistance with toileting hygiene including the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement.R1's Nursing Note, dated 7/09/25, documents a Certified Nursing Assistant (CNA) found R1 on the bathroom floor while doing rounds at 8:35 PM. This note documents the nurse assessed R1 and found there to be a red mark on her left upper back (by the rib cage) and found there to be a displacement or a deformity in her rib cage. Computed Tomography (CT) scan of R1's chest, dated 7/10/25, documents R1 had multiple left-sided rib fractures, a collection of blood in the chest cavity, and a left sided collapsed lung. A follow-up X-ray of R1's chest, dated 7/10/25, documents R1's left-sided collapsed lung had worsened, was moderate in size, and had an increase in bleeding and bruising. This x-ray also documents multiple rib fractures.On 9/03/25 at 9:45 AM, V10, Licensed Practical Nurse, stated she was the nurse caring for R1 at the time of R1's fall. V10 stated R1 was a known fall risk and R1 didn't have any fall interventions in place. On 9/03/25 at 12:48 PM, V11, CNA, stated R1 was a known fall risk, and the only intervention she knew of was to put R1's bed in the low position.On 9/3/25 at 1:35 PM, V14, MDS/Care Plan Coordinator, stated she did a Baseline Care Plan for R1 on admission, and it included falls as a problem. V14 stated the only intervention that was marked on the Care Plan was for staff to ensure R1 was wearing appropriate footwear. V14 stated other fall interventions should have been on the R1's Care Plan for the prevention of falls.On 9/03/25 at 2:27 PM, V15, CNA, stated she knew R1 was a fall risk and there were no fall interventions in place that she was aware of.On 9/03/25 at 2:38 PM, V16, CNA, stated she didn't know R1 was a fall risk, but some of the CNA's would put R1's bed in the low position. V16 stated there were no other fall interventions.On 9/03/25 at 1:40 PM, V13, Assistant Director of Nursing/LPN, confirmed R1's fall risk assessment was completed on 6/29/25, and R1's score was 13, indicating she was at a high risk for falls. V13 stated fall risk assessments are completed to determine a resident's risk for falls and to develop appropriate interventions according to the resident's risk.On 9/03/25 at 2:54 PM, V12, Regional Nurse Consultant, stated they have an IT (Information Technology) issue with Care Plans, and fall interventions should have been in place.On 9/03/25 at 1:35 PM, V2, Director of Nursing, stated R1 was pleasantly confused and easily redirected. V2 stated R1 was a fall risk, and that having fall interventions in place could have changed R1's outcome. On 9/03/25 at 3:47 PM, V17, Physician (former Medical Director), stated if there had been proper fall protocols and precautions in place for R1 it might have changed R1's outcome.

Based on observation, interview, and record review, the facility failed to identify one (R4) resident's Sacral Deep Tissue Injury, failed to obtain and provide treatment orders, failed to updat careplan timely, and failed to implement pressure reducing interventions out of three residents reviewed for pressure ulcers in a sample list of eight residents. As a result of these failures, R4 had pain from her Stage 3 Sacral pressure ulcer which was acquired and worsened under the care of the facility. Findings include: R4's undated Face Sheet documents R4 admitted to the facility on [DATE]. This same face sheet documents R4 has medical diagnoses of Pressure Ulcers, Paraplegia, Urinary Tract Infection (UTI), and Osteomyelitis. R4's Electronic Medical Record (EMR) documents R4 admitted to the facility with a Stage Four Pressure Ulcer to her Right Ischium and Stage Four Pressure Ulcer to her Left Knee. R4's Minimum Data Set (MDS), dated [DATE], documents R4 as cognitively intact. This same MDS documents R4 is dependent on staff for bed mobility, toileting, dressing, and requires maximum assistance with bathing and personal hygiene. R4's Physician Order Sheet (POS), dated May 2025, documents a physician order starting 4/11/25 and ending 5/7/25 to cleanse R4's Sacrum Pressure Ulcer, apply Calcium Alginate and cover with bordered foam daily. R4's POS does not include any orders for the treatment of R4's Sacral Stage Four Pressure Ulcer prior to 4/11/25. R4's Careplan, initiated 4/11/25, does not document R4's Stage Four Sacral Pressure Ulcer. R4's Pressure Ulcer Risk Assessment, completed 4/21/25, documents R4 as being high risk for obtaining a pressure ulcer. R4's initial facility Wound Summary report, dated 4/7/25, documents R4's Sacral Stage Two Pressure Ulcer as facility acquired, with dated identified as 4/7/25 measuring 5.0 centimeters (cm) long by 3.0 cm wide by undetermined depth. R4's Initial Wound Evaluation and Management Summary dated: -4/9/25 documents R4's Sacral Pressure Ulcer as an Unstageable pressure ulcer measuring 12.0 centimeters (cm) long by 6.0 cm wide with undetermined depth. This same summary documents R4 should have her Left Lateral Stage Four pressure ulcer off-loaded with two pillows above the wound. This same summary documents a physician order starting 4/9/25 for 30 days to apply Calcium Alginate and foam daily to R4's Sacral pressure ulcer. -4/17/25 documents R4's Sacral pressure ulcer as an open Unstageable pressure ulcer due to necrosis, full thickness wound with moderate serous drainage. -4/23/25 documents R4's Sacral pressure ulcer as a Stage Four with 80% thick adherent devitalized necrotic tissue measuring 9.0 cm long by 6.0 cm wide by undetermined depth. This same summary documents R4's Stage Four Pressure Ulcer is not at goal. -4/30/25 documents R4's Sacral pressure ulcer as a Stage Four with 80% thick adherent devitalized necrotic tissue measuring 9.0 cm long by 6.0 cm wide by 1.5 cm deep. This same summary documents R4's Stage Four Pressure Ulcer is not at goal. -5/5/25 documents R4's Sacral pressure ulcer as a Stage Four with 85% muscle, fascia and subcutaneous tissue measuring 9.0 cm long by 6.0 cm wide by 1.5 cm deep. This same summary documents R4's Stage Four Pressure Ulcer is not at goal. On 5/7/25 at 11:30 AM-2:00 PM, R4 was laying on her back in her bed, with no pillows/blankets used for off loading pressure areas. On 5/8/25 at 11:40 AM, V4, Licensed Practical Nurse (LPN)/Wound Nurse, completed wound care for R4's Left Knee Stage Four Pressure Ulcer. After V4 completed R4's Left Knee dressing change, R4 declined to have her Sacral pressure ulcer dressing changed, due to R4 having pain in her Sacral area. R4 was laying on her back in her bed with no pillow/blankets for support. There were two extra pillows sitting in the chair in the corner. V4 stated R4 should have the pillows placed under her back and knee to off -load the pressure to her current pressure areas. R4 was grimacing with her dressing change to her Left Knee. R4 stated after the dressing change, she is a Paraplegic and has little feeling in her legs. R4 stated, I can feel my butt though. And it hurts a lot most of the time, especially when they (staff) change that dressing. On 5/7/25 at 11:35 AM, V6, Agency Licensed Practical Nurse (LPN), stated residents are having to wait to be turned and positioned for more than the two hours, due staff being busy. V6, LPN, stated R4 requires the staff assistance for turning and positioning. On 5/8/25 at 12:00 PM, V4, LPN/Wound Nurse, stated R4 should be propped on pillows to help alleviate pressure. V4, LPN, stated R4's Left Knee Stage Four Pressure Ulcer showed slough, Fascia, Tendon, and bone, with yellow serous drainage. V4, LPN/wound nurse, stated she did have to soak off the previous dressing because it had adhered to the wound due to the excess drainage. V4 stated R4's Stage Four Sacral Pressure Ulcer started at the facility. V4, LPN, stated she was made aware on 4/7/25, but forgot to obtain and implement the dressing orders. V4, LPN, stated V23, Wound Physician, saw R4's Sacral Stage Four Pressure Ulcer on 4/9/25, and documented it as an Unstageable pressure ulcer. V4, LPN, stated V23, Wound Physician, ordered Calcium Alginate with an absorbent pad and wrapped in gauze on 4/9/22, but those orders were not entered into the EMR until 4/11/25. V4, LPN/Wound Nurse, stated R4's Sacral wound deteriorated in that time, because no one was treating it, due to there were no updates to the careplan and no physician orders were entered. V4, LPN/Wound Nurse, stated the floor nurses were dressing R4's Right Ischium Stage Four Pressure Ulcer twice daily prior to 4/7/25, and should have known to tell V4, LPN/Wound Nurse, about R4's Sacral area. V4, LPN/Wound Nurse, stated the floor nurses failed to communicate to V4 that R4 had a new Sacral wound until 4/7/25. V4 stated the facility is unable to provide any documentation that R4's Sacral pressure ulcer was provided any kind of treatment prior to 4/11/25. The facility policy titled Pressure Ulcer Prevention, effective April 2025, documents dependent residents should be turned approximately every two hours or as needed. Position dependent residents with pillow or pads protecting bony prominences as needed. Use positioning devices or pillows, rolled blankets etc. to reduce pressure and/or friction/shearing as indicated.

