Every finding on record at Arc at Sangamon Valley

Based on interview and record review, the facility failed to ensure the right to a clean environment for 1 of 5 (R25) residents reviewed for clean environment from a total sample of 34. Findings include:On 5/14/26 at 3:40 PM, R25 stated staff assisted him after throwing up, but they did not change his soiled gown or bed linens, left soiled incontinence brief in the bathroom, and soiled clothing in the room on 5/9/26.On 5/15/26 at 1:22 PM, V34, R25's family member, stated on 5/9/26 at 3:00 PM when they arrived to visit R25's bed linens and gowns were soiled, used incontinence brief and soiled clothing were left on the floor.On 5/19/26 at 8:30 AM, V31 Certified Nursing Assistant (CNA) stated on 5/9/26 she went to R25's room after V34 complained about the condition of R25's room. V31 stated the gown and bed linens were soiled and there was a used incontience brief and soiled clothing left on the floor.R25's progress note dated 5/9/26 at 3:16 PM documents V34 stated she had concerns with the condition of R25's room.The Illinois Long-Term Care Ombudsman Program booklet titled Residents' Rights for People in Long-Term Care Facilities revised 11/2-18 documents Your facility must be safe, clean, comfortable and homelike.

Based on interview and record review, the facility failed to assist residents with showers. This applies to 2 of 4 (R17 and R34) residents reviewed for showers. 1. R17's Brief Interview for Mental Status dated 3/5/26 documents R17 is cognitively intact. R17's undated care plan documents R17 is to receive showers on Wednesdays and Saturdays.On 5/15/26 at 10:00 AM, R17 stated they missed my shower on Wednesday (5/13/26).R17's shower/bath log documents R17 did not receive a shower on 5/9/2026 or 5/13/26.R17's concern form dated 3/16/26 documents a concern that R17 did not receive a shower on Saturday 3/14/26. This form documents V3 Assistant Director of Nursing confirmed that R17 did not receive a shower on 3/14/26.2. R34's undated care plan documents R34 was admitted on [DATE] and has shower days scheduled for Mondays, Thursdays and as needed. R34 BIMS assessment completed on 5/18/26 documents R34 is cognitively intact.On 5/19/26 at 8:45 AM, R34 stated I've had 1 since I've been here.R34's shower log documents R34 received a shower on 5/15/26 but did not document a shower for 5/18/26.

Based on observation, interview and record review, the facility failed to implement safety interventions to prevent falls. This applies to 2 of 4 (R7, R32) residents reviewed for falls from a sample of 34. Findings include:1. R32's Minimum Data Set (MDS) dated [DATE] documents R32 is severely cognitively impaired. R32's medical record dated 2/9/2026 documents R32 has a diagnosis of Altered Mental Status and History of Falling. R32's care plan dated 2/9/2026 documents R32 requires a mechanical lift to transfer between surfaces. R32's care plan dated 4/13/2026 documents R32 is to have fall mat placed next to bed.On 5/15/2026 at 3:20 PM, R32 was lying in bed with call light in reach. R32 demonstrated how to use the call light and was able to activate it. R32 did not have fall mats on the floor next to the bed.On 5/19/2026 at 7:55 AM, R32 was sitting up in the wheelchair. R32 did not have any fall mats at the bedside. R32's medical record dated 4/10/2026 at 8:45 AM, R32 was lowered to the floor during