Every finding on record at Arc at Kankakee

Based on observation, interview, and record review, the facility failed to provide professional standards of care for an arm injury/laceration. The facility failed to adequately assess the degree of the injury/laceration, thoroughly document the injury/laceration, and provide necessary wound care. R1 was sent to the emergency room for a large laceration with bone and tendon exposed to R1's left arm. This failure applies to 1 of 3 residents (R1) reviewed for quality of care. The findings include: R1's electronic medical records show R1's diagnoses including metabolic encephalopathy, dementia, Alzheimer's disease, lack of coordination, and hearing loss. R1 was admitted to the facility January 06, 2026. The Facility's incident report dated July 02, 2026, shows that R1 was observed lying in her bed on her back with a golf ball sized skin tear on her left forearm, and R1 stated they did not know what happened.The report does not include any measurements or other detailed information about the wound.The facility's Initial Incident Investigation Report shows the state agency was notified July 06, 2026, of R1 having an accident that resulted in R1 sustaining a skin tear to her left forearm that was treated with adhesive. On July 07, 2026, at 2:00 PM, R1 was in her room sitting in her wheelchair. V8 (Registered Nurse/RN) removed R1's sweater and shirt and there was an elastic bandage wrapped around several inches of R1's arm. V8 said the bandages were applied to R1's skin injury that was identified July 02, 2026. R1 could not provide any information about how she developed the injury.On July 07, 2026, at 3:06 PM, V9 (Registered Nurse) said during her evening shift on July 02, 2026, she observed R1's arm after the nurse reported a new skin injury and saw that R1's wound was not a small injury. On July 07, 2026, at 3:27 PM, V11 (Medical Director) said he was unable to provide proof that he had received a call from the facility regarding R1's injury and could not recall speaking with the facility about it on July 2, 2026. V11 said on July 3, 2026, at 2:41 PM, he was made aware that R1's family wanted to see the skin tear and after looking at the wound, the family requested to have R1 sent to the hospital. V11 said he received a picture of the wound with wound closure strips applied and if the skin tear was in the condition it appeared to be in the photo he received, she would have needed to be evaluated at the hospital because it wouldn't have been able to heal on its own. V11 said a skin tear is when the superficial layer of skin is separated, causing a bit of skin tissue to be exposed underneath and a superficial layer separated which doesn't bleed much because there are not many blood vessels involved. V11 said movement wouldn't cause a skin tear to grow deeper unless the patient hits it with a wheelchair or something hard.On July 08, 2026, at 9:11 AM, V5 (Certified Nursing Assistant) said on July 02, 2026, while providing care to R1 when he removed R1's sweater he observed a layer of her skin was pulled back and was a bit open and he immediately informed the nurse. V5 said he then dressed R1 for bed and wrote a statement and left it by the nurse's station.On July 08, 2026, at 8:38 AM, V12 (Family Member) said when she visited R1 at the facility on July 03, 2026; at approximately 12:30 PM after lunch, she had the nurse remove R1's sweater and gauze bandage from her arm. V12 said the nurse had to remove the bandage with water because it was stuck to the wound, and once it was removed, she saw raw meat and a gaping wound on R1's arm that was approximately 6 inches. V12 said R1's wound had 4-5 wound closure strips placed on it that were not closing the skin and were just lying on top of the wound. The nurse immediately called the ambulance and said R1 needed to go to the emergency room and should have been sent out on the night the wound was identified. This was a deep cut and wasn't just a skin tear. V12 said the emergency room doctor said he saw bone in R1's wound and he was praying she didn't develop an infection. On July 08, 2026, at 12:35 PM, V13 (emergency room Physician) said when R1 arrived at the emergency room on July 03, 2026, she had a large laceration on her left forearm with bone and tendons exposed. V13 said anytime R1 moved her fingers you could see exposed bone and tendons moving in her forearm because the wound was so deep and essentially, she had band aids placed over a large and deep wound. V13 said it is not likely that R1's wound would have transitioned from a small or golf ball sized skin tear from the time it was identified at the facility during the previous night into the deep wound she had when she arrived at the hospital because subcutaneous (tissue underneath the skin) tissue and fascia (connective tissue) were exposed and there is no way the patient could have made it that much worse in that timeframe.R1's hospital reports dated July 03, 2026, show R1 arrived to the emergency room from the facility by ambulance due to complaints of left arm pain and for evaluation of an injury that occurred the previous night, the facility applied wound closure strips to a very large forearm skin injury but did not send R1 out to the hospital. R1 reports pain and ongoing bleeding from the injury, the injury was dressed and bleeding was controlled. R1's wound was assessed to be 8 inches long and was explored through full range of motion and entire depth of wound visualized. Risks discussed included infection, poor wound healing, and tendon and vascular damage. There was no plan for delayed closure given and it had been nearly 24 hours since the injury was initially sustained. R1 was treated for a laceration with reinforced antimicrobial wound closure strips and wound adhesive. An adult protective services case was opened due to poor quality wound care. Photos included in the hospital report show five spaced wound closure strips applied to a very large and long wound on R1's arm with separated skin and a deep cut in the skin tissue present.On July 08, 2026, at 1:05 PM, V14 (Power of Attorney/Family Member) said on July 02, 2026, at approximately a little after 8PM, she received a call from a nurse at the facility who informed her that R1 had a slight skin tear on her arm that was being taken care of. V14 said when she asked the nurse how the skin tear happened; she responded that they didn't know. V14 said she asked V12 (Family Member) to look at the skin tear when she visited R1 the next day.On July 08, 2026, at 1:40 PM, V2 (Director of Nursing) said he is the facility's wound nurse. V2 said after a skin tear is identified, first aid should be applied. V2 said after identifying the skin tear the nurse should perform a skin assessment then document findings in the progress/skin wound notification notes. V2 said from what he saw V3 (Licensed Practical Nurse) did document her skin assessment; however, he would have liked more specific notes of who she spoke to; the size, type, and depth of R1's skin tear and how much blood was present or not present. V2 said on Friday July 03, 2026, at 12:30 PM, one of the staff nurses informed him that R1's wound was supposed to be a superficial skin tear, but she didn't think it was and felt it looked worse. V2 said he advised her to send R1 to the hospital. V2 said when R1 returned to the facility on the same day, the nurse on duty told him that the hospital placed wound closure strips on R1's wound and R1 was doing ok. When asked if R1's family's concerns that lead them to request sending her to the hospital prompted him to follow up on R1's skin injury, V2 said from reading R1's hospital report that was received July 06, 2026, her skin injury was determined to be a skin tear, and in the report it said that her skin was too fragile to suture. V2 said he has not yet seen R1's skin injury. V2 said he usually sees new skin conditions as soon as he can and will request to see it when the nurse's change the bandages. V2 said he was not at the facility from Friday July 03, 2026, to Monday July 06, 2026. When asked is a laceration the same as a skin tear, V2 responded a laceration is like a straight-lined cut whereas a skin tear is when the skin is pushed over. V2 said skin would have to be cut in order to see tendons.The facility's Skin Condition Assessment & Monitoring Pressure and Non-Pressure policy received July 08, 2026 shows: The purpose of the policy is To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown and other non-pressure skin conditions and assuring interventions are implemented. A wound assessment will be initiated and documented in the resident chart when non-pressure skin conditions are identified by licensed nurse.The initial observation of skin breakdown will also be described in the nursing progress notes.Wound Assessment/Measurement procedures include: Measure length. Measure width. Measure depth. The facility's Physician - Family Notification - Change of Condition policy received July 08, 2026, shows, The facility will consult with the resident's physician or authorized designee such as Nurse Practitioner when there is: An accident involving the resident which results in injury and has the potential for requiring physical intervention.

Based on observation, interview, and record review, the facility failed to timely report an injury of unknown origin to the state surveying agency. This failure applies to 1 of 3 residents (R1) reviewed for reporting alleged violations. The findings include:R1's electronic medical records R1's diagnoses including metabolic encephalopathy, dementia, Alzheimer's disease, lack of coordination, and hearing loss. R1 was admitted to the facility January 06, 2026. On July 07, 2026, at 2:00 PM, R1 was in her room sitting in her wheelchair. V8 (Registered Nurse/RN) removed R1's sweater and there was an elastic bandage wrapped around several inches of R1's arm. V8 said the bandages were applied to R1's skin injury that was identified on July 02, 2026. R1 could not provide any information about how she developed the injury. On July 08, 2026, at 1:05 PM, V14 (Power of Attorney/Family Member) said on July 02, 2026, at approximately 8PM, she received a call from a nurse at the facility who informed her that R1 had a slight skin tear on her arm. V14 said when she asked the nurse how the skin tear happened; she responded that they didn't know. On July 08, 2026, at 8:38 AM, V12 (Family Member) said when she visited R1 at the facility on July 03, 2026, at approximately 12:30 PM, she had the nurse remove R1's sweater and gauze bandage from her arm. V12 said once it was removed, she saw raw meat and a gaping wound on R1's arm that was approximately 6 inches long. V12 said the nurse immediately called the ambulance and said R1 needed to go to the emergency room. On July 08, 2026, at 9:11 AM, V5 (Certified Nursing Assistant) said on July 02, 2026, while providing care to R1 when he removed R1's sweater he observed a layer of her skin was pulled back and was a bit open and he immediately informed the nurse. V5 said he then dressed R1 for bed and wrote a statement and left it by the nurse's station. R1's skin observation notes created by V3 (Agency Licensed Practical Nurse) dated July 2, 2026, show R1 had a new golf ball size skin tear located on her left arm. On July 07, 2026, at 3:06 PM, V9 (RN) said during her evening shift on July 02, 2026, she observed R1's arm after V3 reported a new skin injury. V9 said she looked at R1's arm and said it was not a small injury. On July 8, 2026, at 1:40 PM, V2 (Director of Nursing/DON) said on Monday July 06, 2026, he received the report from the hospital that showed wound adhesive was used to hold R1's skin together and that's when he reported the injury to the state agency. V1 (Administrator) and V2 said they still don't know how R1 sustained her skin injury. R1's hospital records dated July 03, 2026, show R1 was sent to the ER (Emergency Room) by ambulance due to complaints of left arm pain and for evaluation of an injury that occurred the previous night. R1's Nursing Notes created by V15 (Agency Licensed Practical Nurse) dated July 03, 2026, at 7:01 PM show R1 returned from the emergency room with skin adhesive and wound closure strips per nurse-to-nurse report from the hospital to the facility. V2 (DON) was made aware. The facility's incident report dated July 02, 2026, shows R1 was observed lying in her bed on her back with a golf ball sized skin tear on her left forearm, and the resident stated they did not know what happened.The facility's Initial Incident Investigation Report shows the state agency was notified July 06, 2026, of R1' injury of unknown origin. The incident form was dated July 6, 2026. The time and date of the event was July 6, 2026, and 8:00 AM. The facility documented on the form that R1 was not sent to the hospital and then documented that the hospital diagnosis was repair of skin tear The facility's Abuse policy received July 08, 2026, shows: Employees are required to report any incident they observe to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in the administrator's absence.Any allegation of abuse will be reported to the Department of Public Health immediately. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours.The nursing staff is additionally responsible for reporting on a facility incident report the appearance of suspicious lacerations or other abnormalities as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the administrator or other person designated to act on behalf of the administrator in the administrator's absence. For resident injuries not involving an allegation of abuse or neglect, the administrator will appoint a person to gather further facts to make a determination as to whether the injury should be classified as an injury of unknown source. An injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident: and The injury is suspicious because of the extent of the injury.If classified as an injury of unknown source, the person gathering facts will document the injury, the location and time it was observed, any treatment given, and notification of the resident's responsible party. The Department of Public Health will be notified.