Based on observation, interview, and record review, the facility failed to identify, assess, intervene, and treat pressure wounds for three (R171, R183, and R1) of four residents reviewed for pressure ulcers from a total sample list of 27 residents. These failures resulted in R171 and R1 developing facility acquited unstageable wounds underneath immobilizers. Findings include: The facility provided Skin Condition Assessment and Monitoring-Pressure and Non-Pressure Policy, dated 4/2025, documents the purpose of the policy is to establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries, and other non-pressure skin conditions and assuring interventions are implemented. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the Certified Nursing Assistant (CNA). Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. If the resident receives a shower, it will be necessary to have the resident stand or be returned to bed to visualize the buttock area and groin. Care givers are responsible for promptly notifying the charge nurse of skin breakdown. Changes in the wound requires physician notification. The resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches, and goals for care. A licensed nurse will observe the condition of a wound with dressing changes and these observations will be documented in the nurse's notes. If observations are acute, the physician, resident and resident's responsible party will be notified and notification will be documented in the medical record. 1a.) R171's Minimum Data Set, dated dated [DATE], documents R171 is cognitively intact. R171's wound assessment, dated 3/24/25, documents a facility acquired unstageable pressure ulcer on the right calf with an area of .50 centimeters (CM), first identified on 3/21/25. On 4/15/25 at 10:23AM, R171 had an immobilizer on his right leg. On 4/15/25 at 10:23AM, R171 stated he has a wound on his leg from the immobilizer. On 4/16/25 at 11:30AM, R171's wound dressing change was observed on the right posterior calf. The wound size was approximately that of a quarter requiring a daily treatment of Calcium Alginate and a foam boarder dressing. On 4/16/25 at 11:35AM, V5, Wound Nurse, stated R171 developed a stage three wound under an immobilizer while in the facility because the immobilizer was not removed, and that daily skin checks should be completed. On 4/16/25 at 3:00PM, V26, Physical Therapy Assistant, stated daily skin checks should always be done with immobilizers to prevent skin breakdown. 1b.) On 4/15/25 at 10:16AM, R171 stated he has a wound on his buttock and it has been there for a couple of weeks. On 4/16/25 at 11:45AM, R171 stood up with the assistance of V5, Wound Nurse, and displayed an open wound on his left buttock, approximately the size of a pencil eraser. On 4/16/25 at 11:47AM, V5, Wound Nurse, stated she did not know R171 had a wound on his buttock, because no one had ever told her about it. R171's medical record has no documentation of R171's buttock wound. 2.) R183's wound assessment, dated 3/24/25, documents R183 admitted to the facility with an unblanchable area of skin on his right buttock that appeared to be a deep tissue injury with an area of .75 CM. R183's wound assessment, dated 4/1/25, documents R183's right buttock deep tissue injury remains with an area of .75CM. R183's wound assessment, dated 4/7/25, documents R183's right buttock deep tissue injury remains a size of .75CM. R183's wound assessment, dated 4/14/25, documents R183's right buttock deep tissue injury remains a size of .75CM. R183's April treatment administration record documents the use of zinc paste for incontinence. On 4/16/25 at 9:30AM, observed a wound the size of a half dollar, with slough covering the wound. On 4/16/25 at 9:09AM, V4, Certified Nursing Assistant (CNA), stated R183 has an open area on his bottom that has been there for at least a week. On 4/16/25 at 9:35AM, V5, Wound Nurse, applied Zinc paste over the wound mashing the paste into the slough and over the open wound bed. On 4/16/25 at 9:40AM, V5, Wound Nurse, stated she had not notified the physician of R183's wound change, nor had she asked for a treatment order for the wound. R183's physician orders, dated 4/18/25, document the first treatment orders for a wound. 50430 3.) R1's hospital discharge records, dated 1/8/25, documents R1 was readmitted to the facility with a right leg immobilizer following inpatient surgery to repair a right distal femur fracture following a mechanical fall at the facility. R1's Physician Orders, dated 1/30/25, documents to perform skin checks under leg immobilizer every shift. R1's Braden Score Assessment, dated 2/6/25, documents R1 is high risk for developing pressure ulcers. R1's current Minimum Data Set (MDS), dated [DATE], documents R1 is dependent on staff for activities of Daily Living. The same assessment documents R1 is severely cognitively impaired. R1's Wound Assessment, dated 2/20/25, documents a facility acquired pressure ulcer on R1's right lower extremity measuring 4 centimeters cm x 1 centimeter cm, and depth is unknown. The same assessment further documented moderate amounts of serosanguinous drainage and redness to wound edge. R1's Wound Assessment, dated 4/14/25, documents a facility acquired pressure ulcer on R1's right lower extremity measuring 2 cm x .7 cm x .3 cm (depth) with moderate serous drainage. This wound is documented as unstageable. R1's February 2025 Treatment Administration Record (TAR), does not contain documentation of skin checks on 2/4/25, 2/8/25, 2/9/25, 2/10/25, and 2/14. The facility census documents R1 was in the building on these dates. On 4/16/25 at 1:00 PM, V5, Wound Nurse, stated the facility nurses could have not noticed R1's pressure ulcer developing because it was on back of leg under the immobilizer. V5 further stated she did not review R1's treatment record to see if staff were signing off on skin checks, and was not aware there were days skin checks were not completed.

Based on observation, interview, and record review, the facility failed to ensure pain medication was effective, available, and provided when pain was present for one (R179) of two residents reviewed for pain on the sample size of 27. These failures resulted in R179 going without pain medication, canceling his doctors appointment due to pain, and reporting pain of 8 out of 8. Findings include: The facility's pain management program policy, dated 4/2025, documents the facility will manage a resident's pain by developing an optimal pain management plan. This policy also documents the facility will use pharmacological and nonpharmacological interventions which will be included in the resident's care plan. R179's Care Plan, dated 4/11/2025, documents R179 is at risk for pain. This care plan includes interventions to administer pain medications and evaluate the effectiveness of pain interventions. On 4/15/25 at 8:59 AM, R179 was lying in bed in a slouched upright position, with the head of the bed slightly elevated. R179 stated, I have to stay in this position or else I am in pain. R179 then attempted to move in bed to reach the breakfast tray, and began to scrunch eyebrows together and grimace. R179's physician order, dated 4/11/25, documents an order for one to two 37.5-325 milligram tablets of Tramadol-Acetaminophen every 8 hours as needed for moderate pain. On 4/16/25 at 8:57 AM, R179 was lying flat on his back in his bed. R179 stated, I hurt all over, but especially in my back. I'd say its 100% hurting. R179's Controlled Substance Proof of Use sheet, dated 4/12/25, documents one tablet of Tramadol-Acetaminophen 37.5-325 milligrams was given on 4/15/25 at 7:00 AM. This sheet documents this tablet as the last dose of this medication. On 4/16/25 at 10:30 AM, V7, Licensed Practical Nurse, stated she just met R179 this morning. V7 stated she was informed by the night shift nurse that R179 came to the facility with an order for Tramadol for pain relief, but he ran out and agency nurses did not request a refill or new orders. V7 stated R179 canceled his appointment with his doctor this morning because he was in so much pain. V7 stated she gave R179 Tylenol this morning, but he is going to need something stronger. V7 stated she is going to reach out to R179's primary doctor today to see if he can give an order for pain relief. V7 stated R179 said he would just lay in a certain position to stay comfortable. On 4/16/25 at 11:15 AM, V16 (R179's granddaughter) stated R179 called her, and V17 (R179's daughter) at 2:00 am and 3:00 am this morning because he was in pain and he couldn't reach his call light. V16 stated they ran out of his pain medication, which had helped with his pain. On 4/16/25 at 2:40 PM, V2, Director of Nursing, confirmed R179 was out of Tramadol/Acetaminophen, and stated the pharmacy dispersed six tablets on 4/11/25. V2 stated R179 rated his pain as an eight out of eight today. V2 stated a prescription should be refilled when there are four doses left. V2 stated the facility did not attempt to refill it until yesterday (4/15/25).