morning care. On 5/15/2026 at 4:35 PM, V26 (LPN) stated R32 was sitting upright on the side of the bed. V26 stated when V40 (CNA) stood R32 up, R32 became weak and was lowered to the floor. V26 (LPN) stated V40 (CNA) was assisting R32 with a gait belt and assist of one. V26 (LPN) stated the fall interventions in place for R32 included a lowered bed, non-slip socks or footwear, and the use of a mechanical lift for transfers. On 5/19/2026 at 7:55 AM, V39 (CNA) stated R32 is supposed to have fall mats but R32 did not have any. V39 said that she assisted R32 from the bed to the wheelchair this morning with a gait belt and stood R32 up with assist of one and did not use a mechanical lift. On 5/19/2026 at 8:00 AM, V6 (LPN) stated R32 requires a mechanical lift for transfers. On 5/19/2026 at 9:20 AM, V3 (ADON) stated R32's fall care plan documents to have non-skid footwear, assist of two with a mechanical lift, and mats placed on the floor at bedside. On 5/19/2026 at 4:30 PM, V22 (CNA) stated V22 (CNA) did not know what R32's fall interventions were. On 5/20/2026 at 8:10 AM, V50 (Physical Therapist, PT) stated R32 is a mechanical lift for nursing transfers. V50 (PT) stated transfer status is communicated through a notification sheet passed from therapy to nursing. On 5/20/2026 at 8:20 AM, V51 (PT, Director of Therapy) stated R32 is a mechanical lift for transfers. On 5/20/2026 at 8:30 AM, V3 (ADON) confirmed and stated R32's care plan documents R32 is a mechanical lift for transfers. R32's progress note dated 4/10/2026 at 5:35 PM documents R32 is no weight bearing to left lower leg. R32 was returned to the facility in a wheelchair and was transferred into a facility wheelchair using a gait belt and assist of two to stand and pivot. The facility Fall Prevention Program dated January 1, 2026 documents transfer conveyances shall be used to transfer residents in accordance with the plan of care. The facility Transfer-Manual Gait Belt and Mechanical Lifts policy dated December 2025 documents is the responsibility of the Licensed Nurse, Certified Nursing Assistance (CNA), Restorative, and Therapy that mechanical lift devices shall be used for any resident needing a two person assist, or who cannot be transferred comfortably and/or safely by normal transfer technique. Resident transferring and lifting needs shall be documented in care plans and reviewed via care plan time frame and as needed. 2. R7's medical record dated 12/16/2025 documents R7 has a diagnosis of Obesity, Urinary Tract Infection, Insomnia, and Weakness. R7's care plan dated 12/16/2025 documents as an intervention for R7 to use side rails for turning and repositioning. On 5/13/2026 at 1:10 PM, V15 (Power of Attorney, POA for R7) stated the facility called when R7 fell out of bed. V15 (POA) stated R7 was rolled onto the floor when assisted with one CNA.On 5/13/2026 at 3:06 PM, V17 (Licensed Practical Nurse, LPN) recalled V35 (CNA) reported R7 had rolled out of bed during bed check. V17 stated when R7 was turned for perineal care, R7 continued to roll onto the floor.On 5/19/2026 at 8:20 AM, V35 said she was assisting R7 with perineal care when V35 rolled R7 over and R7 continued to roll onto the floor. V35 said the mattress was slick and there were no bed rails for R7 to hold onto. R7's progress note dated 1/27/2026 at 11:04 PM documents that R7 had rolled out of bed onto the floor.