Based on observation, interview, and record review, the facility failed to immediately investigate an injury of unknown origin after it was identified. This failure applies to 1 of 3 residents (R1) reviewed for investigating alleged violations. The findings include:R1's electronic medical records show R1's diagnoses including metabolic encephalopathy, dementia, Alzheimer's disease, lack of coordination, and hearing loss. R1 was admitted to the facility January 06, 2026. The Facility's incident report dated July 02, 2026, shows that R1 was observed lying in her bed on her back with a golf ball sized skin tear on her left forearm, and R1 stated they did not know what happened.The facility's Initial Incident Investigation Report shows the state agency was notified July 06, 2026, of R1 having an accident that resulted in R1 sustaining a skin tear to her left forearm that was treated with adhesive. On July 07, 2026, at 2:00 PM, R1 was in her room sitting in her wheelchair. V8 (Registered Nurse/RN) removed R1's sweater and shirt and there was an elastic bandage wrapped around several inches of R1's arm. V8 said the bandages were applied to R1's skin injury that was identified July 02, 2026. R1 could not provide any information about how she developed the injury.On July 07, 2026, at 3:06 PM, V9 (Registered Nurse) said during her evening shift on July 02, 2026, she observed R1's arm after the nurse reported a new skin injury and saw that R1's wound was not a small injury. On July 07, 2026, at 3:27 PM, V11 (Medical Director) said he could not remember, or find the facility phone number in his call log for July 2, 2026 in order to confirm if the facility had called and notified him of R1's injury of unknown origin.V11 said on Friday, July 3, 2026, he was sent a photo of R1's arm with wound closure strips applied. V11 said if R1's skin tear was in the condition it appeared to be in the photo he received, R1 would have needed to be evaluated at the hospital because it wouldn't have been able to heal on its own. V11 said a new injury of unknown origin needs to be investigated right away.On July 08, 2026, at 9:11 AM, V5 (Certified Nursing Assistant) said on July 02, 2026, while providing care to R1 when he removed R1's sweater he observed a layer of her skin was pulled back and was a bit open and he immediately informed the nurse. V5 said he then dressed R1 for bed and wrote a statement and left it by the nurse's station.On July 08, 2026, at 8:38 AM, V12 (Family Member) said when she visited R1 at the facility on July 03, 2026; at approximately 12:30 PM after lunch, she had the nurse remove R1's sweater and gauze bandage from her arm. V12 said the nurse had to remove the bandage with water because it was stuck to the wound, and once it was removed, she saw raw meat and a gaping wound on R1's arm that was approximately 6 inches. On July 08, 2026, at 12:35 PM, V13 (emergency room Physician) said when R1 arrived at the emergency room on July 03, 2026, she had a large laceration on her left forearm with bone and tendons exposed. V13 said anytime R1 moved her fingers you could see exposed bone and tendons moving in her forearm because the wound was so deep. V13 said it is not likely that R1's wound would have transitioned from a small or golf ball sized skin tear from the time it was identified at the facility during the previous night into the deep wound she had when she arrived at the hospital because subcutaneous (tissue underneath the skin) tissue and fascia (connective tissue) were exposed and there is no way the patient could have made it that much worse in that timeframe.On July 08, 2026, at 1:05 PM, V14 (Power of Attorney/Family Member) said on July 02, 2026, at approximately a little after 8PM, she received a call from a nurse at the facility who informed her that R1 had a slight skin tear on her arm that was being taken care of. V14 said when she asked the nurse how the skin tear happened; she responded that they didn't know.On July 08, 2026, at 1:40 PM, V2 (Director of Nursing) said he is the facility's wound nurse. V2 said after a skin tear is identified, the medical director, himself and the family should be notified and if the medical director is not available a message should be left with V11's messaging service. V2 said V3 (Agency Licensed Practical Nurse) did not report R1's skin tear to him on July 02, 2026. V2 said on Friday July 03, 2026, at 12:30 PM, one of the staff nurses informed him that R1's wound was supposed to be a superficial skin tear, but she didn't think it was and felt it looked worse. R1's family's concerns and the request to send R1 to the hospital did not prompt V2 to follow up on R1's skin injury to determine the status of the injury; V2 responded that based on being told when R1 returned from the hospital, that wound closure strips were placed on her skin injury and that it was just a skin tear he determined that R1's wound was just a superficial skin tear. V2 said he has not yet seen R1's skin injury. V2 said he was not at the facility from Friday July 03, 2026, to Monday July 06, 2026. V2 said if he had known R1's injury to be a reportable injury he would have come to the facility even if he was off work. V2 said injuries that require sutures or glue/adhesive are reportable injuries. V2 said an investigation should be initiated immediately after a reportable injury has been identified. V2 said he would be responsible for initiating the investigation into a reportable injury. V2 said skin would have to be cut in order to see tendons. V2 said if he was informed by staff when R1 returned to the facility that skin adhesive was applied to her skin injury, he would have come to the facility and initiated investigating the injury. V2 said they still don't know how R1 sustained her skin injury. The facility's Abuse policy received July 08, 2026, shows: Employees are required to report any incident they observe to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in the administrator's absence. Upon learning of the report, the administrator or a designee shall initiate an investigation.

Based on observation, interview, and record review the facility failed to maintain the kitchen facility in a manner to prevent foodborne illness. This applies to 22 residents in the facility receiving dietary services. Findings include: On 05/06/25 at 10:30 AM, V6 (Dietary Manager) confirmed 22 residents in the facility receive food services from the kitchen. 1.) On 05/06/25 at 11:29 AM, V6 tested red sanitization bucket #3 at 500ppm (Parts Per Million). On 05/08/25 at 11:13 AM, V6 stated the red disinfecting bucket should be 200 to 400ppm. If the sanitizer level is too high could cause a chemical reaction to the skin. If it comes in contact with food, it may contaminate the food and cause illness. The facility policy Sanitizing Food Contact Surfaces dated 1/25 states the sanitizer solution must be at 200 ppm to 400 ppm. 2.) On 05/06/25 at 11:00 AM, the walk-in cooler contained a one-gallon bottle of barbeque sauce with no opened-on or use-by dates. A one-gallon bottle of barbeque sauce good thru 3/29/25. Hot dogs in a zippered bag good thru 4/23/25. A lump of grayish white meat in a silver facility metal pan, identified by V6 as turkey, had no contents label, opened on, or use by date. An opened one-gallon bottle of Balsamic vinaigrette without an opened on or use by date. A dented 6lb 6oz can of diced pears with a greenish gray furry substance growing on the can. A 6lb 12oz can of tapioca pudding with a greenish gray furry substance and white glaze-like substance on the can. Two factory sealed containers of rice pudding with a good-thru date of 4/8/25. Parmesan cheese in a zippered bag good-thru 4/24/25. Processed cheese block factory packaging half ripped off, with product open to air and did not have an opened on or use by date. American cheese in a zippered bag with a use by date of 5/1/25. Three 5lb bags of mozzarella good thru 3/17/25. A 1lb 14oz tub of basil pesto good thru 4/14/25. 3.) On 05/06/25 at 10:30 AM, the dry storage contained a zippered bag of white flakes identified by V6 as coconut flakes did not have a contents label opened on or use by date. Cherry pie filling 20 lbs. (pounds) no opened on or use by date. Quinoa 8lbs no opened on or use by dates. Two dented 6 lbs. 9oz. (ounce) cans of ground tomatoes. A dented 6lb. 10oz can of mandarin oranges. A dented 6lb 15oz can of kidney beans. A dented 6.6lb can of diced pears. A facility bin of penne pasta good thru date of 5/5/25 Egg noodles good thru 5/5/25. A 5lb bag of pepitas open to air. A box of gelatin agent 1lb 1/4 oz open to air. Sliced strawberry topping 7lb 6oz that had been accessed. Manufacturer's label read to refrigerate after opening. Maraschino Cherries 4.5lbs did not have an opened-on or use-by date. The manufactures label read to refrigerate after opening. A 5lb bag of graham cracker crumbs that were accessed, did not have an opened-on or use-by date. A 25lb bag of panko Japanese breadcrumbs was open to air and had a good thru date of 1/10/25. Shelving with emergency food contained a 6.56lb can of pear halves good thru 4/1/23. A dented 3lb 2 oz can of chicken noodle soup good thru 4/1/25. Two 3lb 2oz cans of chicken noodle soup good thru 4/1/25. On 05/08/25 11:13 AM, V6 (Dietary Manager) stated, dented cans that arrive at the facility dented are rejected because we can't verify if it was packaged incorrectly or not properly sealed- they may have botulism. If we dent it the cans, we are ok to use them because we know we dropped it and there is nothing wrong with it. If the edges are dented even if we dropped the can, we would not use the can of food. Food should be labeled with an opened on and use by date, so we know when to pull it off the shelf. There is a safety risk using food that is outdated it could be spoiled and cause illness. Food items should be labeled with the contents in case someone has an allergy we don't want to serve it to them. Food items that should be refrigerated should not be stored in the dry storage area because it could start to grow bacteria. Food items should be securely sealed so no contaminates get inside- contaminates could cause illness. Outdated food items could be spoiled and cause residents to become sick. V6 stated I don't know how those cans got in the refrigerator- the stuff growing on top looked like mold. We wouldn't want it growing in the refrigerator because it could cause illness. The Facility policy Receiving (dated 1/25) showed to refuse dented cans. The facility did not provide a policy for dented cans stored in the facility. The facility policy Food Supply and Storage (dated 1/25) showed all food, non- food items, and supplies that will be used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Foods past the use-by, sell by, best-by, or enjoy by date should be discarded. Cover, label, and date unused portions and open packages. Discard food past the use-by or expiration date. The facility Refrigerated Storage Life of Foods chart (dated January 2024) shows fruit purees, fillings and sauces are good for one month after opening and must be refrigerated. 4.) On 05/06/25 at 11:24 AM, the walk-in freezer was observed with V8 (Server). Meat patties in a clear plastic bag had no contents label, opened-on, or use-by date. Corned beef labeled good thru 3/21/25. Food in a clear bag identified by V8 as cut-up sausage was without a label to identify contents or use-by date. Food identified by V8 as potato wedges was in a clear bag without a label to identify contents or use-by date. 5.) On 05/06/25 at 11:35 AM, the reach in coolers were observed with V8. Reach in cooler #1 contained an unlabeled plastic bag with creamy white substance in a facility container identified by V8 as a multi-use container of yogurt. The container had no label to identify contents or any dates. 6.) On 05/06/25 at 11:40 AM, The kitchen shelving was observed with V6 (Dietary Manager.) A zippered bag of white powder identified by V6 as pureed bread had no label to identify contents, opened-on or use-by dates. A 4.5lb bag of pureed bread had no opened-on or use-by dates. On 05/07/25 at 12:10 PM, V9 (Cook) tested the food holding temperatures. Between temperature testing the dressing and ground turkey. V9 used the same small probe wipe. V9 then tested the gravy then the sliced turkey without wiping the probe in between. On 05/08/25 at 11:13 AM, V6 stated usually we use a new wipe for testing each food item. Not using a fresh wipe to temperature each food item could cause a cross contamination and negatively affect persons with food allergies. The facility policy Meal Quality and Temperature (dated 1/25) showed thermometers are cleaned and sanitized before use, between food items, and after use with approved sanitizer wipes or solutions.

Based on interview and record review, the facility failed to provide residents and/or their representatives written notification of the reason for transfer to the hospital and failed to notify the ombudsman of the hospital transfer. This applies to 2 of 2 residents (R15 and R21) reviewed for discharge in a sample of 14. The findings include: 1. R15's Face Sheet showed R15 was admitted to the facility on [DATE]. R15 had multiple diagnoses which included cerebral infarction, aphasia, convulsions, occlusion and stenosis of right carotid artery, vascular dementia, and diabetes. R15's MDS (Minimum Data Set) dated 04/07/25 showed R15 had severe cognitive impairment. R15's Progress Note dated 01/27/25 at 8:23 PM, showed Approximately around noon, noted with change in mental status. Notified (Doctor), received order to send to ER (emergency room ) for eval. R15 transferred to (Hospital) at approximately around 1:40 PM. Progress Note dated 02/03/25 at 11:57 PM, showed Assigned CNA (Certified Nursing Assistant) requested assistance in resident's room stating that resident was being verbally and physically aggressive with her. The CNA stated she told R15 that she needed to turn off his call light and R15 smacked her hand and pushed her. Writer spoke with (Doctor) and explained the situation with orders given to send resident to ER for further evaluation due to the physical and verbal aggression. Progress note dated 02/28/25 at 7:12 PM, showed Writer to resident's room at 3:00 PM, resident yelling for help. Writer observed resident speaking nonsensically. Stroke assessment performed, noted right side weakness. R15's EMR (Electronic Medical Record) contained no documentation of written notice for reason of transfer to the hospital provided to R15 and/or the representative. The EMR contained no documentation of notification of the ombudsman of the hospital transfers for February 2025. The facility was unable to provide documentation for written notification of the reason for transfers to the hospital and notification of the ombudsman for February 2025. 2. R21's Face Sheet showed R21 was admitted to the facility on [DATE]. R21 had multiple diagnoses which included encephalopathy, gait abnormalities, diabetes, depression, anxiety, and hypertensive heart disease. R21's MDS dated [DATE] showed R21 had moderate cognitive impairment. R21's Progress Note dated 03/07/25 at 7:50 AM, showed Called to resident's room by CNA. Resident pulled indwelling foley out. Noted with massive bleeding from his penis area, with blood clots. Progress Note dated 03/07/25 at 7:53 AM Wife and MD (Medical Doctor) notified with orders to send to (Hospital) ED (Emergency Department). R21's EMR contained no documentation of written notice for reason of transfer to the hospital provided to R21 and/or the representative. The facility was unable to provide documentation for written notification of the reason for transfers to the hospital. On 05/07/25 at 3:38 PM, V1 (Administrator) stated written notification of the reason for transfer to the hospital was not given to the residents and/or their representatives. V1 stated they were not aware that written notification should have been given. The ombudsman was not notified of the residents' transfers to the hospital for February 2025. The facility's Clinical Protocol: Transfer or Discharge Notice, last approved 06/2022 showed Policy Statement: Our community shall provide a resident and/or the resident's representative (sponsor) with a thirty (30) day written notice of an impending transfer or discharge. Exceptions to the 30-day requirement apply when the transfer or discharge is affected because of the following, in these cases, the notice is provided as soon as practicable and the notice to the ombudsman is sent when practicable. 1. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the community. 6. An immediate transfer or discharge is required by the resident's urgent medical needs.