Based on interview and record review, the facility failed to ensure two staff members completed a mechanical lift transfer for one of three (R1) residents reviewed for accidents in a sample list of three residents. This failure resulted in R1 injuring R1's leg during a transfer and suffering a femur fracture requiring hospitalization and retrograde nailing. Findings include: The Facility's Mechanical Lift Policy, dated 5/26/2009, documents when using a mechanical lift for transfers two staff members need to be present. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is severely cognitively impaired. R1's care plan, dated 11/27/24, documents R1 transfers with a mechanical lift and assistance of two people. R1's Nurse Progress Note, dated 1/6/25 at 2:30 AM, documents R1 began yelling to get up around 12:15 AM, V6, Certified Nursing Assistant, assisted R1 out of the bed with a mechanical lift and transferred R1 to her wheelchair. The Note documents R1 was brought out to the nurses' station around 1:00 AM and R1 began yelling and screaming that her leg hurt. V7, Licensed Practical Nurse, documented R1 was unable to move her right lower extremity independently and it appeared displaced. The Note documents when given medications around 7:00 PM, R1 was in normal mood without pain. There was no trauma or injury to affected area, no recent fall, and no popping sounds within the shift. V7 further documented 911 was called around 1:30 AM, and R1 was sent to the emergency room . R1's x-ray report, dated 1/6/25, documents oblique displaced fracture of the distal right femur. The Hospital Discharge Summary, dated 1/8/25, documents R1 underwent a retrograde nailing on 1/6/25 to repair R1's fractured femur. On 2/26/25 at 10:35 AM, V6, Certified Nursing Assistant, stated on 1/6/25, R1 was yelling out that she needed to go to the bathroom. Using the mechanical lift (sit to stand lift), V6 assisted R1 up out of the bed and transferred her to her wheelchair. V6 stated R1 was complaining of pain once she got in the wheelchair. V6 stated she took R1 to the nurse's station where the nurse assessed R1 and sent her to the emergency room because her right leg did not look right. On 2/26/25 at 12:50 PM, V7, licensed Practical Nurse, stated she came into work at 6:00 PM on 1/6/25. V7 stated she gave R1 her evening medications between 7:00-8:00 PM. R1 was sitting up in her chair and went to bed like normal. V7 stated R1 woke up around 1:00 AM, yelling to get out of bed, V6, Certified Nursing Assistant, went to R1's room and assisted R1 out of bed using the mechanical lift, and brought her out to the nurse's station in R1's wheelchair. R1 was screaming and yelling that her leg was hurting. V7 stated she assessed R1, and her right leg looked like it was dangling, and V7 could tell with R1 sitting in the chair that her leg looked displaced. V7 stated, I can't say that (R1) was transferred incorrectly because I was not in the room during the transfer. We placed (R1) in her bed to get her ready before the ambulance arrived, and (R1's) leg was clearly displaced and paramedics gave (R1) pain medications prior to leaving for the emergency room . R1's Incident Report, dated 1/10/25, documents R1 had not had any recent falls or injuries in the facility. On 2/26/25 at 11:45 AM, V8, Family Member, stated he never received answers as to what happened to R1 on 1/6/25 from the facility. V8 stated his concern was R1 went to bed fine, and then at 1:00 AM, R1 was screaming and in pain stating her leg hurt. V8 stated he spoke with V9, Orthopedic surgeon, at the hospital, and he stated R1 had a spiral fracture of her right femur and felt like it may have been caused during R1's transfer at the facility. On 2/26/25 at 1:25 PM, V9, Orthopedic Surgeon, stated he may have told R1's son the facility transferred R1 incorrectly, but he doesn't like to put information or opinions out there that can be used against a facility.

Based on interview and record review, the facility failed to implement pressure relieving interventions, assess, monitor, and treat a pressure sore, notify the physician of a reopened pressure sore/worsening pressure sore, and notify the physician of a facility acquired deep tissue injury for two of seven residents (R1, R4) reviewed for pressure sores in the sample list of seven residents. These failures resulted in R1's left elbow pressure sore progressing to an infected stage 4 pressure sore requiring hospitalization , surgery, a wound vacuum, and intravenous antibiotic theray and R4's right heel deep tissue injury deteriorating to an open unstageable pressure sore. The Immediate Jeopardy began on 8/13/24, when R1 obtained an open wound to her left elbow that was not reported to V14 (R1's) Physician/Medical Director. R1's left elbow wound progressed to an infected stage 4 pressure sore requiring hospitalization , intravenous antibiotics, surgical removal of R1's left elbow hardware and wound vacuum post surgery. The Administrator was notified of the Immediate Jeopardy on 9/6/24 at 3:03 PM. The surveyor confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on 9/10/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training through ongoing Quality Assurance Performance Improvement (QAPI) review. Findings include: 1.R1's undated Face Sheet documents R1's medical diagnoses as Alzheimer's Disease, Parkinson's Disease, Dementia, Tremors, Presence of Left Artificial Shoulder Joint, Iron Deficiency Anemia, Vitamin D Deficiency, Osteoporosis, and history of Urinary Tract Infections. R1's Minimum Data Set (MDS), dated [DATE], documents R1 as severely cognitively impaired. This same MDS documents R1 as requiring maximum assistance with eating and dependent on staff for toileting, bathing, dressing, personal hygiene, bed mobility and transfers. R1's Care plan intervention, dated 4/27/22, documents R1 transfers with one person assist, roller walker, and gait belt. This same careplan documents a focus area of R1's left elbow pressure sore, dated 8/15/24. R1's Careplan did not include goal and interventions for R1's left elbow pressure sore until 8/21/24. R1's Pressure Ulcer Risk Assessment, dated 8/1/24, documents R1 as moderate risk for skin breakdown. R1's Physician Order Sheet (POS), dated August 2024, documents physician orders: -starting 4/26/24 and ending on 8/8/24 to monitor left elbow for redness, swelling, pain and warmth every shift. -starting 4/27/24 and ending 8/29/24 to ensure left elbow protection is in place at all times every shift. -starting 7/3/24 and ending 8/8/24 to apply border gauze daily to left elbow. R1's Skin Evaluation, dated 8/13/24, documents an open wound on R1's left elbow. This same evaluation documents V14, Physician, nor V5, R1's Power of Attorney (POA), were notified. R1's Electronic Medical Record (EMR) does not document an assessment of R1's new left elbow wound noted on 8/13/24. R1's Skin Evaluation, dated 8/15/24, documents R1 has a new facility acquired unstageable pressure ulcer on her left elbow that shows slough and eschar measuring 1.6 centimeter (cm) long by 1.3 cm deep with no measurable depth. This same evaluation does not document R1's Physician (V14) nor Power of Attorney (POA) (V5) being notified of R1's new pressure ulcer. The facility provided documentation, dated 8/16/24, documents V14, Medical Director, was faxed notification of R1's left elbow pressure sore. R1's Nurse Progress Notes dated: -8/13/24-8/19/24 there were no nurse progress notes addressing R1's left elbow pressure sore during this time period. -8/20/24 at 3:07 PM, documents, On 8/16/24 a facsimile was sent to (V14, Physician) to inform of (R1's) left elbow wound. (V14) responded asking if wound physician was following (R1). Response sent to inform (V14) that wound physician no longer follows (R1) due to left elbow wound healing in the past. Awaiting response. -8/21/24 at 7:26 PM, documents, (V23, Wound Physician) to follow up on Monday (9/2/24). (R1's) Left Elbow wound is open and pin in elbow is exposed. Wet to dry applied, management notified of worsening of wound. -8/24/24 at 12:05 PM, documents, Noted that (R1's) left elbow wound is worsening. Wound is red and warm to the touch. Wound is open and has exposed bone and internal hardware present and visible. (R1) sent to the emergency room . R1's Hospital Record, dated 8/24/24, documents R1 was admitted to the hospital with Cellulitis of the Left Elbow and Altered Mental Status secondary to Left Elbow prosthetic joint infection. This same record documents R1 underwent Left Prosthetic hardware removal and Incision and Drainage (I and D) of Left Elbow followed by a Wound Vacuum placement on R1's left elbow on 8/27/24. This same record documents, Discussed wet to dry dressings and applying support to avoid putting any pressure on the wound as this occurred from chronic pressure on the left elbow most likely. R1's Final Report to the State Agency, dated 8/29/24, documents, (R1) had an area to her left elbow that is a result of an Olecranon fracture with surgical repair with hardware placement prior to her admission to the facility on [DATE]. From the time of admission, (R1) had a chronic area to her left elbow that will frequently open and resolve. The area to the left elbow most recently resolved as of 7/29/24. This same report documents V21, Registered Nurse (RN), visualized (R1's) Left elbow and it appeared to be the same as usual, the area was linear and there was a small amount of dried drainage on the dressing, no changes from usual for (R1). This same report documents R1 had a left elbow wound that required monitoring and dressing changes. R1's X-Ray report, dated 8/24/24, documents, Findings: Post surgical change to the Olecranon noted with a pin and wire construct. There is separation of the hardware from the native bone posterior with protrusion through the skin surface. No significant lucency is noted at the hardware/bone interface. The fracture is healed. The radiocapitellar and ulnar trochlear joints are anatomic in alignment. On 9/4/24 at 8:00 AM, V5, R1's Power of Attorney (POA), stated, I saw (R1's) left elbow wound for the first time on 8/24/24 and it was horrible. I could see (R1's) bone. It was just awful. It had a bad odor and yellow/green drainage. I was never informed of (R1's) left elbow wound getting so bad. Now (R1) is on Intravenous (IV) antibiotics for the next four to six weeks. (R1) is in terrible shape now because of this facility. On 9/5/24 at 10:20 AM, V19, Certified Nurse Aide (CNA), stated R1 had an open wound on her left elbow that was being treated by the nursing staff. V19 stated, The long-term area where (R1) lived was using agency nurses. Those (agency) nurses did not attend to (R1's) left elbow wound like they should have. The dressing was never on. (R1) like to lean on her Left side when she sat up in her wheelchair. (R1's) left