Based on observation, interview, and record review the facility failed to prevent potential cross contamination during personal care for 1 of 3 (R16) reviewed for catheter care from a total sample of 34. Findings include: R16's medical record dated 7/17/2025 documents R16 has a diagnosis of Urinary Tract Infection, Bladder Disorders, Urinary Retention, and Neuromuscular Dysfunction of Bladder. R16's Minimum Data Set (MDS) dated [DATE] documents R16 is severely cognitively impairedR16's care plan dated 5/1/2025 documents R16 has an indwelling catheter related to neurogenic bladder. On 5/13/2026 at 12:50 PM, V22 Certified Nursing Assistant (CNA) and V23 (CNA) transported R16 to room the room in a wheelchair. V22 (CNA) retrieved cleaning wipes and wash basin and V22 returned to the room with gloves on. V22 and V23 assisted R16 to bed with a mechanical lift. V22 removed R16's shoes and pants. R16's catheter was no secured with a catheter securement device. V22 opened R16's incontinence brief and performed perineal care to R16's frontal perineal area. R16 rolled to R16's right side with use of grab bar on bed and assist of V22 and V22 performed perineal care to R16's backside. R16's catheter was not cleansed. V22 removed soiled gloves and donned a new pair of clean gloves. V22 applied barrier cream to R16's buttocks. V22 applied a new incontinence brief to R16. V22 removed soiled gloves and donned a new pair of gloves. V22 then retrieved a urinal and drained R16's catheter collection bag. V22 did not perform hand hygiene during this care. On 5/14/2026 at 12:10 PM, V22 said that V22 did not have any hand sanitizer when performing perineal care. V22 confirmed that hand hygiene is needed during personal care. V22 also confirmed that the catheter should be cleaned during care and this was not completed. V22 also said that the catheter needed a securement device, but she did not have one. V22 also said she is aware the catheter should be cleansed but did not perform catheter cleaning. The facility policy for Urinary Catheter Care dated December 2025 documents to perform hand hygiene before and after touching any part of the urinary catheter. The policy documents indwelling catheters may be secured to prevent trauma and tension. The facility policy for Incontinence Care dated January 2026 documents to perform hand hygiene before perineal care. The policy documents after perineal care to change gloves and perform hand hygiene. Record review of R16's physician order dated 5/26/2025 documents to provide catheter care and securement device every shift and as necessary.

Based on interview and record review, the facility failed to ensure an antibiotic was given as ordered by the physician for one (R6) of six residents reviewed for medication administration in the sample of 34.Findings include:R6's Skilled Nurse Hospice Visit Note dated 3/27/2026 documented by V21 (Hospice Registered Nurse -RN) shows a new order for Azithromycin (antibiotic) 250 milligrams (mg) give two tabs on day one and one tab for the next four days.R6's Medication Administration Record dated 3/27/26 does not document R6 received the Azithromycin.On 5/14/2026 at 9:49 AM, V21 said she ordered the Azithromycin for R6 on Friday 3/27/2026. V21 stated that she verbally told the facility nurse caring for R6 at that time that there was a new order for an antibiotic to be processed. V21 stated the nurse stated to her that she did not have time to process the order at that time. V21 stated she could not recall the name of the nurse she talked to. V21 stated she then put the handwritten order in the hospice binder and left it face down on the nurse's station so that the nurse would know it still needed to be processed. V21 stated she returned to the facility on Tuesday 3/31/2026 and found the Azithromycin order had not yet been processed by the facility nurse. V21 stated she sat down at that time with V7 RN, R6's nurse at that time, and assisted her with putting the order into the computer system. V21 stated the medication did not arrive until the next day, Wednesday 4/1/2026. V21 stated she returned to the facility a few days later on Friday 4/3/2026 and saw the resident's medication card had the medications still in it, showing that R6 had missed several doses of the Azithromycin.On 5/14/2026 at 12:56 PM, V7 RN stated she recalls on 3/31/2026 R6's Azithromycin had been written by hospice to be ordered the day prior, however this never got done, therefore V7 RN sat down with V21 Hospice RN to put the order into the computer.R6's physician order dated 3/31/2026 shows the initial order for Azithromycin was transcribed five days after V21 Hospice RN had initially notified the facility of the new order. The order is written as Azithromycin 250 mg tablet, give two tablets by mouth in the morning for possible pneumonia until 4/1/2026 11:59 PM and give one tablet by mouth in the morning for possible pneumonia for four administrations.The facility's pharmacy requisition sheet shows that R6's Azithromycin was dispensed to the facility on 4/1/2026.R6's Skilled Nurse Hospice Visit Note dated 3/31/2026 shows New orders received from V41 Advanced Practice Registered Nurse (APRN) on 3/27/2026 was not entered or administered by facility. Spoke with V7 RN, facility nurse, and she entered medication orders during hospice visit. V41 APRN notified of delay.R6's Skilled Nurse Hospice Visit Note dated 4/3/2026 shows (V19), R6's family member, states patient has not been getting medications as prescribed. This nurse discussed with facility nurse and noted antibiotics to have four of the five pills remaining. The pills should have been gone by this time. Educated facility staff on patient's need for antibiotic and reinforced importance of patient receiving this. (V41 APRN) notified of facility not administering antibiotics as prescribed. (V19) states she will discuss with the (V2) Director of Nursing (DON) again, as this is the second medication issue this patient has had. On 5/14/2026 at 10:49 AM, V2 DON stated on 4/3/2026 she received an order R6's Azithromycin to be given for an additional five days because the medication had been delayed, however she cannot remember how many days the medication had been delayed for.On 5/14/2026 at 2:31 PM, V2 DON stated she would expect nurses to process any verbal or written orders given to them by hospice on that same day.On 5/19/2026 at 11:21 AM, V1 Administrator stated the facility does not have a specific policy regarding initiating physician orders immediately after they are received.