Based on observation, interview, and record review, the facility failed to implement dietician-recommended interventions for resident with significant weight loss. This applies to 1 resident (R13) reviewed for weight loss in a sample of 14 residents. The findings include: On 5/6/25 at 10:57 AM, R13 was asleep in bed with his mouth hanging open and his cheeks sunken in, appearing thin. R13's MDS (Minimum Data Set) dated 3/20/25 shows his cognition is severely impaired and he requires supervision with eating. R13's Nutrition note written on 5/6/25 by V12 (Dietician) states R13 has had a 14.5% weight loss in the last 6 months. V12 wrote R13 gets large portions, fortified pudding at lunch, and fortified ice cream with lunch and dinner. V12 noted that R13 has a pressure ulcer to his sacrum. V12 wrote that R13 is meeting majority of his nutrition needs with supplements and the rest of his nutrition is provided with meals. V12 wrote that R13's weight loss continues, despite multiple interventions. R13's weights documented in EHR (Electronic Health Record) as the following: 5/1/25- 141 pounds, down from 11/2/24- 165 pounds (14.55% in the last 6 months). On 5/8/25 at 12:34 PM, R13 was observed eating lunch in the facility dining room, sitting next to V11 (R13's wife). R13's lunch did not include a large portion, fortified pudding, or fortified ice cream. V11 said last she knew, R13 weighed right around 175 pounds. V11 said R13 did not get pudding or a fortified ice cream and R13's appetite fluctuates. R13 ate a slice of pie, about 25% of his sweet potatoes, 80% of his pea salad, and 20% of his BBQ pork. R13 did not eat any of his cornbread and he received regular sized portions of lunch items. Throughout lunch service, no staff were seen checking on R13 to see how much he had eaten, how his appetite was, or to encourage him to eat. At 12:57 PM, V11 unlocked R13's wheelchair and removed him from the dining room. Lunch had ended and R13 never received fortified pudding, a fortified ice cream, or a large portion. On 5/8/25 at 2:25 PM, V2 (Director of Nursing) said, if ordered, fortified pudding and fortified ice cream should be given by dietary staff. V2 said if dietician recommendations are not followed, there is a risk the resident will continue to lose weight. V2 said this is a concern because weight maintenance is important for preventing disease and illnesses and promoting wound healing. V2 said she knows R13 is supposed to be receiving double portions at mealtimes. On 5/8/25 at 2:42 PM, V6 (Food Service Director) said V12 (Dietician) emails V2 and V6 to let them know when she orders supplements for a resident. V6 said V12 (Dietician) will then put the recommendations directly into the menu system so the supplements/recommendations will print out on the resident's meal ticket for each meal. V6 said she then highlights on the meal ticket if it says double portion or fortified pudding. V6 said the kitchen staff just had a meeting about supplements in which she told the staff if any items are highlighted on the meal ticket, the resident must get those items. V6 said the server is responsible for giving the resident fortified pudding and fortified ice cream and the [NAME] is responsible for making sure the resident gets double, or large portions. V6 then provided surveyor with R13's meal ticket, which showed large portions with all meals and fortified pudding at lunch. V6 said residents with large portions ordered should get double scoops. V6 said V12 (Dietician) did not add fortified ice cream onto R13's meal ticket. V6 then spoke with V12 to verify and V12 told V6 that R13 is also supposed to be on fortified ice cream. When V6 was told R13 did not get fortified pudding, fortified ice cream, or large portion with lunch, V6 said she did not know what happened, but it is a concern that R13 didn't get the recommended supplements because he could lose more weight. V6 said weight maintenance is important for the resident's immune system, strength, and overall health. R13's Care Plan initiated on 10/6/22 states resident has a compromised nutritional status related to the diagnosis of weight loss, and interventions include provide supplements as ordered, monitor and document food intake at each meal, report any intake decline to physician, and provide diet as ordered. The facility's policy titled, Significant Weight Gain or Loss Policy last revised 2/24 states, Purpose: To ensure that insidious/significant weight gain or loss will be identified so that nutritional needs can be evaluated, and appropriate intervention provided. Responsibility: Licensed Nursing Personnel/Dietician/Dietary Manager. Guidelines: .2. Dietician/Nursing will determine significant weight changes: .c. gain or loss of 10% in the last six months. 3. Dietician will review these clients and document the change. 4. If recommendations are indicated, will be communicated to nursing to notify the provider of the significant weight changes and recommendation . The facility's policy titled, Weight Monitoring last revised 01/2023 states, Policy Statement: It is the policy . that appropriate nutritional care shall be provided to residents who have a significant weight change. A significant weight change is identified as a weight loss or gain of 5% in 30 days, 7.5% in 90 days, or 10% in 180 days. Policy Interpretation and Implementation: . E. The RD should make recommendations for nutritional interventions . RD recommendations should be reviewed and initiated by nursing associates .

Based on observation, interview, and record review the facility failed to follow the physician order to administer intravenous (IV) antibiotics. This applies to 1 of 1 resident reviewed (R225) for IV antibiotics in a sample of 14. The Findings include: R225 is an [AGE] year-old male admitted on [DATE] with an admitting diagnosis including infection and inflammatory reaction due to an indwelling urethral catheter. Record review on R225's Physician Order Sheet (POS) dated 5/6/25 indicates: Meropenem-Sodium Chloride intravenous solution reconstituted 1 gram in 50 milliliters (1gm/50ml). Use 1 gm IV every 8 hours for bacterial infection until 5/11/25 23:00. On 5/6/25 at 10:31 AM, R225 was observed in his bed with a 100 ml 0.9 NS reconstituted with 1-gram Meropenem infusing at 50 ml/hr. The infusion pump was programmed for Meropenem infusing at 50 ml/hr with only 50 ml as the volume to be infused. On 5/6/25 at 11:58 AM, V2 (Director of Nursing) stated, I am supposed to mix Meropenem 1 gram with 50 ml of 0.9 NS, but I didn't have 50 ml bag and that's why I mixed with a 100 ml bag After reconstituting 1 gm of Meropenem with 100 ml 0.9 NS, the resident is going to get only half the dose if I run it at 50 cc/hr for an hour. On 5/6/2025 at 11:58 AM, there was no documentation in R225's medical record that showed R225's Physician was notified that 50ml IV bags were not available and that 100ml would need to be infused for the full Meropenem dose, or if the 100ml with the full dose would require more time for the infusion, or if infusing 100ml over one hour was acceptable. The facility presented a policy on Administering Medications through Secondary IV tubing document (last approved 1/2024): Review physician order and confirm the 5 rights of medication (right resident, medication name, dose, route, rate). If no rate is ordered, calculate the rate according to dose, volume, and time ordered.

Based on observation, interview, and record review, the facility failed to follow Enhanced Barrier Precautions (EBP) during high contact resident care activities and failed to perform hand hygiene during incontinent care. This applies to 3 of 3 residents (R6, R13, and R225) in a sample of 14. The findings include: 1. R6 is a [AGE] year-old female admitted on [DATE] with diagnoses including urinary tract infection and neuromuscular bladder dysfunction. On 5/6/25 at 10:39 AM, R6 was in her bed with an EBP sign on the entry door, requiring gloves and a gown to provide high-touch resident care activities. R5 was observed with an indwelling catheter bag on the floor with full of urine. On 5/6/25 at 10:40 AM, V5 (Certified Nursing Assistant/CNA) stated that she is not aware of the last time the bag was emptied, and it was supposed to be emptied every shift. V5 emptied 1600 milliliters (ml) of urine without wearing a gown and stated that the bag shouldn't be on the floor. 2. R225 is an [AGE] year-old male admitted on [DATE] with diagnoses including infection and inflammatory reaction due to an indwelling urethral catheter. On 05/06/25 10:35 AM, R225 was in his bed with an EBP sign at the entry door, requiring gloves and a gown when providing high-touch resident care activities. On 05/06/25 at 10:36 AM, observed V4 (Licensed Practical Nurse/LPN) touching the resident's linen and indwelling catheter tubing without wearing a gown. 05/08/25 10:38 PM V2 (Director of Nursing/DON) stated all of our staff are supposed to wear a gown and gloves when providing high touch resident care activities, including indwelling catheter care, for residents on EBP, and the indwelling catheter bag shouldn't be on the floor. The facility provided the Enhanced Barrier Precaution Guidelines dated 05/2024 document: 1. Enhanced Barrier Precautions (EBP) is an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. 45906 3. On 5/8/25 V14 (Wound Care Family Nurse Practitioner) and V13 (Registered Nurse) were observed providing incontinence care for R13 prior to performing wound care. V13 and V14 rolled R13 onto his right side. Then with gloved hands, V13 used a wipe to remove stool from R13's buttocks. After wiping away R13's stool, V13 did not change her gloves. V13 and V14 then switched sides of the resident so V14 could measure R13's sacral wound. When V13 arrived at the right side of R13's bed, she placed her left hand with the soiled glove on R13's left buttock and her soiled right gloved hand on R13's posterior thigh to hold R13 in place while V14 measured his wound. On 5/8/25 at 2:25 PM, V2 (DON) said after providing incontinence care and wiping away stool from a resident, the first thing the staff member should do is remove their gloves, wash their hands, and put on new gloves. V2 said the staff member should remove soiled gloves before touching a clean area of the resident for infection control purposes, to prevent cross contamination. The facility's policy titled, Hand Hygiene/Handwashing last revised 03/2023 states, Definition: Hand Hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, or antiseptic hand rub .Guidelines: .Examples of When to Perform Hand Hygiene: . If hands will be moving from a contaminated body site to a clean body site during patient care .

Based on interview and record review, the facility failed to investigate an allegation of potential abuse and report it the State Agency within the timeframes. This applies to 1 of 1 resident (R1) reviewed for abuse. The findings include: On 12/13/24 at 2:35 PM, the facility submitted State Agency Serious Injury Incident and Communicable Disease Report (Initial Reportable) that documented the following: On 05/20/24, a resident's daughter reported witnessing staff being rough with ADL (Activities of Daily Living) Care, which was noted in our grievance log. The resident has since been discharged from the community. Upon discovery, investigation was started immediately. On 01/02/25 at 1:00 PM the Service and Recovery Form date completed 05/20/24 was reviewed. The form documented [R1's] daughter reports witnessing staff being rough with mother and other patients. Specific examples- dressing, getting out of bed. [R1's] daughter is concerned the rough handling is why mom's wound is bleeding today. More on back: [R1's] daughter reported one staff she is concerned with was [V10] (CNA/Certified Nursing Assistant) but said there have been others. [R1's] daughter also reports some staff have been very gentle. On 01/07/25 at 9:00 AM R1's progress notes were reviewed. The progress notes documented 05/20/24 at 9:55 AM Nurse was informed by staff that blood was leaking from resident's wheelchair. Writer inspected resident's body while sitting in wheelchair, noted copious amounts of dark red blood coming from wound of left hip. Resident placed in bed for wound cleansing. Pressure dressing applied. 05/20/24 at 10:15 AM Wound continues with excessive bleeding, uncontrolled. Another pressure dressing applied. 05/20/24 at 10:18 AM Doctor called, left message with on-call. 05/20/24 at 10:25 AM Doctor returned call with orders to send to ED (Emergency Department) for eval of wounds. 05/20/24 at 10:32 AM (Ambulance) called with ETA (Estimated Time of Arrival) of 20-30 minutes. 05/20/24 at 10:34 AM Daughter called and informed of resident's condition and pending transfer. 05/20/24 at 10:37 AM (Ambulance) arrived with three attendants to transfer resident to (Hospital) ED via stretcher. 05/20/24 at 10:38 AM (Doctor) attending MD (Medical Doctor) given report regarding patient. R1 was admitted to the facility on [DATE] with multiple diagnoses which included metabolic encephalopathy, dementia, acute embolism, hypertension, and cognitive communication. R1's progress note dated 05/11/24 at 12:30 PM documented Writer received resident from (Hospital) arrived via stretcher accompanied by 2 EMT's (Emergency Medical Technician). Complete body assessment performed. Several bruising on skin related to fall at home. Two wounds present on right hip and left hip covered with (dressing). Lives alone discovered by family lying on floor. Wound left hip debridement in hospital. On 01/07/25 at 10:30 AM a State Agency Serious Injury Incident and Communicable Disease Report (Follow-up Reportable) was reviewed. The Investigation Summary dated 12/17/24 documented the following: The grievance was given immediate, full attention to the bleeding wound and the DON (Director of Nursing) investigated. The same report documented it was determined that the new blood thinners caused spontaneous bleeding from the wound. The following written statements were attached to the report. V2 (DON) wrote I recall the grievance only from re-reading it. I do not recall when it was presented to me. I was off on May 21, 2024. The SSD (Social Services Director) signed it on 05/28/24 so I am assuming that is when I wrote in my part about the wound that was bleeding. I did not respond to the complaint of a CNA being rough. My concerns were focused on the wound. A written statement dated 12/11/24 documented Admin spoke with [former CNA V10] to receive a statement regarding the grievance of rough care back on 05/20/24. [V10] does not recall the incident. The initial and final reportables showed that the facility initiated the rough handling allegation investigation on 12/11/24, seven months after the incident. On 01/02/25 at 9:37 AM V7 (Former Administrator) stated She was on PTO (Paid Time Off) on 05/20/24 when the incident of alleged rough handling had taken place. V7 stated she did not report the incident to State Agency because she was not made aware of the incident until December 2024 when the consultant came to the facility to audit. V7 stated the allegation was not investigated in May. On 01/02/25 at 2:25 PM V2 (DON) stated on 05/20/24 she was not aware of R1 being rough handled. Stated she was only notified by the floor nurse that R1 was having bleeding from her wound, and she was being sent out to the hospital for evaluation. V2 stated she did not speak with R1's daughter that day (05/20/24). V2 stated R1's bleeding was being caused by the wound debridement on its own. The resident was taking Eliquis. After the resident was sent out for evaluation, she was admitted to the hospital but did not return to the facility. I only zoned into the bleeding wound; I did not address the rough handling. V2 stated on 05/28/24 she signed off on the grievance regarding the bleeding wound. I am not sure if the issue of rough handling was told to the abuse coordinator. The abuse coordinator was the administrator. The social services department handles the grievances. When there is an issue, it is their responsibility to notify the proper department manager. That is the normal process. All issues are handled from there. V2 stated V10 was not terminated, she left voluntarily for a position with better pay and closer to home. V2 stated V10 was not sent home pending investigation. I am not aware of an investigation regarding the rough handling. On 01/02/25 at 3:30 PM V1 (Administrator) stated he does not have any knowledge of the alleged rough handling because he was not working at the facility at the time. V1 stated he started as the administrator on 12/18/24. When I started, the investigation was completed. From what I read and heard; I see no evidence of any rough handling occurred. If I got a report of a resident being rough handled, I will follow the company and state guidelines. V1 stated he is the abuse coordinator for the facility. The facility's Abuse Investigation and Reporting Policy last approved 12/2024 showed: Policy statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, electronic mail, social media, videotaping, photographing, and other imaging of resident, and/or injuries of unknown source ('abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by community management. Conclusions of investigations will also be reported, as defined by the (Facility) Abuse Prevention policy. Policy Interpretation and Implementation: Role of the Administrator or designee: D. The administrator or designee will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. E. The administrator or designee will monitor for any further potential abuse, neglect, exploitation, or mistreatment is prevented while the investigation is in progress. Reporting: A. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported to the Administrator or designee and to the following other officials or agencies: 1. The State licensing/certification agency responsible for surveying/licensing the community. E. The Administrator or his/her designee will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident .

Based on observation, interview, and record review the facility failed to notify the physician of the inability to complete ordered testing timely. This applies to 1 of 4 residents (R1) reviewed for physician ordered testing in a sample of 4. Findings include: R1's Face Sheet documents R1 was admitted to the facility on [DATE] after a peri-prosthetic right hip fracture. On 5/17/2024 at 11:50 AM, R1 was sitting in a wheelchair with swelling to his right lower leg. R1 stated he fractured his right hip at home and since then his right lower leg has been swollen. R1 denied any recent increases or changes to the swelling or any additional symptoms. R1 stated he has been taking medications to prevent blood clots since he was admitted . R1's Orthopedic Treatment Note dated 5/9/2024 documents an order for a stat ultrasound of his right leg to rule out a deep vein thrombosis (DVT). R1's Right Lower Venous Ultrasound Report dated 5/13/2024 documents completion of the ultrasound and diagnosed R1 with a DVT involving the right mid superficial femoral vein. On 5/17/2024 at 12:05 PM, V2 (Director of Nursing) stated she was notified on 5/10/2024 by V4 (Nurse) that R1 needed an ultrasound. V2 stated she called their contracted radiology, and they were unable to get it completed on 5/10/2024 but were going to try to complete the testing over the weekend (5/11-5/12/2024). V2 stated the contract company did not come to complete the ultrasound until 5/13/2024. V2 stated the facility policy for stat orders is to complete as soon as possible and confirmed the timeframe in which R1's ultrasound was completed would not have met stat criteria. V2 stated she should have contacted the physician to determine next steps. R1's Brief Interview of Mental Status dated 5/11/2024 documents R1 as cognitively intact. R1's Electronic Health Record did not show that the physician was notified regarding the delay in completing the ordered stat ultrasound. The policy Clinical Protocol: Guidelines for Notifying Health Care Providers of Clinical Problems documents the guidelines are to ensure that medical care problems are communicated to the health care provider in an efficient and effective manner. These guidelines document that when the need arises the facility is to notify a health care provider regarding a change in medical conditions. The charge nurse or supervisor should contact the attending physician any time they feel a clinical situation requires immediate discussion and management.

Based on observation, interview, and record review, the facility failed to properly label and date refrigerated items and remove expired food items in the kitchen. This applies to all 16 residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated [DATE] documents that the total census was 17 residents. On [DATE] at 11:14 AM, V3 (Dietary Manager) said there is 1 resident that does not eat from the facility kitchen. On [DATE] (starting at 10:01 AM), the facility kitchen was toured in the presence of V3 (Dietary Manager), and the following was found: In the walk-in cooler: 1. Quarter of a large processed turkey breast, opened [DATE], expiration date [DATE] (expired 11 days earlier). 2. Thawed ground beef sitting on a tray with juices leaking out of the bottom, wrapped in plastic wrap with no label or date. 3. 1.25 lbs. (pounds) Swiss cheese opened [DATE], not sealed with a good through date of [DATE]. Expired. 4. 24-ounce provolone cheese with a received-on date of [DATE] on box, no expiration date on package. 5. Medium silver bin of approximately 20 hot dogs, not in original bag, undated. 6. Half of a large processed ham, opened, expiration date [DATE]. Expired. 7. Medium silver bin labeled tomatoes with a good through date of [DATE]. Expired. 8. 26 half pint lactose free low-fat milks with expiration date of [DATE]. Expired. 9. 3 hard-boiled eggs with expiration date [DATE]. Expired. 10. Opened 5 lb. bag of shredded mozzarella cheese, undated. 11. Opened 5 lb. bag of shredded cheddar cheese, undated. On [DATE] at 10:30 AM, V3 (Dietary Manager) said it is the cook's responsibility to go through the foods to check for expiration dates and throw away expired items, it is part of their daily checklist. On [DATE] at 10:39 AM, V3 said expired items should be thrown away right away. V3 said all food items should be labeled at least with a received-on date and when the food item is opened it should be labeled with an opened date and an expiration date. V3 said the risk with not throwing away expired items is that the food might accidentally be fed to the residents and make them sick. The facility's policy titled, Food and Supply Storage last revised ,d+[DATE] states Policies: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption . Procedures: .Cover, label and date unused portions and open packages .Products are good through the close of business on the date noted on the label .Discard food past the use-by or expiration date .

Based on interview and record review the facility failed to initiate CPR (Cardiopulmonary Resuscitation) for a resident (R2) with full code status. The facility also failed to have a system in place to ensure that Advance Directives were accurate and complete (R1, R5, R11, R12). These failures resulted in R2 not receiving CPR as desired; and R1 being sent to the hospital, intubated, and later compassionately extubated at the hospital. These failures have the potential to affect all 22 residents residing in the facility. Findings include: These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was noted to begin on [DATE] when the facility failed to initiate CPR for R2. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 11:45 AM. The surveyor confirmed by observation, record review, and interview that the immediacy was removed on [DATE]. Although the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level II because additional time is needed to evaluate the implementation and effectiveness of the plan of correction, including the in-servicing of staff, the completion/accuracy of all resident Advance Directives, review of policies and Quality Assurance monitoring. The [DATE] Facility Data Sheet showed 22 residents reside at the facility. 1. R2's Face Sheet dated [DATE] identified R2 as a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include Rhabdomyolysis and DVT (Deep Vein Thrombosis). The Department of Public Health Practitioner Ordered for Life Sustaining Treatment Form (POLST), completed [DATE], documents R2 as a full code. R2's Nursing Notes dated [DATE], completed by V6 (Agency Registered Nurse), document, Received report from night nurse at 7:35 AM that resident expired in bed at 7:10 AM. Verified death at 7:45 AM, no respirations, no pulse, no BP (blood pressure). Notified MD (physician) of resident death that resident expired at 7:50 AM. On [DATE] at 12:48 PM, V8 (Certified Nursing Assistant) stated around 6 AM on [DATE] she observed R2 in her bed without any concerns, asleep and breathing. V8 stated sometime shortly after 7 AM she went back into R2's room and she noted R2 was not breathing. V8 stated R2 was newly admitted , and she was not aware of her code status, so she immediately alerted V7 (Agency Licensed Practical Nurse), also requesting V7 to check the code status. V8 stated V7 responded to the room, assessed R2, but did not start cardiopulmonary resuscitation (CPR) so she assumed R2 was a DNR. On [DATE] at 11:52 AM, V6 (Agency Nurse) stated, when she arrived to begin her shift on [DATE], V7 (Agency Nurse) reported to her that R2 had expired at 7:10 AM. On [DATE] 10:59 AM, V3 (Medical Director) stated he had reviewed R2's history and confirmed R2 was a [AGE] year-old with no apparent prior significant medical history, a full code status, and was living at home independently prior to her [DATE] hospitalization for DVT (Deep Vein Thrombosis) and Rhabdomyolysis. V3 stated he was aware an agency nurse failed to code R2 when she was found expired in bed on [DATE] and he expects them to initiate CPR if they are a full code status as she was. The facility's code blue policy dated ,d+[DATE] documents, The Procedure: Cardiopulmonary Resuscitation (CPR) and Code Blue policy documents if an individual is found unresponsive and not breathing the staff member who is certified in CPR shall initiate CPR. The chances of surviving sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse. The facility Serious Injury and Communicable Disease Report dated [DATE] documents at 7AM R2 was found unresponsive and not breathing. The investigation determined R2 was a full code status and CPR was not administered. 2. R1's Face Sheet dated [DATE] documents R1 as a [AGE] year-old admitted to the facility on this date at 9:42 PM with diagnoses to include herpes viral disease. R1's emergency contact is listed as V9 (R1's Daughter). R1's [DATE] Physician Ordered Sheet shows R1 with a Do Not Resuscitate Order (DNR/do no attempt CPR) dated [DATE]. On [DATE] at 9:20 AM, V4 (Registered Nurse Manager) stated on [DATE] she provided R1 medications at approximately 8:30 AM and R1 was talking and had no identified change. Approximately an hour later R1 was not responding but was breathing and had a pulse; 911 was called. During this event V4 was unable to locate R1's POLST form but there was a physician order in the electronic medical record (EMR) indicating R1 was a DNR. V4 stated without the POLST form the resident is always a full code and considered without advanced directives so the DNR order was not honored. V4 contacted R1's family who stated R1 was a DNR. A final Serious Injury and Communicable Disease Form dated [DATE] documents R1 was found unresponsive but was breathing and had a pulse. This form documents a POLST form could not be located and V9 (R1's Power of Attorney/POA) was contacted and confirmed R1's code status as no intubation or CPR; R1 was transferred to the hospital due to not having a POLST form. R1 was intubated at the hospital where she expired later that day. The facility investigation identified the POLST form had not been completed after admission on [DATE]. R1's Initial Emergency Department (ED) History and Physical dated [DATE] at 10:22 AM documents R1 with respiratory arrest and arriving in the emergency room biting at her intubation tube which was placed by emergency medical personnel prior to arriving to the ED. This report shows R1 was found with bradycardia (slow heart rate) and liver shock. R1's ED Triage Notes [DATE] at 10:13 AM show R1 arrived in the ED in respiratory distress, breathing over the intubation tube and fighting the placement of the tube. R1's Social Service/Case Manager Note, dated [DATE] at 12:27 PM, completed by V10 (Hospital Social Worker), documents V9 as R1's POA. This note documents V9 reporting to V10 on the phone, a DNR had been done previously at another hospital, but it was unsigned by the physician (invalid). V9 stated R1 was not supposed to be intubated. V10 made V9 aware that R1 was currently intubated, and V9 stated no treatment was to be discontinued until V9 arrived at the hospital to assess R1. V9 provided V10 with direction to include R1 was not to receive CPR and was to be provided comfort treatment only. V10 initiated the DNR per V9's wishes, had the physician sign and the advanced directive was implemented after the phone conversation. The ED Note [DATE] at 3:40 PM documents V9 agreed R1 could be extubated under comfort measures. The ED Notes Addendum [DATE] at 4:47 PM documents R1 expired at 4:38 PM. On [DATE] at 10:27 AM, V5 (Social Service Director) states upon admission the admitting nurse is to clarify advance directive status and V5 then additionally meets with resident and/or family to verify and discuss their advanced directive wishes. V5 stated R1 arrived at the facility on [DATE] late in the evening and V5 was busy on ,d+[DATE]-,d+[DATE] and unable to find time to meet with R1 and/or family to review R1's advanced directive status. V5 stated it is facility policy that all residents are a full code until a completed, signed POLST form is received. On [DATE] 10:45 AM, V5 further stated, advanced directives are completed within the first 24 hours except weekends, in which V5 then follows-up on the following Monday. V5 stated she is responsible to follow up with the resident's physician to obtain a signature to activate the POLST form. V5 verified on weekends no staff are available at the facility to finalize advanced directives. V5 stated she educates the resident and family at the time of completion of the POLST that it will not be in effect until the physician signs. [DATE] at 10:59 AM, V3 (Medical Director) stated he was aware R1 was admitted to the facility on [DATE] and her advanced directives were not obtained timely after her admission. V3 stated on [DATE] R1 was noted unresponsive, and the facility did not have her POLST form showing her as a DNR. V3 stated when the facility called him, he instructed them to send R1 to the emergency department (ED) and R1 was intubated. V3 stated he spoke with R1's family at the hospital and they were upset she had been intubated. V3 stated after further discussions in the ED, R1's family decided to extubate her where she passed away shortly after. V3 confirmed that the facility should have advanced directives put in place timely so R1's wishes (DNR) could have been addressed at the time she had a change in condition. V3 stated, Yes, she would have had a more peaceful death had she remained at the facility as a DNR status. V3 confirmed if her advanced directives had been in place R1 would not have experienced the trauma from insertion of the intubation tube, hospital transfer, and unnecessary treatments. 3. R11's Face Sheet dated [DATE] documents R11 admitted on this date. On [DATE] at 11:20 AM R11 stated, Today is the first time they (advanced directives) were discussed. R11's POLST form dated and signed by V3 on [DATE] shows R11 requests no intubation or mechanical ventilation. R11's BIMS dated [DATE] documents R11 as cognitively intact. 4. R5's Face Sheet dated [DATE] documents R5 admitted on this date. On [DATE] at 11:30 AM, R5 stated she has a POLST form completed through a lawyer years ago and requesting no intubation. R5's POLST form dated [DATE] shows R5 requests all treatment, including intubation. R5's BIMS dated [DATE] documents R5 as cognitively intact. 5. R12's Face Sheet dated [DATE] documents R12 admitted on this date. R12's POLST form signed on [DATE] shows R12 as a DNR. R12's November Physician Orders List shows R12's code status as full code dated [DATE]. [DATE] at 11:52 AM, V6 (Agency Registered Nurse) stated, It is not correct, I will fix that. R12's November Physician Orders form documents a new ordered dated [DATE] for R12 to be a DNR. The policy Advanced Directives dated ,d+[DATE] states it is the policy of the facility to inform residents/residents representatives about Advanced Directives to assist those who wish to complete advanced directives, honor choices identified in the advanced directives and to maintain records of advanced directives. Upon admission, the resident will be provided with information concerning the right to refuse or accept treatment and to formulate an advanced directive if he or she chooses to do so. If the resident is incapacitated and unable to receive information about his or her right to formulate an advanced directive, the information may be provided to the resident's representative. Prior to or upon admission of a resident the Social Services Director or designees will inquire about the existence of any written advance directives. Advanced directives shall be displayed prominently in the medical record. If the resident indicates that he or she has not established advanced directives, the facility will offer assistance in establishing advanced directives. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. A resident will not be treated against his or her own wishes the Director of Nursing Services or designee will notify the Attending Physician of advanced directives so that appropriate orders can be documented in the resident's medial record. The Immediate Jeopardy that began on [DATE] and was removed on [DATE] when the facility took the following actions to remove the immediacy: 1. Corrective action for residents noted to have been affected by the deficient practice. a) R2 expired [DATE] after staff failed to initiate CPR when the resident was found unresponsive, and vital signs absent. No further resident follow up required at this time. b) R1 was transferred to the hospital with no POLST which resulted in intubation requiring compassionate extubation. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice? a) Residents currently residing in the community on [DATE] have the potential to be affected by the identified practice. b) A review of all current resident's medical records was completed by DON/designee on [DATE] to ensure that a current and valid POLST was on the resident's file and coincides with the provider order and care plan updated. Any incomplete POLST forms will be updated and completed by the social services director or designee and provider orders updated by the DON or designee by [DATE]. c) Mock Code drills were performed on all shifts on ,d+[DATE], ,d+[DATE], ,d+[DATE] and [DATE]. Education was provided during drills to associates. 3. The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not recur. a) AdHoc QAPI meeting held by the interdisciplinary team on [DATE] and this plan of correction was developed and implemented. b) The Medical Director was notified by the Executive Director on [DATE] and the plan of correction was reviewed and approved. c) All direct care licensed nurses, all agency nurses and CNAs will be re-educated by the Director of Nursing or designee by [DATE] or prior to working the next scheduled shift on Do Not Resuscitate Order, POLST forms, and Cardiopulmonary Resuscitation and Protected Code Blue. d) Executive Director notified staffing agency of the incident on [DATE]. e) Interdisciplinary team has reviewed policies and procedures Do Not Resuscitate Order, POLST forms, and Cardiopulmonary Resuscitation and Protected Code Blue and is in compliance with CMS regulation F Tag 678. f) The nurse on duty will verify the presence of advance directives or the resident's wishes with regard to CPR, upon admission. If the resident's wishes are different than the admission orders, or if the admission orders do not address the resident's code status and the resident does not want to receive CPR, the admitting nurse will document the resident's wishes in the medical record and contact the physician to obtain the order. A verbal declination of CPR by a resident, or if applicable a resident's representative, should be witnessed by two staff members and documented. While the physician's order is pending, staff will honor the documented verbal wishes of the resident or the resident's representative, regarding CPR. g) Social Services Director or designee has been educated on the expectation to follow up and complete POLST forms within 72 hours of admission that coordinate with advance directive orders. h) Reviews of POLST, physician orders and care plans will be completed by the DON or designee weekly at Resident at Risk for all admissions and readmissions. Monthly reviews will be completed by the Executive Director or designee. i) Any nursing staff receiving any changes in provider's orders r/t change in CPR status will notify the Social Service Director to update the POLST form. 4. Quality Assurance Plans to monitor facility compliance to make sure that corrections are achieved and permanent. a) Monthly reviews of POLST forms to ensure any changes to advanced directives or new admission are completed and initiated in a timely manner will be completed by the Executive Director or designee and reported at QAPI. b) The DON or designee will interview 3 nurses per week to ensure they are able to verbalize the expectations on how to respond when finding a resident unresponsive and what to do when a change of condition was observed. c) The Director of Nursing, or designee, will complete 2 mock code drills weekly with all direct care staff on varying shifts for three months. d) A summary report of findings will be provided to the QAPI committee for review. The QAPI committee will review findings and trends monthly and will reevaluate if further monitoring is indicated.