elbow would sit directly on her arm of her wheelchair when it wasn't dressed or padded with anything. That was about half of the time. I told the agency nurses about this, but they didn't do anything. On 9/5/24 at 11:00 AM, V15, Orthopedic Surgeon, stated R1 had hardware placed in R1's left elbow [AGE] years ago. V15 stated V15 took over R1's care on 8/24/24. V15 stated R1's hardware removal could have been caused by her pressure ulcer or her infection. V15 stated, It is difficult to tell if (R1's) pressure ulcer or her infection caused the removal of the hardware, but the hardware itself did not cause the infection. V15 stated the facility nursing staff should have notified the Physician (V14) on 8/13/24 when noting R1's left elbow had an open wound. V15 stated R1's infection could have addressed at that time and was not. On 9/5/24 at 11:30 AM, V1, Administrator, stated the facility staff should have obtained a treatment order and made notifications to R1's Physician and Power of Attorney (POA) on 8/13/24 when R1's open wound on her left elbow had re-opened. V1 stated an open wound would cause an infection. V1 stated the nursing staff treated R1's open wound off and on for the entire length of R1's stay. V1 stated the nursing staff did not obtain orders for treatment due to This was a common problem for (R1). The nursing staff would apply an absorbent pad when her wound would drain off and on. It was the general thought from the nurses that the order to apply elbow protectors meant to provide treatment. (R1's) open left elbow pressure ulcer should have had a separate physician order for treatment. On 9/6/24 at 9:30 AM, V14, Medical Director, stated R1 admitted to the facility with a known medical history of having a left elbow hardware placed [AGE] years prior to admission. V14 stated after reviewing R1's hospital records from her 8/24/24 admission, R1 did not have a deep infection due to her C-Reactive Protein (CRP) level not being extremely high. V14 stated R1's infection was in her left elbow pressure ulcer. V14 stated, The facility nurses should have been more aggressive in contacting me due to (R1's) wound was open and draining. I would have provided orders until the wound Physician could take over her care. Apparently, the facility sent a fax to my office after hours on a Friday (8/16/24) which was not received until 8/19/24. They (facility) should have called me to get the necessary orders. They (facility) did not give proper care for (R1). V14, Medical Director, stated the facility should have contacted him on 8/13/24 when R1's left elbow pressure ulcer was first noted as open with drainage. V14 stated, (R1's) infection in her left elbow pressure ulcer could have been prevented from getting so bad if it would have been treated earlier. The undated facility policy titled Change in Condition documents it is the policy of the facility that a licensed staff member will notify the attending physician and responsible party of change in the resident's condition. The physician/responsible party will be notified when there is a marked changed in relations to usual signs and symptoms and/or the signs and symptoms are unrelieved by measures already prescribed. The physician/responsible party notification is to include but is not limited to onset of pressure ulcers. If the physician cannot be reached the Medical Director will be contacted to report the change in condition until the attending physician can be contacted. Calls will be made to the family/responsible party until they are reached. A message may be left on an answering machine that does not give specifics but leaves a request for the community to be called. The nurse will document in the clinical record. Documentation and assessment will be ongoing until condition has stabilized. The Immediate Jeopardy that began on 8/13/24 and was removed on 9/10/24 when the facility took the following actions to remove the immediacy: 1. The facility completed skin audits of 100% of the residents on 8/24/24, 8/30/24, and an audit of the skin audits on 9/5/24. These audits were completed by V2, Interim Director of Nurses (DON), V3, Senior [NAME] President of Operations, V4, Regional Director of Operations, V17, V31, Minimum Data Set (MDS)/Registered Nurse (RN), and V6, former Assistant Director of Nurses (ADON)/wound nurse. The skin audit on 8/24/24 showed R4 had a previously unidentified facility acquired deep tissue injury (DTI) to her right heel. R4's right heel pressure sore was not reported to V14, Physician, until 9/10/24. R4's careplan intervention to apply heel protectors was initiated on 9/10/24. R4's Electronic Medical Record (EMR) was updated with a treatment order on 8/27/24. 2. V1, Administrator, and the Interdisciplinary Nursing Team inserviced licensed nursing staff starting 9/2/24 on Wound Protocols, Change of Condition, Skin Evaluations, Pressure Ulcer Risk Evaluations, Wound assessment and management and Skin Check Policy. On 9/10/24, V31, Agency Registered Nurse (RN,) was observed actively working with her assigned residents, passing medications, managing staff, and providing direct care to residents. On 9/10/24, V31, Agency RN, stated she had already completed R5's Moisture Associated Skin Damage (MASD) treatment. V31 stated she did not know what R5's skin interventions were, due to she had not received any training and was not able to find R5's careplan. On 9/10/24, V22, Clinical Documentation Specialist/Licensed Practical Nurse (LPN), showed V31, Agency RN, how to find a resident's careplan and abatement inservicing was provided to V31. 3. V1, Administrator, and the Interdisciplinary Team inserviced Certified Nurse Aides (CNA) starting on 9/2/24 and ending on 9/5/24 on Skin Checks and following the resident careplan. 4. A Quality Assurance Performance Improvement (QAPI) Ad hoc meeting was held on 9/3/24 for QAPI team to discuss concerns and plan of action. 5. On 9/3/24, V3, Senior [NAME] President of Operations, who is wound care certified, provided training to V16, current Wound Nurse/Licensed Practical Nurse (LPN). 6. Weekly assessments of all skin conditions and pressure injuries were completed, started on 8/24/24. V23, Wound Physician, completed weekly wound assessments/treatments, started on 8/19/24. 7. V22, Clinical Documentation Specialist, confirmed daily clinical meetings have occurred and will continue. V22 stated V1, Administrator, V2, Interim DON, V17, V31, Minimum Data Set/MDS RN, all attend daily meetings. V22 stated resident Treatment Administration Records (TAR), Physician Order Set (POS), Nurse Progress Notes and 24-hour reports are all reviewed. V2, Interim DON, stated she has reviewed all residents with skin alterations and V23, Wound Physician, will review all residents with any kind of skin alteration i.e., skin tear, abrasion, pressure ulcer, surgical wound, diabetic wounds, etc. on an ongoing basis. 8. V2, Interim DON, stated R4's right heel wound should have been provided a treatment, and V14, Physician, should have been notified. V2, Interim DON, stated R4 has had Interdisciplinary Team meetings twice after R4's wound was identified on 8/24/24 and prior to V14, Physician, being notified. V2, Interim DON, stated, This should have been caught and it wasn't. We (facility) are looking closely at everyone now who has a risk for skin alterations. 9. V1, Administrator, stated daily and weekly clinical meetings have been completed and will be ongoing. 10. Audits of five residents per week for pressure interventions have been completed and will be ongoing. Audits of three residents per week for any skin conditions have been completed and will be ongoing. Monthly skin audits were initiated on 8/24/24 and will be ongoing. All resident audits were completed by V2, Interim DON, V17, V31 Minimum Data Set (MDS) nurses, V16, Wound Nurse, V8, Infection Preventionist, and V22, Clinical Documentation Specialist. V4, Regional Director of Operations, stated she has been reviewing all audits and will continue to review future audits. V4 stated V4 is not aware of any new skin conditions, other than R4 that had been identified through the auditing process. 11. All new agency and/or new hire nursing staff were to be provided training. On 9/10/24, V31, Agency Registered Nurse (RN), was assigned a group of patients to provide nursing care for, and stated she had not been trained prior to starting her shift. 12. Annual and as needed training conducted by V16, Wound Nurse, and/or V2, Interim DON, will be ongoing. The facility presented an abatement plan to remove the immediacy on 9/6/24. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility three separate times on 9/10/24 for revisions. The facility presented revised abatement plans on 9/10/24 and the survey team accepted the abatement plan on 9/10/24. 2. R4's undated Face Sheet documents R4 admitted to the facility on [DATE]. This same Face Sheet documents R4's medical diagnoses of Intertrochanteric fracture of Right Femur, Falls, UTI's, COPD, Iron Deficiency Anemia, Disorders of Bone Density and Structure, and neuromuscular dysfunction of bladder. R4's Admission assessment, dated 8/13/24, does not include any pressure areas. This same assessment documents R4's skin as intact. R4's Minimum Data Set (MDS), dated [DATE], documents R4 as severely cognitively impaired. This same MDS documents R4 requires maximum assistance with bed mobility, bathing, dressing, personal hygiene and is dependent on staff assistance for toileting. R4's Pressure Ulcer Risk Evaluation, dated 8/20/24, documents R4 is a high risk for obtaining a pressure ulcer. R4's Nurse Progress Note, dated 8/24/24 at 10:46 PM, documents, (R4's) Right Heel discoloration with discomfort noted. Foam dressing applied to protect the area and heel lifted to reduce pressure, which provided relief. Power of Attorney (POA) and on-call manager were informed. Ongoing monitoring will continue and (V25, Registered Nurse/RN) dayshift nurse will follow up with the (V23) wound Physician for further evaluation and treatment. R4's Skin Evaluation, dated 8/25/24, documents R4's new facility acquired deep tissue injury (DTI) to R4's right heel. This same evaluation documents R4 had discoloration and discomfort noted and measures 1.2 centimeters (cm) long by 1.9 cm wide by immeasurable depth. R4's Physician Order Sheet (POS), dated September 2024, documents a physician order starting 8/27/24 to apply skin prep and foam every shift and as needed to R4's right heel. R4's Careplan intervention, dated 8/29/24, documents R4's facility acquired deep tissue injury (DTI). This same careplan, dated 9/11/24, instructs staff to apply heel protectors. R4's Initial Wound Evaluation and Management Report, dated 9/9/24, documents R4's Unstageable Full Thickness Right Heel Pressure Ulcer measuring 2.0 centimeters (cm) long by 3.0 cm wide