Based on interview, observation, and record review, the facility failed to provide sufficient staffing to provide safe and timely care for residents reviewed for sufficient staffing in the sample of 32. This failure has the potential to affect all 126 residents living in the facility.Findings include: On 2/9/26 at 2:00 PM, V2, Director of Nursing (DON), stated their normal staffing pattern is the following: Day and Evening Shifts have 6 Nurses total: 1 on 100-hall, 1 on 200-hall, 1 on 300-400 halls, 1 on Grace North, 1 on Grace South, and one split/floater. V2 stated there are 12 Certified Nursing Assistants (CNAs) total: 2 on 100-hall, 2 on 200-hall, 3 split the 300 and 400-halls, and 5 on Grace Points. V2 stated the Night Shift has 4 Nurses total: 1 on 100-hall, 1 on 200-hall, 1 on 300-400 halls, and 1 that splits the Grace Point units. V2 stated the Night shift CNAs have 8 total - 3 on 100-200 halls, 2 on 300-400 halls, and 3 on Grace Point units. V2 stated they use agency as needed but first they try to get regular staff in, then the charge nurse covers, then the on-call manager covers, and finally the scheduler covers for call-ins.On 2/2/26 at 9:40 AM, R38 stated he is incontinent at times, uses his call light and it depends on who is working because some will answer it timely, while others take a while, especially if not enough people working. R38 stated some days there is enough staff and some days not, and the nights and/or weekends are usually short. R38 stated it's too easy for them to call off. R38's Minimum Data Set (MDS), dated [DATE], documents R38 is cognitively intact.On 2/2/26 at 10:26 AM, R154 stated there is not enough staff. R154 stated he does not know what was going on past weekend as he had asked for a stool softener in the morning and did not get one until that evening. Stated the CNA would report have to find a nurse. R154's MDS, dated [DATE], documents R154 is cognitively intact. On 2/2/26 at 11:00 AM, R1 seen sitting in wheelchair with full body mechanical lift device sling under her. R1 stated the staff use that to transfer her, sometimes only with one person because they don't have enough people. R1's MDS, dated [DATE], documents R1 is cognitively intact.On 2/2/26 at 11:01 AM, R42 stated his oxygen wasn't working and V7, CNA, stated she would let his nurse know then left. V8, LPN, came to the room a minute later and stated she would have to switch R42's oxygen from the tank to the concentrator because the tank was empty. V8 stated R45 wasn't getting ready to leave anywhere when he had been brought back a while ago to his room, but she wasn't notified his oxygen was low. V8 stated it's not an excuse but the CNAs have 16 residents each and she has 32 and that's why stuff like this happens.On 2/2/26 at 11:46 AM, After both CNAs and the Nurse was in R130's room for approximately 30 to 45 minutes, other residents were waiting to be taken to the dining room for lunch, one call light was seen on and unknown how long it has been on. Both CNAs began taking residents to the dining room while lunch had already begun. R130's MDS, dated [DATE], documents R130 has a severe cognitive impairment.On 2/2/26 at 12:00 PM, V14, CNA, state Today, and usually every day, the 300-hall has one CNA and one nurse, the 400-hall has two CNAs, and they share the nurse. It always seems like we are short staffed. We have most of our residents that require assistance with transfers, a lot of (full body mechanical lift device) transfers that take two people, and we have residents with behaviors and need closely watched. It's hard to be everywhere, watch everyone, and help everyone with just two of us.On 2/5/26 at 8:55 AM, V12, CNA, stated The staffing is terrible here, we are really short of staff. It has always been like this but since the new owners took over, they have been cutting things thin. Today we only have two of