Based on interview and record review the facility failed to notify the physician of a resident's change of condition. This applies to 1 of 12 residents (R2) reviewed for advanced directives in a sample of 14. This failure resulted in a potentially avoidable death when R2's change in condition was not addressed and R2 expired unexpectedly. Findings include: R2's Face Sheet dated [DATE] identified R2 as a [AGE] year-old admitted to the facility on [DATE] with diagnoses to include Rhabdomyolysis and DVT (Deep Vein Thrombosis). On [DATE] at 12:50 PM V12 (Certified Nursing Assistant/CNA) stated around 8:20 PM [DATE] R2 was moaning and groaning like she was in pain and was breathing abnormal when she was moved. V12 stated she couldn't stand as she could the previously when V12 cared for her and V7 (Agency Licensed Practical Nurse) was informed that something was wrong. On [DATE] at 12:33 PM V4 (Registered Nurse Manager) stated a voicemail was left for V2 (Director of Nursing) by V7 on [DATE] at 8:25 PM. V4 stated she is covering while V2 is on vacation, therefore, V2 forwarded the voicemail to V4. V4 replayed the voicemail for the surveyor and the message heard included .(R2's) breathing was not stable .I do not know what to do V4 stated she called V7 at 8:35 PM and instructed V7 to contact V3 (Medical Director) for further instructions to address R2's shortness of breath. V4 stated she became aware the next morning V7 did not contact V3 as instructed. On [DATE] at 11:52 AM V6 (Agency Registered Nurse) stated, when she arrived to begin her shift on [DATE] at approximately 7:35 AM, V7 reported to her that R2 had expired at 7:10 AM. V6 stated V7 also reported around 8:30 PM on [DATE] R2 was short of breath, and she provided R2 a pain pill which seemed to help. On [DATE] V3 (Medical Director) stated he had reviewed R2's history and confirmed R2 was [AGE] years old with no apparent prior significant medical history, a full code status, and was living at home independently prior to her [DATE] hospitalization for DVT and Rhabdomyolysis. V3 stated the night before R2 passed, she was having difficulty breathing and the agency nurse was instructed by a facility nurse manager to call him, and the agency nurse did not. V3 stated, Unfortunately they didn't call me. I would have sent her to ED (Emergency Department). They would have completed a cardiac work-up and evaluated her symptoms. She had a DVT in the leg and it could have been a pulmonary embolus .One thing I do know is they should have called me. V3 confirmed R2's death was potentially avoidable, further stating, Yes, calling me to report her breathing the night before as instructed .could have potential changed the outcome. My job is to take care of my patients. They did not give me the opportunity to care for her. I cannot say she would have lived, but ED would have evaluated her and if they found something, treated it . R2's [DATE] EMAR (Administration Record) documents R2 received oxycodone-acetaminophen ,d+[DATE], 1 tablet, [DATE] at 8:48 PM. The policy Change in Resident's Condition or Status dated ,d+[DATE] documents the facility shall promptly notify the residents healthcare provider of changes in the resident's medical condition or change in status.

Based on interview and record review the facility failed to keep a resident free from neglect when they failed to notify the physician of a change in condition, provide medications as ordered, and initiate cardiopulmonary resuscitation. This applies to 1 of 12 residents (R2) reviewed for advanced directives in a sample of 14. This failure resulted in a potentially avoidable death when R2's change in condition was not addressed. R2 was later observed unresponsive and resuscitation and/or emergency interventions were not initiated. Findings include: R2's Face Sheet dated [DATE] identified R2 as a [AGE] year-old admitted to the facility on [DATE] with diagnoses to include Rhabdomyolysis and DVT (Deep Vein Thrombosis). The Department of Public Health Practitioner Ordered for Life Sustaining Treatment Form (POLST), completed [DATE], documents R2 as a full code. R2's Hospital Discharge Instructions [DATE] documents R2 to receive Eliquis 10 milligrams twice daily for 7 days. R2's [DATE] EMAR (Administration Record) documents R2 did not receive Eliquis 10 milligrams on [DATE] at 4 PM and [DATE] at 8 AM and 4 PM. On [DATE] at 9:45 AM V2 (Director of Nurses) confirmed R2 did not receive her Eliquis as ordered for the treatment of her DVT and should have. V2 stated the first dose she received after admission was the morning of [DATE]. On [DATE] at 12:50 PM V12 (Certified Nursing Assistant) stated around 8:20 PM [DATE] R2 was moaning and groaning like she was in pain and was breathing abnormal when she was moved. V12 stated she couldn't stand as she could previously when V12 cared for her and V7 (Agency Licensed Practical Nurse) was informed that something was wrong. On [DATE] at 12:33 PM V4 (Registered Nurse Manager) stated a voicemail was left for V2 (Director of Nursing) by V7 on [DATE] at 8:25 PM. V4 stated she is covering while V2 is on vacation, therefore, V2 forwarded the voicemail to V4. V4 replayed the voicemail for the surveyor and the message heard included .(R2's) breathing was not stable .I do not know what to do V4 stated she called V7 at 8:35 PM and instructed V7 to contact V3 (Medical Director) for further instructions to address R2's shortness of breath. V4 stated she became aware the next morning V7 did not contact V3 as instructed. On [DATE] at 12:48 PM V8 (Certified Nursing Assistant) stated on [DATE], shortly after 7 AM, she went into R2's room and noted R2 was not breathing and immediately alerted V7. V8 stated V7 responded to the room, assessed R2, but did not start cardiopulmonary resuscitation (CPR). On [DATE] at 11:52 AM V6 (Agency Registered Nurse) stated, when she arrived to begin her shift on [DATE] at approximately 7:35 AM, V7 reported to her that R2 had expired at 7:10 AM. V6 stated she assessed R2 who was cold and was past resuscitation efforts. V6 stated V7 also reported around 8:30 PM on [DATE] R2 was short of breath, and she provided R2 a pain pill which seemed to help. R2's Nursing Notes dated [DATE], completed by V6, document, Received report from night nurse at 7:35 AM that resident expired in bed at 7:10 AM. Verified death at 7:45 AM, no respirations, no pulse, no BP (blood pressure). Notified MD (physician) of resident death that resident expired at 7:50 AM. On [DATE] V3 (Medical Director) stated he had reviewed R2's history and confirmed R2 was [AGE] years old with no apparent prior significant medical history, a full code status, and was living at home independently prior to her [DATE] hospitalization for DVT and Rhabdomyolysis. V3 stated the night before R2 passed, she was having difficulty breathing and the agency nurse was instructed by a facility nurse manager to call him, and the agency nurse did not. V3 stated, Unfortunately they didn't call me. I would have sent her to ED (Emergency Department). They would have completed a cardiac work-up and evaluated her symptoms. She had a DVT in the leg and it could have been a pulmonary embolus. Did the nurse really give her Eliquis? If they did, it was likely not a clot. Who knows? One thing I do know is they should have called me. V3 stated he was aware an agency nurse then failed to initiate CPR when R2 was found expired in bed on [DATE]. V3 stated he expects the nurses to initiate CPR if a resident is a full code status. V3 confirmed R2's death was potentially avoidable, further stating, Yes, calling me to report her breathing the night before as instructed and implementing CPR could have potentially changed the outcome. My job is to take care of my patients. They did not give me the opportunity to care for her. I cannot say she would have lived, but ED would have evaluated her and if they found something, treated it . R2's [DATE] EMAR (Administration Record) documents R2 received oxycodone-acetaminophen ,d+[DATE], 1 tablet, [DATE] at 8:48 PM. The facility's code blue policy dated ,d+[DATE] documents, The Procedure: Cardiopulmonary Resuscitation (CPR) and Code Blue policy documents if an individual is found unresponsive and not breathing the staff member who is certified in CPR shall initiate CPR. The chances of surviving sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse. The policy Change in Resident's Condition or Status dated ,d+[DATE] documents the facility shall promptly notify the residents healthcare provider of changes in the resident's medical condition or change in status. The facility Abuse Prevention policy dated ,d+[DATE] documents the failure of the community, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish or emotional distress. The community's goal is to achieve and maintain an abuse free environment. As part of the resident abuse prevention program, the administration will provide a safe resident environment and protect the residents from abuse by anyone including, but not limited to community associates, other residents, consultants, volunteers, associates from other agencies, family members, legal representatives, friends, visitors, or any other individual.