by immeasurable depth due to necrosis. This same evaluation documents R4's Right Heel Unstageable Pressure Ulcer as an open ulceration. R4's Nurse Progress Note, dated 9/10/24 at 9:45 AM, documents, (V14, Physician) states to follow up with (V23, wound Physician/(V16), wound nurse) to evaluate and treat coccyx in addition to the (right) heel. On 9/10/24 at 11:30 AM, R4 was sitting in wheelchair in her room. R4 was wearing non-skid socks with her feet directly on foot pedals. On 9/12/24 at 12:15 PM, R4 sitting up in her wheelchair with her feet on the foot pedals by her bed in her room. R4's heel protectors were laying on the opposite side of R4's bed on the floor. On 9/12/24 at 12:20 PM, V10, Certified Nurse Aide (CNA), stated R4 should have her heel protectors on at all times. V10, CNA, confirmed R4 did not have her heels floated, and was not wearing her heel protectors. V10, CNA, stated, They (facility) just got those heel protectors for (R4) two days ago. (R4) didn't have them before. On 9/10/24 at 12:00 PM, V4, Regional Director of Operations, stated the facility identified R4's right heel deep tissue injury (DTI) on 8/24/24, during a whole house skin sweep. V4 stated R4's facility nurse should have notified the Physician on 8/24/24 when the new facility acquired right heel pressure sore was identified. V4 stated, There should have been a skin assessment completed, order obtained, and the Physician should have been notified. We (facility) are working through training our nursing staff on all of these things. There was a delay in treatment for (R4) for three days. That should have never happened. V4 stated the delay in treatment for R4's right heel may have contributed to its deterioration. On 9/11/24 at 2:00 PM, V25, Registered Nurse (RN), stated V25 was the dayshift nurse for R4 on 8/25/25. V25 RN stated, I am so sorry. I was endorsed that information and must have forgotten to notify (V14, Physician). I should have called (V14, Physician) to obtain orders for the treatment of (R4's) right heel pressure ulcer. On 9/11/24 at 2:45 PM, V14, Physician, stated the facility should have notified the on-call system about R4's new facility acquired right heel pressure sore on 8/24/24. V14 stated, This is the second time in the recent past that this has happened. The nurses need to notify the Physician so that an order can be obtained. (R4's) right heel is now open which could have been prevented. If they (facility) are unable to contact the Physician on call system, then they need to reach out to me as the Medical Director. V14, Physician, stated V14 was notified of R4's right heel pressure sore on 9/10/24, per the nurse progress note documented in R4's Electronic Medical Record (EMR). The facility policy titled Wound Assessment, revised 7/1/2019, documents new wounds and/or other skin impairments/abnormalities will be assessed and documented using the skin and wound program in the electronic medical record upon being observed. The designated wound nurse will ensure that all wounds have a weekly assessment completed and monitor all wounds for improvement, deterioration or healing.

Based on interview and record review, the facility failed to notify the physician of a significant change in condition and failed to provide supervision following a significant change in condition for one resident (R1) of five residents reviewed for falls and condition change in a sample list of five residents. These failures resulted in R1 falling face first out of bed and sustaining a hematoma to the forehead. Findings Include: R1's Care Plan, revised 2/29/24, includes the following diagnoses: Hemiplegia/Hemiparesis following Cerebral Vascular Accident Nondominant Side, Hypertension, Status Post Coronary Artery Bypass and Graft, Tricuspid Valve Replacement, Hypertrophic Cardiomyopathy. Chronic Obstructive Pulmonary Disease, Aortic Stenosis, Implanted Pacemaker, and Chronic Anticoagulation. R1's MDS (Minimum Data Set), dated 2/25/24, documents R1 is moderately cognitively impaired. R1's Functional Assessment, dated 2/14/24, documents R1 requires partial to moderate assistance to rise from sit to stand. R1's sit to stand assessment is scored at three which the document defines as Helper does less than half the effort. R1's progress note, dated 03/06/2024 at 1:57PM, documents, (R1) returned from hair appointment and lunch with (family member). R1's progress note, dated 03/06/2024 at 2:40PM, documents, (R1) is vomiting large amount of undigested food. Pizza with olives and tomatoes. Zofran given. No vital signs are documented at this time. R1's progress note, dated 03/06/2024 at 5:01PM, documents, vital signs taken. Temperature 97.9. Pulse 76, Respiration 20, Blood Pressure 152/82, Oxygen 94% 4/Liters by Nasal Cannula. Bowel Sounds very active all four quadrants. R1's progress note, dated 03/06/2024 at 5:06PM, documents, (V7) Doctor notified of the vomiting. Ordered clear liquids for 24 hours. Will be out to see (R1) tomorrow around 1:00PM. R1's progress note, dated 03/06/2024 at 5:39PM, documents, CNA found (R1) with head on floor on the right side of bed, legs and lower trunk on bed. Bed was in low position. Assessment indicated that (R1) needs to be evaluated in ER.(emergency room ) Daughter notified of fall and that (R1) was being transferred to ER for further evaluation. R1's Blood Pressure flow sheet documents on 3/6/24 at 5:19PM, R1's blood pressure was 120/64, and at 5:30PM R1's blood pressure was 180/107. The facility's Incident Log, dated 3/6/24 at 5:30PM, documents, upon further assessment (R1) was noted with a hematoma on her left temple, measuring a total circumference of 7.6 Centimeters, a length at 3.3 Centimeters, and a width at 3.3 Centimeters. Additionally, upon checking (R1's) neurological signs (V4, Registered Nurse RN) observed (R1's) left pupil to be enlarged and (R1's) the right pupil to be at pinpoint. R1's emergency room report, dated 3/6/24 at 7:04PM, documents ,intracranial hemorrhage resulting in loss of consciousness. On 3/18/24 at 2:06PM, V4, (RN, Registered Nurse) stated, (R1) was out with her (Family member) on 3/6/24 until shortly before 2:00PM. (R1) had her hair done and went out for pizza. At 2:40PM (R1) vomited. It looked like pizza. I gave (R1) Zofran. (R1) usually can use the call light and is able to stand with gait belt and one CNA. They use her walker or wheelchair if (R1) is tired. That day (R1) was weak and it took (V5,CNA, Certified Nurse's Aide), (V6,CNA,Certified Nurse's Aide) and I to get (R1) to bed. (R1) wasn't really picking up (R1's) arms and wasn't talking. I think (R1's) blood Pressure and Pulse were elevated, but (R1) had been vomiting. I then finished my Medication pass and checked on other residents. The CNAs told me later (R1) had vomited again at around 4:15PM. I called the doctor (V7) a little after 5:00PM and (V7) said to put (R1) on clear liquids and (V7) would see (R1) tomorrow around 1:00PM. The next I knew (5:39PM per Progress Note) I was called to (R1's) room by CNAs. (R1) was lying on the floor face down with (R1's) legs and hips on the bed which was in the lowest position. (R1) had a bed alarm, but because (R1) was partially in the bed. The alarm did not sound. (R1) had a large hematoma on (R1's) face near the left eye. (R1) had one constricted pupil and one dilated pupil and wasn't responding. We then called EMS (Emergency medical Services) and sent (R1) out to the hospital. On 3/18/24 at 2:47PM, V5, CNA, stated, Around 5:30PM (3/6/24) I was helping a resident across from (R1's) room and I heard (R1) yell out 'help help'. I called the nurse and the other CNA and went in to see what was going on. I found (R1) with (R1's) face and shoulders on the floor and (R1's) feet and legs still in the bed. (V4) the nurse and (V6) the other CNA came in soon. We got (R1) back up in the bed. (R1) really wasn't answering then and was not able to move at all. I didn't notice the big swollen area around (R1's) eye until (V4) pointed it out. (V4) then called the ambulance and (R1) went out. Before that I helped (V6) get (R1) cleaned up after (R1) vomited. It took three of us to put (R1) to bed. It usually only took one of us with a gait belt or walker to transfer (R1). (R1) was weak and couldn't even lift up (R1's) arms. That was a big change. On 3/18/24 at 2:52PM, V6, CNA, stated, The evening (R1) went to the hospital (R1) started vomiting at somewhere around 2:30PM. I called (V4) the nurse. (R1) wasn't herself. I was assigned to (R1). I can usually transfer (R1) with a gait belt and a walker or wheelchair by myself, but (R1) seemed like (R1) couldn't lift up her arms. The nurse gave (R1) some nausea medicine, but (R1) continued to vomit. I am sure (R1) vomited at least four times. Then around 5:30PM (V5) CNA called out and (R1) was on the floor with her face down but her legs were still in bed. (R1) had a big goose egg on her forehead. The nurse came and sent (R1) to the hospital by ambulance. On 3/18/24 at 2:00PM, V2, Director of Nursing, stated, I was in the building when (R1) fell and went out to the hospital (3/6/24). I went to the room after (R1) fell . (R1) had a large edematous hematoma above the left eye, but (R1) also had petechia across her cheeks. I wonder if she may have vomited again and leaned out to vomit and went to the floor. On 3/19/24 at 4:25PM, V7, R1's Primary Care Physician, stated, (R1) did have an intracranial bleed into the fourth ventricle of the brain. I think it could have been a spontaneous bleed given the fact (R1) was chronically anticoagulated following a heart valve replacement and had been vomiting. However, there might be a slight possibility the bleed resulted from the fall. All I was told when the nurse originally called me was (R1) was vomiting. With that information, I told the nurse to put (R1) on clear liquids and I would come to see (R1) the following day. Had I been told (R1) wasn't lifting her arms and had gone from a one person transfer that morning to a three person transfer and wasn't talking, I certainly would have had (R1) transported to the hospital at that time. I think from 1:40PM until 5:39PM is an unacceptable delay in treatment. I really don't think the delay probably affected the outcome given (R1's) overall condition, but (R1) should have been seen earlier. I do believe that the fall and the hematoma were caused by (R1's) sudden decline in condition. The facility's policy Change in Condition, revised 12/7/11, states, It is the policy of (the facility) that a licensed staff member will notify the attending physician and responsible party of change in the residents condition. 1. The physician/responsible party will be notified when: a. the change is sudden in onset, or b. Represents a marked change in relation to usual signs and symptoms, or c. The signs and symptoms are unrelieved by measures already prescribed.