us on 400-hall and 1 on the 300-hall. It makes it hard to get things done when most of the residents need assistance with transfers. The call lights take longer to answer because we are busy with the residents.On 2/5/26 at 10:55 AM, R1 sitting in wheelchair next to her bed with soft touch call light on bedside table and within reach. R1 stated she put her call light on, and it was answered once by someone who told her they would let her aide know. R1 stated that was 20 minutes ago and no one has come back in. R1 stated she needs to have a bowel movement (BM) and needs someone to put her on a bedpan. R1 put her call light back on and waited. No staff was seen in the hallway or at the desk. V14 answered the call light at 10:59 AM, shut the light off and told resident she must wait for V12 to get back from break. R1's MDS, dated [DATE], documents R1 is cognitively intact.On 2/5/26 at 11:02 AM, V12 was seen returning from break and assisted another resident to the restroom.On 2/5/26 at 11:07 AM, R1 stated I don't get upset with the staff because they are busy and trying the best they can. When I can't hold it any longer and have an accident, it is embarrassing and that upsets me because I don't like doing that.On 2/5/26 at 11:10 AM, Both V12 and V14 stated This is what we are talking about, it takes two of us to help these residents when a lot of them are (full body mechanical lift device) transfers. There is not enough staff here to take care of these residents.On 2/5/26 at 11:13 AM, Both V12 and V14 was then seen assisting another resident from her bed to her wheelchair.On 2/5/26 at 11:15 AM, V14 left that resident's room and failed to tell V12 about R1 waiting for a bedpan. On 2/5/26 at 11:18 AM, When V12 was exiting that room, V12 was advised that R1 has been waiting for a bed pan. V12 had V14 assist her with R1.On 2/5/26 at 11:21 AM, V12 and V14 finally in with a full body mechanical lift device assisting R1 from her wheelchair to her bed. R1 was then lowered to the bed, sling removed and R1 was placed on a bedpan. It was approximately an hour since R1 initially put her light on. On 2/10/26 at 9:35 AM, V31, CNA Supervisor, stated I am given a set number of CNAs to have working each shift. If our census goes up, they may add one or two. I have had just about everyone complain that they need more staff to take care of the residents here, but I can't do anything about it until the census goes up and it gets approved, that's our guidelines I have to follow. When advised that when all staff are in one room assisting a resident, there is no one else around answering call lights, assisting the residents, or the case that was observed, no one to take the residents to the dining room when time to eat. V31 stated I saw that too.On 2/10/26 at 10:40 AM, V26, Mobile Director of Nursing (DON), stated The only nurses working here work the night shift and that is by choice. We are hiring RNs and trying to get some more in and even have referral bonuses for staff. I thought some of the managers were RNs and were in house covering, but now I see they are LPNs.On 2/10/26 at 10:45 AM, V33, CNA, stated We don't have enough people working here. Having two CNAs covering one hall is not enough. The residents call lights are delayed and I have seen residents saturated in urine because we can't get to them in time. There are a lot of residents that need two-person assists like today, my rooms I am covering there are five (full body mechanical lifts) that require two staff members. The other CNA working with me (V14) also has five (full body mechanical lifts) so we have to work together to get these ten residents up and down. That takes a lot of time away from other residents. We just can't get to everyone when they need us.On 2/10/26 at 10:50 AM, V16, LPN, stated The staffing is horrible here. There are not enough CNAs to take care of all