Based on observation, interview, and record review, the facility failed to store food items in a sanitary condition. This affects all 22 residents consuming food from the kitchen. Findings include: On [DATE] at 10:04 AM, during the initial tour with V4 (Dietary Manager), two corn grit packages (24 ounces each) showed an expiration date of [DATE]. On [DATE] at 10:10 AM, the kitchen walk-in cooler had a five-pound sour cream container that expired on [DATE]. On [DATE] at 10:15 AM, the dietary freezer was noted with ice build-up on a big opened cardboard box having 12 bags of 3-pound Okra inside. On [DATE] at 9:44 AM, V4 stated, I am the one who is supposed to check on expired food items to discard them. I missed a couple of food items that expired. I called the company to fix the condensation issue with our freezer. Food items shouldn't have ice built upon the box. On [DATE] at 11:16 AM, V2 (Director of Nursing) stated that all 22 residents were consuming food from the kitchen. The facility presented Food and Supply Storage policy revised on ,d+[DATE] document, Foods past the use by, sell by, best by, or enjoy by date should be discarded.

Based on observation, interview, and record review, the facility failed to provide catheter care to prevent potential urinary tract infection (UTI) by having the catheter bag touching the floor, not maintaining the catheter bag below bladder level, and not maintaining a closed system of the indwelling catheter. This applies to 1 of 2 residents (R18) reviewed for indwelling catheter care in a sample of 14. Findings include: On 03/28/23 at 10:36 AM, R18 was sitting in his bedroom chair with an indwelling catheter bag touching the floor and the tubing was noted with cloudy urine and sediment. On 3/28/23 at 10:40 AM, R18 stated that his catheter was leaking. On 3/28/23 at 10:57 AM, V3 (Registered Nurse/RN) stated, R18's incontinent brief is wet with urine, and the catheter is leaking. It was leaking yesterday, but the night nurse reported to me that there was no leak. I called the physician (MD) to relay R18's urine sensitivity result that came out on 3/27/23 at 4:00 AM. We tried to reach him, but MD never answered our call. Finally, I could reach him today (3/28/23) after 8:00 AM. On 3/28/23 at 1:44 PM, V2 (Director of Nursing/DON) stated, They should notify MD as soon as possible (ASAP) when they found out the indwelling catheter was leaking. They should have called the medical director if the attending was not answering. I will educate them on that issue. The urine sensitivity final result should have been relayed to the physician ASAP to start antibiotics to manage the UTI. Indwelling catheter bags shouldn't be on the floor. On 3/28/23 at 11:02 AM, V3 stated that MD ordered Cipro 500 milligrams (mg) twice daily x 7 days for UTI. On 3/28/23 at 10:50 AM, V5 (Certified Nursing Assistant) placed R18's urinary catheter bag on the bed while V3 tried changing the catheter tubing. On 3/30/23 at 11:00 AM, V2 (DON) stated, The indwelling catheter bag should be maintained below bladder level to prevent backflow. The facility presented a urinary catheter care policy (last approved on 01/2022) document: The urinary drainage bag must always be held or positioned lower than the bladder to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on interviews and record review, the facility failed to ensure that a resident did not roll out of bed during provision of care by staff. This applies to 1 of 3 residents (R1) reviewed for fall with injury in the sample of 3. The findings include: R1 has multiple diagnoses which included acute and chronic [CONDITION(S)] with [CONDITION(S)], [CONDITION(S)] in chronic kidney disease, obesity, hereditary and idiopathic [CONDITION(S)], [CONDITION(S)] heart disease of native coronary artery without [CONDITION(S)] pectoris, stage 3 chronic kidney disease, lack of coordination and weakness, based on the diagnosis/history list. R1's current quarterly MDS (minimum data set) dated July 26, 2022 showed that the resident is cognitively intact. The MDS showed that R1 required extensive assistance from the staff during bed mobility, transfer, ambulation, locomotion on and off the unit, dressing, toilet use and personal hygiene. The same MDS showed that R1 was frequently incontinent of bladder and occasionally incontinent of bowel functions. R1's electronic progress notes dated August 12, 2022 (12:28 AM) showed that the resident was on palliative care. R1's weight record showed that the resident weighed 189.60 pounds on August 12, 2022. R1's handwritten progress notes dated August 12, 2022 (10:00 AM) created by V4 (Registered Nurse/RN) showed in-part, Initial fall report. (R1) fell from bed while being changed by (V3 Certified Nursing Assistant/CNA). (R1) and CNA both told me that while CNA was sliding brief under (R1) that he rolled slightly to the left and fell out of bed and on to his left side on to the floor. (R1) suffered from [CONDITION(S)] to left side of his forehead hitting his call light pendant. This happened at 8:25 AM. Ambulance was called and (R1) was taken to hospital where he received a head and [cervical] spine CT (computerized tomography). All scans and x-rays were clear. A (dressing) was applied to forehead laceration and (R1) was transported back to facility. R1's incident report showed that on August 12, 2022 at 8:25 AM the resident had a fall during staff provision of care. The incident report showed, (R1) was getting his brief changed by CNA and was asked to raise his behind to slide the brief under. (R1) raised his behind and turned to the left when suddenly he rolled out of bed. CNA had nothing to grab (R1) by to save him from the fall. The same incident report showed that R1 sustained a superficial laceration to the left forehead measuring 2 mm (millimeters) and bruising to the left eye. R1's incident report sent to the State Agency via facsimile on August 12, 2022 showed that on August 12, 2022 at 8:25 AM, Resident (R1) was asked by CNA (V3]) to turn so she could perform patient care (change brief) while in his room lying in the bed. Resident turned over too far, fell off the bed and hit his head on the call light pendant (worn around the neck). Resident had a bleeding cut on his head, assessment performed by RN (V4), then LPN (V5 Licensed Practical Nurse) dialed 911 for resident to be sent out to the ER (emergency room ). Family notified were left a voicemail. PCP (V6 Primary care Physician) was notified via answering service. R1's hospital emergency room records dated August 12, 2022 showed that the resident was presented at the hospital post fall. Under physical examination the resident had a small left forehead laceration, hemostatic, surrounding mild induration and [CONDITION(S)] consistent with bruising. R1's active care plan initiated by the facility on June 10, 2021 showed that the resident is at risk for falls and fall related injury. The same fall care plan showed that the facility added approaches on August 12, 2022 for a bariatric bed and staff educated. Check space availability before rolling. On November 2, 2022 at 1:54 PM, R1 was inside his room, sitting in his wheelchair. R1 was alert, oriented and verbally responsive. In the presence of V4 (RN), R1 stated that he remembered falling out of bed sometime August 2022. According to R1, someone was changing me and pushed me over the edge of the bed. There was no room for me to move, then I fell out of the bed and hit my head on the floor. I had a lump on the left side of my forehead. They put a patch on it for a long time, now it is healed. R1's bed was observed to be a bariatric bed (wider) with air mattress. On November 2, 2022 at 2:15 PM, in the presence of V1 (Administrator), V4 (RN) stated that she was the nurse on duty on August 12, 2022 when R1 fell out of bed. V4 stated that on August 12, 2022 at around 8:20 AM she heard a staff calling her name from R1's doorway. Upon entrance to R1's room, she did not immediately see R1 because the resident was on the floor on the left side of the bed, near the window which was the side away from the door. She saw R1 on his back on the floor with bleeding coming from the left side of his forehead, the call light pendant that was hanging on the resident's neck had blood and R1's hands had blood on it because the resident kept on touching his head. According to V4, R1 was able to move all his extremities without difficulty but complained of back pain. V4 stated that she immediately got a clean towel and applied pressure on R1's forehead and requested V5 (LPN) to call 911. V4 stated that 911 arrived at the facility within 10 minutes and transported R1 to the hospital for evaluation. While waiting for the 911 personnel to arrive she asked V3 (CNA) what had happened. According to V3, she was changing R1 and had asked the resident to roll to the side of the bed for her (V3) to change the resident's brief. According to V3 while R1's soiled brief was still on, she asked the resident to lift his buttocks to pull the soiled brief out and while R1 was lifting his buttocks, R1's body slightly turned to the left and the resident rolled out of bed. V4 stated that she also asked R1 what had happened. R1 stated that he was trying to grab a piece of candy from the side table and rolled out of bed. According to V4, R1 was oriented as his baseline, prior to the said fall incident. On November 2, 2022 at 2:57 PM, V2 (Director of Nursing) stated that post fall incident of R1, she interviewed V3 (CNA). According to V2, V3 told her that R1 turned himself for her (V3) to take his soiled brief, then R1 fell out of bed. V3 tried to grab R1's gown to stop the fall but was not successful and that when R1 fell , he hit his head on his call pendant and not the floor. V2 stated that R1 sustained a superficial laceration on the left forehead and when R1 returned to the facility from the hospital, bruising around R1's left eye was observed. According to V2, after R1's fall incident, the facility changed R1's bed from the regular/standard size bed with air mattress to a bariatric bed which was wider with air mattress. V2 stated that she also educated V3 and told V3 to make sure to check that there is enough space to turn the resident during care, while in bed, to prevent the resident from rolling out of the bed. On November 2, 2022 at 3:08 PM, V3 (CNA) stated that on August 12, 2022 between 8:00 AM and 8:30 AM, she was changing R1's disposable brief while the resident was in bed. V3 stated that R1 was using a regular/ standard size bed with air mattress and had no side rails. She raised R1's bed slightly higher to reach the bed and positioned herself on the right side of the resident which was the right side of the bed (closer to the door). While R1 was in the middle of the bed in a supine position (face and torso facing up), she unfastened the adhesive on both sides of the resident's disposable brief and then tucked the edges of the left side of the disposable brief as far as she could under R1's left buttock area. She (V3) then told R1 that she will turn the resident on his left side which was away from her to pull out the soiled disposable brief. According to V3, R1 turned himself halfway on his left side and at the same time she (V3) proceeded to pull out the soiled disposable brief from under the resident, but during the process R1 continued to roll further to the left and eventually rolled out of the bed to the floor. V3 stated that the incident happened so fast and that she attempted to grab on R1's gown but because of the momentum and R1's weight she was not able to prevent the fall of the resident. V3 stated that R1 fell from the left side of the bed near the window area. According to V3, she saw R1 with a cut on his head when the resident was already on the floor, and she immediately called the nurse. The nurse assessed R1 and had called 911 to take the resident to the hospital. V3 stated that they waited for the 911 personnel to move the resident from the floor. On November 3, 2022 at 9:53 AM, V6 (Physician) stated that R1 is able to answer questions. According to V6, R1 is weak, and he does not know if the resident can turn himself while in bed. V6 stated that he was aware that R1 had a fall incident. V6 stated that the staff should make sure that there is enough space in bed for the resident to turn, especially during provision of care to prevent fall incident. V6 further stated that it is not expected for any resident to roll out of bed, while a staff is providing care.

Based on observation, interview, and record review, the facility failed to follow standard infection control process related to hand hygiene and change of gloves during provisions of care. This applies to 4 of 6 residents (R2, R3, R4, R12) reviewed for infection control during provisions of care and medication administration in the sample of 12. The findings include: 1. On 12/14/21 at 10:18 AM, V9 and V10 (Both Certified Nursing Assistants/CNA) assisted R12 to the toilet with a sit to stand lift. After R12 used the toilet, V9 provided peri-care while R12 was standing in the sit to stand lift. V9 proceeded to pull the incontinence brief and pants back in place, straightened R12's clothes and transferred R12 back to the wheelchair while wearing the same soiled gloves used while providing peri-care. 2. On 12/14/21 at 11:50 AM, V8 (Assistant Director of Nursing/ADON) and V9 (CNA) assisted R4 to the bathroom. After R4 used the toilet, V8 cleaned R4's buttocks with wet wipes. V8 proceeded to assess R4's skin by palpating/touching the clean area, and then applied a barrier cream while wearing the same soiled gloves. 3. On 12/14/21 at 1:00 PM, V8 and V9 transferred R2 from the motorized wheelchair to the bed using a mechanical lift. While R2 was being lowered to the bed, V8 held on to R2 by her shoes to help with positioning. V8 and V9 provided incontinence care to R2. V8 cleaned R2's perineum and buttocks, assessed the skin by touching/palpating clean body area. After, she (V8) applied protective dressing to the sacral/coccyx area, applied new incontinence brief, pulled pants back on, straightened clothes, transferred R2 back to motorized wheelchair, and assessed R2's feet while wearing the same soiled gloves. V8 and V9 did not change their gloves and sanitized their hands in between task. On 12/15/21 at 1:25 PM, V2 (Director of Nursing/DON) stated that whenever staff is providing care, the staff must change gloves and sanitize their hands in between dirty to clean task. This is to prevent potential spread of infection, or cross contamination. Facility's Hand Hygiene Policy and Procedure showed: Use an alcohol-based hand rub, per CDC recommendation use alcohol-based hand sanitizers with greater than 60% [MEDICATION(S)] or 70% [MEDICATION(S)], alternatively, soap and water for the following situations: 8. Before moving from a contaminated body site to a clean body site during resident care 10. After contact with blood and body fluids. 4. On 12/14/21 at 9:37 AM, V11 (Nurse) prepared the oral medications for R3. While R3 was taking his oral medications, one medication fell out of his hand and the medication landed on the floor. V11 picked up the medication from the floor with her bare hand. V11 placed the medication she picked up on top of the resident's bedside table and waited for R3 to finish taking the rest of his medications. When R3 finished taking his oral medications. V11 went back to the medication cart, opened another packet/plastic wrap of the same medication that was dropped on the floor and placed it inside the medication cup. V11 prepared this medication without performing hand hygiene (hand washing or use of hand sanitizer) after picking up the medication from the floor. V11 went back to R3's room to give the medication to R3. V11 was about to hand/give the medication cup to R3 and stated that she is ready to give the medication. It was during this time that V11 was told that she did not perform hand hygiene after picking up the medication from the floor. V11 acknowledged the failure, went back to the medication cart, used hand sanitizer and prepared another medication for R3. On 12/15/21 at 1:30 PM, V2 (Director of Nursing) stated that when V11 picked up the medication from the floor with her bare hands, V11 should perform hand hygiene either hand washing or use of a hand sanitizer before preparing the medication to replace the one that was dropped on the floor.