Based on observation, interview, and record review, the facility failed to develop a plan of care for a catheter and monitor urine output after catheter removal for two (R2, R8) of three residents reviewed for catheters on the sample list of eight. This failure resulted in R2 requiring emergency medical treatment where R2 was found to have Urinary Retention, Bacteremia, Acute Kidney Injury, and Sepsis. Findings include: 1. R2's Progress notes, dated 1/17/24 at 4:25 PM, documents R2 was admitted to the facility from the hospital with an indwelling catheter. R2's Hospital Discharge Summary. dated 1/17/24, documents R2 was experiencing urinary retention. and an indwelling catheter was placed on 1/12/24 and R2's renal function improved. This Summary documents an order for routine indwelling catheter care. R2's Progress note written by V13, Registered Nurse, dated 1/24/2024 at 7:04 AM, documents, CNA (V6, Certified Nurse's Assistant) was getting (R2) up for the day to dress and bathe (R2) when she noticed that (R2's) (indwelling) catheter was not inserted in the penis. The tip of catheter was just free floating in (R2's) pajama pants. (R2) was dry. (V6) toileted (R2) and (R2) voided independently. Writer notified (V12, Physician) of (R2's) (catheter) being out and am currently awaiting new orders at this time. On 2/14/24 at 1:41 PM, V13 stated R2's indwelling catheter came out on 1/24/24. V13 stated she notified V12, R2's physician. V13 stated V12 stated the catheter could be left out and to monitor his voiding. V13 stated she did not put in an order, and did not ask how to specifically how his voiding should be monitored. R2's plan of care, dated 1/17/24, included a care plan for a catheter. R2's catheter care plan was discontinued after R2's catheter came out on 1/24/24. R2's plan of care did not contain interventions for R2's diagnosis of urinary retention or interventions to monitor R2's urinary output. R2's nurse's notes, dated 1/25/24, does not document that R2's voiding was monitored. R2's nurse's notes, dated 1/26/24, documents R2 is able to urinate freely. This note does not document the amount of the urine that R2 urinated. R2's Bladder Continence documentation, dated 1/26/24, documents R2 voided dark urine with a strong odor at 5:54 PM. R2's Nursing Progress note written by V8, Registered Nurse, dated 1/26/24 at 5:41 PM, documents, (R2) displaying unusual behavior, less alert, less responsive, sweaty, (blood pressure) low 82/46, and increased weakness. 911 contacted and (R2) currently being transported to (hospital) for evaluation. On 2/14/24 at 1:47 PM, V8, Registered Nurse, stated on 1/25/24 and 1/26/24, she was R2's Nurse. V8 stated R2 was more weak than the day before and was sliding in his recliner. V8 stated she does not know how much R2 voided. V8 stated one of his Certified Nurse's Assistants stated he was urinating. R2's hospital records, dated 1/26/24, documents R2 presented to the emergency room with increased confusion. This record documents R2 has a history of urinary retention requiring the use of an indwelling catheter. This records documents R2's indwelling catheter came out at the facility and was not replaced. This records documents R2 was experiencing a mental status change, chest pain, palpitations, nausea, vomiting, fever, sweating, and chills. This record documents R2's bladder was scanned and showed urinary retention. This record documents a catheter was placed, and one liter of urine containing pus was released. This record documents R2 was diagnosed with Septic Shock, Acute Kidney Injury, and Bacteremia. On 2/14/24 at 1:01 PM, V12 (R2's Physician) stated the facility called to say R2's catheter was out. V12 stated he told the facility to monitor R2's urine output. V12 stated, They have a bladder scanner in the facility and should have used it to see if (R2) was retaining urine. (R2's) retention of urine could contribute to (R2's) Urinary Tract Infection, Acute Kidney Injury, and Sepsis. 2. On 2/13/24 at 1:40 PM, R8 was lying in bed. R8 had an indwelling urinary catheter. R8's Admission Assessment, dated 12/28/23, documents R8 was admitted to facility on 12/28/2023 with an indwelling Urinary Catheter, diagnosis of Neuromuscular Dysfunction of Bladder and Urinary Tract Infection. R8's plan of care did not contain a plan of care for R8's indwelling catheter.