the resident needs. When asked about RNs working, V16 stated There are mainly LPNs working, at least days and evenings. The LPNs basically run this building.The Facility's Resident Council Meeting minutes, dated 9/2/25, documents in part Dietary: being served on time, need more staff.The Facility's Resident Council Meeting minutes, dated 12/2/25, documents in part Residents would like to invite the new DON and ADON to the January meeting: re. Call Lights, shower schedules, medications. The Facility's Resident Council Meeting minutes, dated 1/6/26, documents in part Call lights times being long on 2-10 PM shift.On 2/10/26 at 1:12 PM, V1, Administrator, stated they do not have a staffing policy and that they follow Federal Guidelines.The Department of Health and Human Services, Centers for Medicare & Medicaid Services, Long-Term Care Facility Application for Medicare and Medicaid, dated 2/2/26, documented that there were 126 residents living in the facility.

Based on observation, interview and record review, the facility failed to follow physician orders for 2 of 5 (R2 and R38) residents, reviewed for wound care in a sample of 32.Findings include:1.On 2/9/2025 at 10:32 AM, V2, Registered Nurse (RN), Director of Nurses (DON), removed blankets off R2, with her gloved hands, pulled the adult incontinence brief away from his penis and from in between his legs. R2's right groin area was bright red. No ointment was placed to R2's groin area. R2's Physician's orders, dated 2/5/2026, documented, Venelex External Ointment (Balsam Peru Castor Oil) Apply to Groin and buttock topically every shift related to rash. It also documented diagnoses of Type 2 Diabetes Mellitus without complications and unspecified Dementia. R2's care plan, dated 2/5/2025, documented an intervention, Administer all treatments as ordered and monitor for effectiveness. On 02/09/2026 at 1045 am, V2, RN, DON, stated that if the order says to put the cream on his groin, she should have done that. 2. R38's admission Record, dated 2/9/26, documents R38 was admitted to the facility on [DATE] with diagnosis of Cellulitis of right lower limb, chronic ulcer of right lower leg, Venous insufficiency, Atrial Fibrillation, Congestive Heart Failure (CHF), Chronic Kidney Disease-stage 3, Pulmonary Hypertension, Type 2 Diabetes Mellitus (DM), and Hypertension (HTN). R38's Care Plan, dated 11/30/25, documents R38 has infection of cellulitis. Interventions: Follow facility policy and procedures for line listing, summarizing and reporting infections, maintain universal precautions when providing resident care. It continues 12/18/25: R38 has chronic pressure ulcer (right lower leg, left lower leg). Interventions: Administer treatments as ordered and monitor for effectiveness, follow facility policies/protocols for the prevention/treatment of skin breakdown. It continues 10/30/25: R38 is at risk for a skin impairment. Interventions: Treatment as ordered, wound doctor to assess and treat as needed. It continues R38 has an actual skin impairment of bilateral legs. Interventions: Treatment as ordered. R38's Minimum Data Set (MDS), dated [DATE], documents R38 is cognitively intact and is dependent on staff for most Activities of Daily Living (ADLs). R38 is frequently incontinent of both bowel and bladder. R38's Physician Order, dated 12/11/25, documents Left lower extremity cleanse with normal saline (NS) apply xeroform dry rolled gauze and ace wraps daily. Every dayshift for wound, skin integrity. R38's Physician Order, dated 1/27/26, documents Lower extremities elevated on pillows above heart level to reduce edema/drainage as resident will allow. One time a day for preventative and as needed for preventive. R38's Physician Order, dated 2/2/26, documents Santyl External Ointment 250 Unit/GM (gram). Apply to RLL (right lower extremity)/foot slough topically every dayshift for