Based on observation, interview, and record review, the facility failed to follow pureed serving portion sizes for serving pureed pasta and rice. This applies to 2 of 2 residents (R9, R10) reviewed for pureed diets in the sample of 12. The findings include: Facility Portion Scoop Chart listed the following: #8 scoop=4 oz (ounces) #12 scoop=2.67 oz #16 scoop= 2 oz Facility menu diet spreadsheet for lunch on Monday 12/13/21 for pureed diets included the following: Puree Chicken Bowtie Alfredo 6 oz portion (spoodle=6 oz) [puree guide], Pureed Rice =1 scoop #8, Pureed Gingered Carrots 1/2 cup. On 12/13/21 at around 11:15 AM, V6 (Food Service Director) stated that the pureed meat and pureed vegetables were purchased prepackaged and heated and served during the meals. The label on the container of these prepackaged items showed 3 oz/serving. On 12/13/21 at 12:05 PM, the lunch meal tray line service was observed with V7 (Cook) at tray line platting the food. Items for pureed meal on steam table included the prepackaged pureed meat (chicken =3 oz) and prepackaged pureed vegetables (Carrots =3 oz). Additional items included pureed rice served using #12 scoop and mashed potato which had a #16 scoop. V7 stated that mashed potatoes are a side served to those who requested for the same. R9 and R10 received Pureed diets and received one serving of 3 oz pureed chicken, one and half servings (about 4.5 oz) of the prepackaged 3 oz pureed carrots and 2.67 oz (#12 scoop) serving of pureed rice. Facility Resident Listing Report of diets included that R9 and R10 received pureed diets. On 12/13/21 at 12:18 PM and 1:34 PM, V7 stated that she did not prepare pureed pasta as she was instructed to serve pureed rice instead for the pureed diets. V7 added that she was not aware that the menu showed 4 oz for pureed rice. On 12/14/21 at 2:08 PM, V4 (Dietitian) stated that the residents on pureed diets should have received 6 oz of chicken with pasta and 4 oz of pureed rice portions as shown on the menu spreadsheet. Puree Recipe for Bowtie Pasta and Chicken Alfredo included serving portion =6 oz portion. Assembly instructions on the recipe for the chicken and pasta included the following: To serve, place a single portion of pasta puree and top with 2 oz of cream sauce. Place puree chicken breast on top of pasta and ladle 1 oz cream sauce over the chicken.

Based on observation, interview, and record review the facility failed to sanitize laundry with appropriate chemicals. This applies to all 18 residents residing in the facility who were reviewed for infection control. Findings include: On 9/3/21 at 10:00AM, the facility provided a census sheet that showed 18 residents resided at the facility on that date. On 9/3/21 at 10:15AM, a tour of the laundry room was completed. Two commercial washers had signs posted Do Not Use. V3 (Laundry Aide) said the commercial washers had not been working for a while. V3 said one washer had not been working for longer than a year and the other had not been working for several months. V3 said all the laundry from the facility was being washed in the small residential washing machines used for personal clothing. V3 said she washed isolation laundry on the hottest setting. V3 named the particular brand of detergent the facility uses and said it was the only detergent used to wash laundry. V3 denied using any bleach in the laundry. On 9/3/21 at 10:25AM, V4 (Maintenance Assistant) said he was unsure how long the commercial washing machines had not been working. V4 said the washing machines had been assessed by a technician and the parts were too expensive and it would be cheaper to replace the washing machine. On 9/3/21 at 11:37AM, V2 Director of Nursing (DON) stated if the laundry is not washed with the correct detergents it would be possible to spread a number of diseases. V2 said if the laundry is not correctly washed it had the potential to affect every resident and staff member. On 9/3/21 at 12:40PM, V4 (Maintenance Assistant) said he did not know how long the wash cycle of the residential washing machines was. V4 said if heat was used without chemicals, the water temperature would need to be 165 degrees Fahrenheit. V4 said the residential washing machines had a preset amount of detergent added to them by a machine mounted on the wall. V4 said the facility did not have a way of testing the facility detergent for Parts Per Million (PPM). V4 measured the water temperature in the residential washing machine set on the hottest setting and the water measured 79.3 degrees Fahrenheit. On 9/7/21 at 10:44AM, V13 (Safety and Emergency Management Director) said the facility detergent was not intended to be a disinfectant for linens. V13 said Bleach should be used and have a 125 PPM. V13 said temperature was not important with chemical disinfectants. V13 said if relying on temperature alone, the water temperature would need to reach 165 degrees Fahrenheit. V13 said if there is no bleach used, the laundry would not have the appropriate amount of disinfection. V13 said bleach is automatically dispensed in the commercial machines but not in the residential machines being used. V13 said the facility detergent could not treat any virus or spores. The facility policy Environmental Services- Laundry and Linen dated 12/2019 showed . Sorting Soiled Linen . E. Prewash briefs, underpads and any other items soiled with feces, using maximum setting of bleach/ EPA registered germicide, and then process them through a regular cycle . Washing Linen and Other Soiled Items- A. Laundry may be processed in either low temperature or high temperature cycles. 1. For high temperature processing, wash the linen in water that is at least 160 degrees Fahrenheit, for a minimum of 25 minutes. 2. For low temperature processing, wash linen in water that is at least 71 to 77 degrees Fahrenheit and use a 125 part per million chlorine bleach rinse if the material being washed can withstand bleach and remain intact . The facility policy Waste Management, Disinfectants and Cleaning showed the detergent was not included as an approved disinfectant.

Based on observation, interview and record review the facility failed to supervise a resident while toileting, as a result R2 fell and suffered a fractured nasal bone. This applies to 1 of 4 residents (R2) reviewed for falls in the sample of 13. The findings include: R2 was admitted to the facility (MONTH) 20, 2014 per the admission face sheet. The physician order [REDACTED]. On (MONTH) 26, (YEAR) at approximately 10:00am was sitting in a reclining chair with very low arms. R2 was slouched over to the left with left arm hanging in between the bed and the chair. There was a large mat under R2's bed. R2's feet were propped up on a small bench. On (MONTH) 27, (YEAR) at approximately 3:10 pm R2 was again sitting in the recliner just as the day before. The mat was still under R2's bed. V3 LPN (Licensed Practical Nurse) came in R2's room and said that the mat should be on the floor in front of the chair. V3 stated, R2 is at risk for falls and this is a floor mat alarm. This way if resident stands up the alarm will go off. R2's MDS (Minimum Data Set) showed that R2 had a mild cognition deficit requiring frequent cueing for memory. The MDS showed that R2 was an extensive assist for toileting and required a one person assist. The care plans for toileting dated prior to (MONTH) 10, (YEAR) showed to continue monitoring risk factors such as dizziness and [MEDICAL CONDITION], antiepileptic medications, impaired mobility, floor alarms and frequent monitoring as interventions to prevent falls. The fall assessment in R2's clinical record dated (MONTH) 2, (YEAR) showed that R2 was at high risk for falls. Incident reports dated, (MONTH) 9, (YEAR), (MONTH) 3, (YEAR), (MONTH) 6, (YEAR) 3:00 pm and 7:46 pm, (MONTH) 29, (YEAR), (MONTH) 2, (YEAR), April10, (YEAR), (MONTH) 12, (YEAR) and (MONTH) 1, (YEAR) showed that R2 had falls in R2's room, transferring self-unassisted, and in the bathroom. All of the falls were un-witnessed by facility staff. The incident report dated (MONTH) 10, (YEAR) showed that at 9:25 am R2 fell forward off of the toilet and hit the floor face first. The incident investigation/the CNA post fall tool that R2 was confused prior to the fall. The investigative report showed that the CNA had left R2 on the toilet alone. The report showed that when the CNA returned R2 had fallen forward off of the toilet. The report showed that the CNA was unable to prevent R2 from hitting the floor. Nursing notes dated (MONTH) 10, (YEAR) showed that at 9:25 am a CNA called for help in R2's room. The note showed that R2 was laying on the floor face first and R2's legs were straddling the toilet. The note showed that R2 was not responsive. The note showed that R2 was covered with feces and had blood all over R2's face. The note showed that once turned over R2 became more responsive and had a laceration to the bridge of the nose and above upper lip. The nursing note dated (MONTH) 10 (YEAR) showed that at 9:36 am R2 was sent out to the hospital. The notes showed that R2 returned to the facility the same day at 12:35 pm. The note showed that x-rays done at the community hospital showed that R2 had a broken nose. The note showed that x-ray reports from the community hospital dated (MONTH) 10, (YEAR) showed that R2 suffered a fracture and displacement of the nasal bone and septum of the nose. On (MONTH) 27, (YEAR) at 2:00 pm on unit 700 V4 LPN (Licensed Practical Nurse) said that R2 should not be left alone while toileting. V4 stated, Residents who are at risk for falls and sometimes confused should be supervised while toileting. On (MONTH) 27, (YEAR) at 2:45 pm on unit 600 V5 and V6 both CNA's said that residents who were confused and at risk for falls should not be left alone in the bathroom. On (MONTH) 28, (YEAR) at 1:30 pm via telephone V10 Medical Director of the facility stated, R2 should not have been left alone while being toileted. The facility policy for falls dated (YEAR) showed that ongoing communication between all members of the healthcare team is essential for implementation for an appropriate fall prevention plan. The policy also showed that high risk for falls residents should not be left unattended.

Based on interview and record review the facility failed to ensure that a resident was free of a significant medication error by not following a physician's orders [REDACTED]. This resulted in R1 receiving three times the daily dosage of [MEDICATION NAME] for eighteen days. R1 became unresponsive and was hospitalized with toxic blood levels of [MEDICATION NAME]. This applies to 1 one of 3 residents (R1) reviewed for physician's orders [REDACTED]. The findings include: According to the face sheet and physician's orders [REDACTED]. R1's admission orders [REDACTED]. On 8/19/16 at 12:00 PM E1, Director of Nursing (DON) stated R1's medication orders were transcribed by E2, Licensed Practical Nurse (LPN). The transcribed (hand written) orders were then sent to the pharmacy. The pharmacy processed the orders and sent a printed version back to the facility for the following month, (July 1st to July31st). E1 stated she checked the new printed orders against the handwritten orders to ensure the orders were the same. However, the new orders from the pharmacy did not have the correct dose of [MEDICATION NAME] listed and E1 did not detect the error. According to the facility's incident report investigation the error was not caught on reconciliation, nurse double check or audit. According to the MAR (medication administration record) R1 received 1500 mg of [MEDICATION NAME] twice per day from July1st until July18th, 2016. This dose is three times the amount ordered by the physician per day for a total number of 36 incorrect doses. According to the facility's incident report on July 19th, 2016 R1 became lethargic as noticed by the family. R1 was sent to the emergency room where he was admitted with a blood level of [MEDICATION NAME] at 181.1 (normal 50-100). On 8/19/16 at 1:30 PM E3, LPN stated she was assigned to R1 on July 19th. After the report of R1's lethargy E3 reviewed his medication orders and found the discrepancy in the [MEDICATION NAME] order. E3 stated R1 had not shown any signs of distress prior to that day. R1's Hospital emergency room Physician Documentation dated 7/19/16 shows Clinical Impression: 3. Supratherapeutic [MEDICATION NAME] Level. R1's laboratory report dated 7/19/16 shows [MEDICATION NAME] Level of 188.1 Ug/Ml (micrograms per milliliter).