Based on observation, interview, and record review the facility failed to provide range of motion restorative services for one (R28) of one resident reviewed for limited range of motion in the sample list of 36. This failure resulted in R28 developing bilateral hip and knee contractures. Findings include: The facility's Restorative Nursing Programs Policy dated 8/20/21 documents: The community will provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. All residents will receive restorative services as needed, by certified nursing assistants, restorative aides, restorative nurse or other qualified associates. Residents may receive restorative nursing services: 4.7.1 upon admission when not a candidate for specialized rehabilitation services. 4.7.2 when assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . 4.7.4 upon discharge from therapy. A resident's restorative nursing plan will be addressed on the care plan to include: 4.10.1 The problem, need, or strength the restorative tasks are to address. 4.10.2 The type of activities to be performed. 4.10.2 Frequency of activities. 4.10.4 Duration of activities. 4.10.5 Measurable goal and target date. The Restorative Nurse or skilled therapist will communicate to the restorative aide(s) and/or the appropriate C.N.A.'s (Certified Nursing Assistants), the resident's restorative nursing plan, providing any necessary training to carry out the plan. Restorative aides and/or C.N.A.'s will implement the plan and provide required documentation. R28's undated Census documents R28 admitted to the facility on [DATE]. R28's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R28's Minimum Data Set (MDS) dated [DATE] documents R28 has moderate cognitive impairment, requires extensive assistance of two staff for bed mobility and transfers, and has no limitations in range of motion to bilateral lower extremities (BLE). R28's MDS dated [DATE] documents R28 has severe cognitive impairment, and has impaired range of motion to BLE. R28's PT (Physical Therapy) Therapist Progress & Discharge Summary dated 6/23/21 documents R28 demonstrates muscle strength of 4/5 of BLE (good with full range of motion against gravity and moderate resistance.) R28's Restorative Nursing Transfer Form dated 6/23/21 documents therapy recommended for R28 to have range of motion and active range of motion. There is no documentation that a restorative program for range of motion to BLE was implemented after 6/23/21. R28's PT Plan of Care dated 10/14/21 documents: R28 presented with increased hip and knee flexion and abduction as a result of increased BLE muscle tone for 3 to 4 weeks. R28 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Therapy is required to improve BLE range of motion to decrease chances of contracture, loss of skin integrity, and improve R28's comfort while sitting in a wheelchair. R28 has spastic muscle tone to Right and Left lower extremeties, and is able to complete 25 % of normal range of motion to BLE. R28's PT Therapist Progress & Discharge Summary dated 11/3/21 documents: R28 demonstrated minimal improvement in left hip and knee flexion contractures due to increased tone and significant pain with movement despite receiving pain medication prior to therapy sessions. Discharge instructions included transition to a restorative nursing program. R28's Restorative Nursing Transfer Form dated 11/3/21 documents to perform BLE range of motion exercises to avoid progression of bilateral lower extremity deformity, within R28's level of tolerance. This note documents precautions of decreased skin integrity and increased tone to BLE. There is no documentation in R28's medical record that a restorative program for range of motion to BLE was implemented after 11/3/21. R28's Hospital Discharge Summary dated 9/2/21 documents R28 admitted to the hospital on 8/28/21 with lower leg spasms and discharged from the hospital on 9/2/21. R28's emergency room Provider Note dated 8/28/21 at 11:10 AM documents R28 is positive for leg contortion secondary to involuntary muscle use. This note documents R28 stated R28 is unable to straighten R28's legs, and V12 (R28's Spouse) noted R28 was unable to ambulate due to R28's legs being acutely contorted, similar to a muscle spasm. R28's Physical Therapy Evaluation note dated 9/1/21 documents R28 has severe internal rotation of the right hip, moderate internal rotation of left hip, and very weak lower extremities. This note documents transfers were not attempted due to R28's lower extremity posturing. On 3/07/22 at 3:13 PM R28 was sitting in a wheelchair and R28's hips and knees were bent and contracted. On 3/08/22 at 10:38 AM R28 was Lying on R28's right side in bed. R28's legs were bent and contracted. On 3/08/22 at 1:15 PM R28 was lying in bed. V13 and V14 CNAs provided catheter care for R28. V13 stated R28 is very contracted and instructed R28 to open R28's legs. R28's legs were bent and contracted, and R28's thighs and knees were pressed together. R28 was not able to open/move R28's legs. On 3/06/22 at 11:36 AM V12 (R28's Spouse) stated R28's left leg stays in a bent position. V12 stated V12 does exercises for R28's legs since the facility does not. On 3/09/22 at 12:45 PM V9 Physical Therapist stated: R28's ankles were contracted upon admission, and R28 has Lupus which contributes to R28's contractures. Therapy orders were received in October for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Prior to that R28 received PT and Occupational Therapy in June 2021, and R28 had increased muscle tone and [CONDITION(S)] to the lower legs. A restorative nursing form is completed upon discharge from therapy services and given to nursing for implementation. On 3/09/22 at 1:15 PM V9 stated R28 received therapy services from 4/8/21 until 6/23/21. R28 had no impairment to range of motion to bilateral knees and hips at that time. R28 would have benefited from a restorative program, and therapy recommended a restorative program for active range of motion to bilateral lower extremities at that time. On 10/14/21 therapy resumed due to R28 having hip and knee flexion. R28 was discharged from therapy in November with a recommendation for passive range of motion to bilateral lower legs. At that point R28 had impaired range of motion to R28's legs, and had pain with movement. On 3/10/22 at 2:40 PM V1 (adminstrator) stated V1 was unable to provide documentation that R28 received range of motion for BLE as recommended by therapy.

Based on interview and record review, the facility failed to safely perform a resident transfer per resident's plan of care and company policy for one of three residents (R1) reviewed for falls in the sample of three. This failure resulted in R1 falling abruptly at an angled position on to the seat of R1's wheelchair causing R1 to strike R1's left rib cage on R1's left arm rest of R1's wheelchair resulting in left lateral rib fractures of R1's 6th and 7th ribs. Findings include: R1's Care Plans dated 7/20/21 document R1 requires assist of one staff member, a wheeled walker and a gait belt for transfers due to activities of daily living self care performance deficits related to physical limitations, weakness and pain. R1's Fall Occurrence Report dated 7/22/21 at 4:30am documents R1 fell in to R1's wheelchair during a transfer in R1's room. This report documents V5, Certified Nursing Assistant (CNA) notified V3, Licensed Practical Nurse (LPN) R1 sat down hard in R1's wheelchair and R1 stated R1 had a little tenderness and some redness at the brassiere line at the time of the incident. This report documents on 7/23/21 an x-ray performed revealed R1 had left lateral 6th and 7th rib fractures and bones and soft tissues are otherwise negative. This report documents R1 was falling but caught but does not document the use of a gait belt or wheeled walker at the time of the fall. There is no documentation of the root cause of the fall. There is no documentation of what interventions were placed to prevent further falls for R1. R1's Incident/Accident Report or Unusual Occurrence to the State Survey Agency documents R1's Diagnoses including [CONDITION(S)], Urinary Tract Infection, Peripheral [CONDITION(S)], Peripheral Vascular Disease and [CONDITION(S)]. This report documents R1 transfers with one assist and on 7/22/21 at unknown time, R1 sat down hard in (R1's) wheelchair. R1 indicated a little tender and some redness along R1's brassiere line at the time of the incident. This report documents on 7/23/21, R1 had an X-ray performed showing R1 had Acute rib fractures of the left lateral 6th and 7th rib. This report documents late in the day family reported R1 was complaining of left rib pain but R1 had not complained to staff. This report documents R1 is cognitively intact. This report does not document that any assistive devices, including a wheeled walker or gait belt were in use during this transfer or the root cause of R1's fall during transfer on 7/22/21. R1's Progress Notes dated below document: 7/23/21 at 6:31pm Late entry for 07/22/2021 4:30 am V5, Certified Nursing Assistant (CNA) was assisting R1 to the bathroom and R1 sat down hard in R1's wheelchair, bumping R1's left side of R1's body on the arm of the wheelchair. A body assessment was performed and a 3 cm reddened area to the left side of R1's body (even with R1's elbow) was observed. 7/22/21 at 9:25am- R1 had some complaints of pain this morning. 7/22/21 at 5:29pm- R1 complained of generalized pain with no documentation of location of the generalized pain. 7/22/21 at 9:07pm- R1 was complaining of left rib pain that R1 sat down hard last night and it feels tender when R1 moves. The facility's list of interviews for R1's fall on 7/22/21 documents R1 reported R1 fell hard into the side of wheelchair on 7/23/21. This list documents when the facility spoke to V9, R1's family on 7/23/21 at an unknown time, V9 was notified the facility considered this a fall. This list documents V12, CNA stated R1 tends to bend at the knees and go backwards and sits hard. V12 stated R1 had some complaints of pain, even when R1 was sitting on 7/22/21. R1's Progress Notes dated 7/23/21 at 6:12am documents a Date of Service: 07/22/2021 9:17 PM documents R1 stated R1's left side was hurting. R1 reported that R1 sat down hard on R1's chair yesterday and probably hit that side on the arm rest. R1 says it hurts when R1 moves. This note documents orders including rib X-ray stat (immediately or now) to area of discomfort. On 8/3/21 at 8:50pm, V2, Director of Nursing (DON) stated R1 fell /plopped while transferring to R1's wheelchair. V2 stated a wheeled walker was not in use during the transfer and V5 did not use a gait belt to transfer R1 on 7/22/21. V2 stated V5, CNA told V2 V5 did not use a gait belt because V5 did not have one readily available with V5 when V5 went to assist R1. V2 stated gait belts are to be used for all transfers and the staff are aware and this is to help prevent falls. V2 stated X-rays were performed on 7/23/21, following R1's fall that occurred on 7/22/21 showing R1's rib fractures. V2 stated V5, CNA received a final written warning regarding the improper transfer resulting in R1's rib fractures. V5's Disciplinary Report dated 7/22/21 documents V5 transferred R1 without a gait belt when required. This report documents R1 incurred fractures to R1's ribs while sitting down hard and bumping the edge of the wheelchair in the process of the transfer. This report documents staff are to follow the resident's plan of care for transferring residents and V5 chose not to follow the proper procedure causing injury to R1. The facility's Gait Belt policy dated October 21, 2011 documents gait belts are utilized on all residents requiring physical assistance with transfer unless contraindicated. This policy documents direct care staff will utilize the gait belt for all transfers requiring hands on assistance with a pivot or manual transfer. This policy also documents a gait belt is utilized around a resident's waist to help transfer the resident to the destination safely. The facility's Accidents and Incidents policy dated January 26, 2012 documents the facility will provide an environment that remains as free of accident hazards as possible and to provide adequate supervision and assistive devices to prevent accidents. This policy documents to notify the physician and responsible party of the incident/accident. The facility's Fall Prevention - Steady Steps policy dated February 17, 2020 documents the facility will provide each resident with an appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.