Based on observations, interviews and record reviews the facility failed to adequately supervise 2 of 6 residents (R5 and R8) sampled for falls in the sample of 12, who are known to be at risk for falls. The failure resulted in R5 sustaining a right hip fracture and head lacerations (which required medical treatment and 6 to 7 staples) after falling and R8 sustaining skin tears and bruising after falling. Findings include: 1. Review of R5's Admission Face Sheet R5 is a [AGE] year old male with [DIAGNOSES REDACTED]. Facility's Incident Reports show that R5 has experienced multiple falls in the facility. The Fall investigation documents the history of R5's fall occurrences: "6/26/2012 at 4:40 PM... Type of Incident: ...Fall... Type of Injury: ...hip fracture... Description of Event (Including injury): Resident (R5) seen laying on floor on buttocks... R5 was trying to assist roommate. He ambulated over to other resident and fell ... Fall most likely related to internal risk factors... has some slight cognitive and perceptual problems. He would be a poor judge of his own limitation... unable to handle change or new situations..." The corrective action plan for this investigation lacks documentation regarding a method of staff providing supervision for R5. 7/01/2012 at 12:45 PM... Location Resident's (R5's) Room... R5 was found face down laying on the floor..." The investigation documented that the certified nurse caring for R5 on 7/01/2012 at 12:45 PM stated she was in another room taking care of a resident, when R5 fell . This investigation documented that R5 had periods of confusion, recently had surgery and may still be under the affects of anesthesia. The recommended corrective action plan had no documentation of increase in staff supervision of R5 due to periods of confusion. "7/01/2012 at 6:35 PM... R5 had locked himself in bathroom near nurses office... Door to bathroom was unlocked. R5 falling to floor and was then on the floor landing on his right side between wall and wheelchair..." The statements of the staff, on duty for 7/01/2012, did not document any staff providing R5 with supervision before he (R5) locked himself in the bathroom and fell . The recommended corrective action plan did not identify/document a method for staff to supervise R5 to prevent further falls. "12/12/12 at 3:30 AM... R5 calling out for help, upon entering room, noted resident lying on the floor in left lateral position, bleeding from laceration to top of head (which required 7 staples to the laceration)." Review of the staff's statements documented that they were doing other things and not supervising R5. The corrective action plan documented the same interventions and had no documentation of any method to increase staff's supervision of R5. This investigation also did not have a detailed analysis of factors causing R5's fall. It documented R5 sometime had confusion, but not a method for staff to supervise R5. Review of R5's Nursing Note, dated 2/05/2013 at 5:29 PM states: R5 found on the floor at 1630 (4:30 PM)... R5 stated he only slid to the floor on his buttocks..." There was documentation that R5 had a seatbelt alarm, which was unhooked and turned off. The nursing note documented that R5 "has been known" to unhook and turn off his seatbelt alarm. The nursing note lacked documentation of staff using/identifying a more effective mean of supervising R5. Review of R5's care plan had no documentation of a method to provide R5 with increase staff supervision until after R5 had multiple falls, some with serious injuries. On 3/12/2013 at 12:36 PM, R5 was interviewed in his room. R5 was alert, with periods of confusion, and wheel chair bound. R5 stated he was unable to ambulate by himself, and often failed to get staff's assistance. The nurse (E11) and CNA's (E13) providing care for R5 were interviewed on 3/13/2013 at 10:20am and 3/14/2013 at 1:45pm. Both reported that R5 was alert with periods of confusion and impulsive behavior. E11 and E13 stated R5 was at risk for falls and needed to be monitored. The restorative nurse (E4) was identified as being responsible for doing resident fall investigations. E4 stated on 12/13/2013 at 11:15am that R5's fall occurrence on 6/26/2012 "happened before my time as restorative nurse. (R5) was trying to help roommate get up and in the process he fell . R5 fractured his hip and had been on fall precautions. (R5) had a wander guard and alarm cushion. Based on the fall risk score prior to the fall, R5 was at risk for falls. He's alert with periods of confusion. She (the prior restorative nurse) assessed his fall (on 6/26/2012) related to poor cognitive skill and judgement." Upon reviewing R5's care plan dated 4/06/2012, E4 stated, "I don't see anything related to fall on care plan (for R5)... In December 2012, I was here when he had a fall. It happened at 3:30 AM..." E4 said that R5's December fall was caused by: "his impulsive behavior of not waiting for assistance." E12 cared for R5 on 2/05/2013, stated on 3/15/2013 at 10:15 AM, "The CNA was busy... R5 had a seatbelt alarm on. It was on him, but not alarming. R5 frequently took it off and hooked it back up by himself...(R5) is at risk for falls because he is noncompliant, forgetful and impulsive. He's not impulsive all the time but sometimes impatience and does it himself." According to the admitting assessment (12/15/12) R8 is a [AGE] year old female admitted to the facility on [DATE] for rehabilitation after a fall with hip fracture. R8's [DIAGNOSES REDACTED]. R8 has been identified by the facility as a high risk for falls and decreased safety awareness per review of incident investigation following the first unwitnessed fall on 1/5/13. Review of facility Incident Reports indicate the following: On 01/05/13 at 7:30 PM R8 was found sitting on the floor at the side of her bed. R8 stated that she wanted to clean her room and tried to get up by herself. R8 sustained a bruise to the right hip. The fall was unwitnessed. According to the facility's investigation R8 is alert and oriented with periods of confusion. The facility identified decreased memory, periods of confusion and unsteady gait from recent fracture as contributing factors to the fall. R8 was reinstruct regarding use of call light due to her decreased memory. A floor mat alarm was recommended to remind R8 to call for assistance when needed and to alert to staff to her need for assistance. On 02/03/13 at 11:00 AM R8 was again found on the floor in her room. R8 was sitting on the floor alarm with a skin tear noted to the left lower leg. R8 apparently tried to get up while in her recliner. When interviewed by facility staff, R8 was unable to explain why she tried to get up. The facility's incident investigation again identifies impaired cognition and decreased safety awareness as contributing factors to R8's fall but documented that the fall could not be anticipated because the safety interventions had been effective in past days. R8's chair alarm was changed to a contact alarm to alert staff sooner. The fall was unwitnessed. On 02/20/13 at 6:40pm R8 was again found in her room sitting on the floor in front of her wheelchair. The alarm was going off and R8 was taking her shoe off stating she was getting ready for bed. The fall was unwitnessed. The facility's interventions included to continue the current safety precautions and to keep R8 involved in as many activities as possible where she is in full view of others. On 02/23/13 at 6:05pm R8 was again found in her room sitting on the floor after staff heard her alarm going off. R8 stated that she tried to get up but became weak in the knees and fell on the floor. The fall was unwitnessed. R8 sustained a skin tear to the left elbow. The facility scheduled a follow up with a neurologist, continued use of alarms and more involvement in activities. Although the facility had identified R8 as cognitively impaired with decreased safety awareness, R8 was still left in her room unsupervised after 4 unwitnessed falls resulting in 2 injuries. There was no evidence in the medical record that R8 was reassessed for additional activities as stated as an intervention in the last 2 falls or for increased supervision by staff.

(1) Based on observation, interview and record review the facility failed to evaluate and implement interventions to prevent the development of incontinence related wounds. This failure resulted in R 7's development of six new open areas on his right and left upper thighs. This applies to one of one residents (R 7) reviewed for incontinence related wounds in the sample of 12. (2) Based on interview and record review the facility failed to provide scheduled pain medication to R 10 as ordered. This applies to one of five residents (R 10) reviewed for pain in the sample of 12. Findings include: (1) On 04-16-12 at 11:10 AM, R 7 was observed in the room sitting on his wheelchair, with indwelling catheter with thick cloudy output. R 7 stated " I sit too much in my chair (wheelchair), my butt is so sore. I get up at 7:00 AM. They don't come just to change my position. I think that would be a lot of work for them because they use that lift (full mechanical lift) for me. " On 04-17-12 at 12:30 PM, during skin assessment with the Treatment Nurse/ E 4 identified the following open areas: Left upper thigh 1. 1.0 cm X 1.8 cm 2. 1.5 cm X 1.3 cm 3. 2.5 cm X 2.0 cm 4. 1.6 cm X 4.3 cm Right upper thigh 1. 1.0 cm X 1.0 cm 2. 0.8 cm X 0.8 cm On 04-17-12 at 2:10 PM, E4 stated " theses are new wounds! It's related to moisture, his (R 7) catheter was leaking yesterday, and that's probably why he got macerated. " On 04-16-12 at 11:10 AM, R 7 was observed in the room sitting on his wheelchair, with indwelling catheter with thick cloudy output. R 7 stated " I sit too much in my chair (wheelchair), my butt is so sore. I get up at 7:00 AM; they don ' t come just to change my position. I think that would be a lot of work for them because they use that lift (full mechanical lift) for me. " A care plan was developed and presented on 04-17-12. (2)On 04-16-12 at 11:35 AM, R 10 was observed in bed and stated " I' m in severe pain on my back, they ran out of my pain medication for two days now and I'm in severe pain. " The Nurse in Charge (E 8) confirmed R 10's statement and said " yeah, they ran out yesterday. It ' s for her back pain. " Review of R 10's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 04-18-12 at 11:25 AM, interview with the nurse (E 6) and with E 9 (nurse) at 11:35 AM, both E 6 and E 9 stated " we reorder five days before it runs out. All we do is to pull out the sticker from the bingo (medication) card and fax it to the pharmacy. " Review of R 10's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. These were on 04-15-12 at 8:00 AM and 8:00 PM and an 8:00 AM dose on 04-17-12.

Based on observation, record review and interviews facility failed to : - perform thorough skin assessment on admission for one of two sampled residents with pressure sores (R1). - thoroughly assess and identify existing pressure sores on admission , resulting in delay of medical evaluation, treatment and services from 3/24 - 4/18/12. - accurately stage a pressure sore for one of two sampled residents with pressure sores (R1). This failures resulted in the progression of R 1's right heel ulcer from a suspected deep tissue injury to becoming necrotic ulcer (Unstageable). This applies to two of two residents (R1 and R 9) reviewed for pressure ulcer in the sample of 12 residents. Findings include; 1) R1 was admitted to facility 3/24/12 with [DIAGNOSES REDACTED]. R1 was interviewed 4/18/12 and observed to be alert and oriented to time, place and person. R1's 4/02/12 and 4/10/12 right heel wound assessments stage the wound as a stage 2, yet the wound assessment details report dated 4-10-12 with pictures reads: Dark area in middle of wound appears dry blood tissue (a Deep Tissue Injury). R1's 4/17/12 minimum data set assessment (MDS), includes independent cognition and able to communicate freely. This MDS under section M, includes the presence of two pressure ulcers ( one stage 2 and one unstageable), that were both present on admission. R1's 4/17/12 care assessment triggers (CAT), "Problem Area 16: Pressure Ulcer", includes "has open areas noted to her heels. She has a stage 2 with granulation tissue present to her right heel. She has a suspected deep tissue injury to the left heel with necrotic tissue noted. These areas were present upon admission." During R1's 4/18/12 1:30 PM wound treatment observation, E4 (ADON / treatment nurse), said she was unaware of E4's right great toe wound before now. During this treatment observation, R1 stated "I've had the toe sore as long as I've had the heel wounds. My toe sore is from the sheets rubbing against it at the hospital." E4 stated that R1 does not have toe wound treatment orders or any device to prevent sheets from touching her toes at present. 4/18/12 E4 measured R1's wounds as follows: 1) right heel 5 x 5 cm with 80% eschar in center 2) left heel 4 x 4.5 cm with 95% eschar. R1's entire left heel was observed to be boggy with whitish pink color surrounding the 5 x 5 cm eschar covered wound. 3) right great toe .5 x .5 cm brownish / purple blister (possible deep tissue injury), on the tip of toe by toe nail. R1's medical record did not include any descriptive documentation about the right great toe wound 3/24 - 4/17/12. Based on record review, interview and observation the facility failed to prevent one resident (R9) from the worsening of a macerated area into 2 pressure sores, one unstageable. This applies for one resident (R9), 1 of 1 resident, reviewed for skin care in the sample of 12 residents. Findings include: Review of Minimum (MDS) data set [DATE] shows R9 is [AGE] years old with short and long term memory loss and requires extensive assist with all activities of daily living including mobility. Accompanying CAT (care assessment trigger worksheet) for ADL (activities of daily living) states R9 requires extensive assistance of two staff for bed mobility, toileting and transfers with a walker at times but mostly uses a wheelchair. ... R9 is in end of life and is receiving hospice care at this time. The wound section shows R9 is without wounds. Nurse's note dated 2/13/12 states R9 was admitted to the skilled unit (from the sheltered unit) on 2/13/12. Current diagnosis ' include [MEDICAL CONDITION], spinal stenosis, [DIAGNOSES REDACTED], [MEDICAL CONDITION] and history of [MEDICAL CONDITION] with mets to the lumbar spine. Medical record shows R9 has been on Hospice care since November 2011. Review of facility wound report dated 4/16/12 shows the facility identified an acquired wound on 3/9/12 and described as "trauma/excoriation" to the coccyx measuring 5 x 5 cm. Review of R9 ' s wound Assessment report dated 3/9/12 shows R9 is at risk for pressure sores and has developed a facility acquired wound to the coccyx identified as excoriation. This facility acquired wound measures 6 x 6 cm with serosanguineous drainage and 50% granulation. The periwound is documented as having [DIAGNOSES REDACTED] and maceration. The ' current plan and comment ' section states " Open areas with redness and maceration to coccyx and rectum area. " The wound reports dated 3/16/12, 3/23/12, 3/26/12 and 4/4/12 shows the same measurements and description. The ' current plan and comment ' section on 3/16/12 states " Increased open areas redness remains will continue treatment " . The ' current plan and comment ' section on the 3/28/12 report states " Coccyx with two open areas. Coccyx and buttocks red and maceration noted to area. No changes resident has decline in condition. Food intake poor. Will continue to [MEDICATION NAME] dressing to promote intact skin " . The 4/11/12 wound report shows the size is now 5 x 5 cm with all other information remaining the same. The narrative section states " Maceration open areas to coccyx and rectum, assisted to bed after meals, poor oral intake. [MEDICATION NAME] dressing continued " . E4 (wound nurse) stated on 4/16/12 at 11:10 that the area on the coccyx and rectum is not a pressure sore but is more of a macerated area due to incontinence. This area was observed along with E4 on 4/20/12 at 10:00 am. There were 2 wounds clearly visible. E4 stated that originally, R9 had open areas on top of the maceration to the coccyx, but now one of the breakdown areas is on a bony prominence and can be considered a pressure sore. E4 also stated that the treatment now includes a [MEDICATION NAME] agent. The coccyx wound measured 2.2 cm x 1.2 cm with yellowish white slough in the wound bed and irregular macerated edges. The second coccyx wound near the rectum measures 2.5. x 1.0 cm observed a new stage II pressure sore. Both wounds are attributed to excoriation and yet R9 has not been reassessed for incontinence as a factor in the development of the wounds. E18 (nurse's aide) stated on 4/16/12 at 10:10 am R9 knows if she has to go the bathroom but is still incontinent most of time because she must have help to get there.