Based on observation, interview and record review the facility failed to provide supervision during toileting to prevent a fall for one (R297) of four residents reviewed for falls on the sample list of 39. This failure resulted in R297 sustaining fractures of the left arm and left hip requiring emergency services and surgical repair. This failure also resulted in R297 having a decrease in mobility and pain. Findings include: R297's hospital history and physical dated 1/6/21 documents R297 was brought to the emergency room two days in a row after falling at home. The second fall occurred in the bathroom and his wife noticed [CONDITION(S)] like activity. R297 had another [CONDITION(S)] during the ride in the ambulance. R297 was also diagnosed with a right hip fracture. R297's Nursing note dated 1/13/21 at 12:36 PM documents R297 was admitted to the facility. R297's careplan dated 1/13/21 documents, I am at risk for falls r/t (related to) decreased mobility, impaired balance, pneumonia, [CONDITION(S)] disorder, dementia and personality and behavior disorder. I had several falls at home prior to my admission. I had 2 falls in 24 hrs prior to being admitted into the hospital. R297's Initial Report to Public Health form documents R297 was toileted by V6, Certified Nurse's Assistant. This report documents (R297) asked for privacy. This report documents V6 left and was waiting in the bedroom area waiting for R297 to turn on the call light. R297 turned on R297's call light and V6 entered the room. When entering the room there were no gloves in the room. V6 went to go get gloves and R297 tried to get up by self and fell . R297 sustained a left femur fracture and left humerus fracture. R297's nursing note dated 1/21/21 at 8:50 PM, documents R297 is alert with confusion. R297's nursing note dated 1/22/21 at 12:19 AM documents R297 fell in the bathroom. On 2/4/21 at 1:41 PM, V6 Certified Nurse's Assistant (CNA) stated, (R297's) light went on and I got (R297) into the bathroom. (R297) asked me for a couple minutes of privacy. I stepped out of the room. (R297) had the call light. Then (R297) pushed it for me to come back in. There were no gloves so I went to go get the gloves. The gloves were in the hall closet. Then I went back into the room. When I went in his room, I heard an ow sound and then heard (R297) fall on the floor. So when I went in (R297) was on the floor. I yelled for help and then the nurse came down. (R297) was sent to the emergency room . After the fall, the (V2, Director of Nursing) trained me to the look at the care plan before providing cares and to make sure I have gloves and everything I need before going into the room. I didn't know (R297) had a history of falls. If I would have known (R297) had a history of falls I would have stayed with (R297) in the bathroom or left the door cracked to ensure (R297) didn't get up. R297's Hospital History and Physical dated 1/22/21 documents R297 was diagnosed with a left proximal left humerus (arm) and left proximal femur (hip) fracture due to a fall. These records also documents that the left hip fracture required surgery to repair it. R297's Nursing Note dated 1/27/2021 at 2:05 PM documents R297 was readmitted to the facility from the hospital with a diagnosis of left humerus (arm) fracture and left femur (hip) fracture. On 2/2/21 at 11:30 AM, R297 was lying in bed. R297's left arm was in a sling. R297 appeared confused. On 2/5/21 at 10:10 AM, R297 was sitting up in a chair. R297's left arm was in a sling. At that time, R297 stated, I'm not very well, I hurt all over. My left shoulder and my right shoulder hurt. My left hip and my right hip hurt. I am not getting around very well, it hurts too much to move. R297's care plan with a revision date of 1/27/21 documents that R297 now requires two assist with walker and R297 is non-weight bearing to the left upper extremity. On 2/5/21 at 10: 06 AM, V2 Director of Nursing stated when R297 first came to the facility R297 required one assist for transfer since his recent fractures he requires two assist. When we investigated the fall on 1/22/21 we talked to V6 CNA about what V6 should do in the future if there are not gloves in the room. V2 stated that V6 should make sure all supplies are available or push the call light to have someone bring the needed supplies so that R297 is not left alone.

Based on observation, interview, and record review the facility failed to: ensure a resident was not seated on indwelling catheter tubing, identify the subsequent wound that developed as a pressure ulcer/injury, and ensure a dressing was applied to a pressure ulcer for two of seven residents (R5, R15) reviewed for pressure injury in a sample of 18. These failures resulted in R5 developing an unstageable pressure ulcer with full thickness tissue loss and blackened eschar in the wound bed to the back of R5's right upper thigh. Findings include: A Skin Management Program policy (undated) gives as its objective, Prevent pressure ulcers development on at risk residents. Identification of newly acquired pressure ulcers. A Pressure Ulcer Prevention policy (undated) states, A pressure ulcer is defined as any lesion caused by unrelieved pressure that result in damage to underlying tissue. Pressure ulcers may develop from positioning as well as the use of medical devices. Pressure ulcers may develop from the use of nasal tubing, catheters, casts, braces, cervical collars or other medical devices. Monitor all devices for proper placement to avoid pressure on surrounding tissue. Unstageable (pressure ulcer)-Full thickness tissue loss in which the base of the ulcer is covered by slough and /or eschar (tan, brown or black) in the wound bed. The policy shows common pressure ulcer sites which includes the back of the upper thigh. A Wound Dressing policy dated 1/16/14 states that the facility's policy is, To provide an appropriate type of protective wound covering that facilitates the healing process. 1. R5's Minimum Data Set (MDS) assessment dated [DATE] documents that R5 is severely cognitively impaired, requires extensive assistance of two people for bed mobility and transfers, has functional limitation in Range of Motion to both lower extremities, and requires extensive assistance for mobility in the wheelchair. R5's Braden Scale for Predicting Pressure Sore Risk dated 2/13/18 documents R5 is at moderate risk for developing a pressure ulcer. R5's wound investigation dated 2/21/18 states, Writer was called to (R5's) room by CNA (Certified Nurse Aide) found an open area to the back of (R5's) leg, CNA stated that the (urinary catheter tubing) was bunched up at the back of (R5's) thigh which may have caused a laceration. R5's care plan dated 3/17/16 states, I have an actual skin alteration and potential for impaired skin integrity r/t (related to) dementia, age related fragility, and decreased mobility. R5's care plan also documents that a new intervention was added to the skin integrity plan by V4 (Wound Nurse) on 2/21/18 which instructs, Staff to ensure my (urinary catheter) line is in proper placement, thus preventing skin to (urinary catheter) line contact. On 3/4/18 at 10:19a.m., V4 (Wound Nurse) stated that R5 does not have a pressure ulcer but instead has an abrasion to the back of R5's upper thigh. V4 stated that R5's wound is being documented on the wound assessment sheet as an abrasion. V4 stated that R5 developed the abrasion after R5 had been sitting on R5's indwelling urinary catheter tubing. V4 stated that she did not not believe the pressure caused from R5 sitting on the catheter tubing would cause a pressure injury. R5's Wound assessment dated [DATE] documents that a laceration was identified on the back of R5's right upper thigh on that date which measured 1.4cm (centimeters) long x 1.9cm wide. R5's Wound assessment dated [DATE] documents that R5's laceration had deteriorated and had increased to 2.1cm x 2.0cm wide x 0.1cm deep. R5's Wound assessment dated [DATE] documents that R5's wound was now being assessed as an Unstageable Pressure Ulcer in which R5's wound bed was obscured and had full-thickness skin and tissue loss measuring 3.4cm long x 2.7cm wide. The Wound Assessment also documents that R5's wound had 30% (percent) of the wound bed covered with eschar (dead tissue). On 3/5/18 at 3:30p.m., V4 and V5 (Licensed Practical Nurse) entered R5's room to evaluate the abrasion on the back of R5's right upper thigh. V4 removed R5's soiled dressing to expose a wound approximately 3.4cm (centimeters) long x 2.7cm wide. The wound was reddened around the edge of the wound bed with a moderate amount of serous drainage. A rectangular area covering the center of the wound was blackened. V4 stated that R5's wound was now considered a pressure ulcer which had deteriorated to an unstageable pressure ulcer because of the dead tissue covering part of the wound. On 3/6/18 at 2:00p.m., V10 (R5's physician) stated that R5 has very fragile skin that is easily injured. V10 stated that it was unfortunate that R5 developed a wound caused from sitting on R5's catheter tubing. V10 stated that because R5's skin is so fragile, any wound can progress to a much larger wound. 2. R15's Wound assessment dated [DATE] documents R15 developed a Deep Tissue Injury to the left heel which measured 1.9cm (centimeters) long x 2.0cm wide and which had 80% of the wound bed covered with eschar (dead tissue). R15's physician's orders [REDACTED]. heel with wound cleanser before covering the wound with a [MEDICATION NAME] dressing which is to be changed every three days. On 3/5/18 at 9:50a.m., V4 (Wound Nurse) stated that R15's left heel wound is suppose to have a dressing in place which is changed every three days. V4 and V5 (Licensed Practical Nurse) entered R15's room in order to examine R15's left heel wound. R15 was dressed and seated in a high backed wheelchair. V4 removed the sock from R15's left foot and noted that R15's dressing was missing from R15's heel. V4 searched in R15's sock and bed linens but could not locate R15's missing dressing that was suppose to be covering R15's left heel.