wounds. R38's Physician Order, dated 2/5/26, documents Cleanse R (right) foot with wound cleanser and normal saline. Pat dry. Weak Betadine-soaked gauze between toes daily and PRN (as needed). R38's Wound Healing Center Physician Orders, dated 2/2/26, documents Cleanse wound(s) with Normal Saline, Soap and Water, Wash with soap and water with dressing changes. Right lower leg/foot: Santyl to slough areas, dry and rolled gauze/ace wrap. Right foot (toes 1-5): Betadine to toes, weave gauze between toes. Left dorsal foot: Xeroform, dry and rolled gauze/ace wrap. Apply ace wraps to knees. R38's Medication Administration Record (MAR)-Treatment Administration Record (TAR), dated February 2026, documents Santyl External Ointment 250 UNIT/GM (Collagenase), Apply to RLL/foot slough topically every dayshift for wounds and is documented as completed on 2/3/26, 2/4/26, and 2/5/26. On 2/5/26 at 1:40 PM, V2, Director of Nursing (DON), was observed providing wound care to R38. V2 stated the wound nurse is off today and she is doing wound assessments today, so she will be the one doing wound care on R38. All supplies are already on bedside table with old bilateral leg dressings off. V2 used NS and 4X4 gauze to wipe R38's left foot, then wiped R38's left toes. V2 put Xeroform over the open area on top of R38's left foot, then covered the foot with 4X4 gauze and wrapped with rolled gauze from toes up the leg to the knee. V2 then wrapped R38's leg with ace wrap. R38's right leg from just above his ankle to his toes were oozing serosanguinous fluid and blood, appearance as very swollen, reddened, with white patches and open sores throughout the lower leg and foot. V2 used NS and 4X4 gauze to wipe R38's right toes, foot, and ankle areas. V2 then wiped Betadine between R38's right toes and top of his foot. V2 then got Xeroform and applied to the top of R38's foot. R38 stated I had an appointment two days ago and they are not using that stuff (Xeroform) anymore. They changed it to Santyl. R38 showed V2 the orders from the wound physician which documents to use Santyl to right lower leg/foot. V2 stated Well, I will have to correct the orders then. and continued to apply the Xeroform. V2 left the Xeroform on the foot and applied an absorbent sponge dressing to R38's foot, then wrapped with rolled gauze and ace wrap from toes up to just below the knee. When asked what the nurses have been doing the past couple of days, R38 stated They used the Santyl like the order said. They even took the yellow copy of the orders when I got back from the appointment, so I know they have the orders. On 2/5/26 at 2:15 PM, after finishing R38's wound care, V2 stated You know I looked at the orders before I went in there and there was no Santyl order. I see the new orders, and I guess the nurse never put the new order in after his appointment. On 2/5/26 at 2:25 PM, V2 returned and stated, I looked and the Santyl order was already in there from 2/2/26, but they did not discontinue the original order for Xeroform. The facility's Skin Condition Assessment & Monitoring-Pressure and Non-Pressure, dated 12/2025, documents in part To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented.

Based on observation, interview and record review the facility failed to maintain enough batteries for the mechanical lifts for 1 of 4 residents (R154) reviewed for essential equipment in the sample of 32. Findings include:On 2/2/2026 at 10:26AM R154 in bed with mechanical lift sling underneath him. R154 stated they are supposed to get me up. R154 stated Certified Nursing Assistant (CNA) came in and said the mechanical lift doesn't work so she is going to tell therapy. R154 stated I guess she is going to pass it off on therapy. On 2/2/2026 10:51 AM V3, and V4 CNA enter room with mechanical lift. R154 stated I have to be at dialysis at 11:00AM. V3 and V4, CNA transferred R154 from bed to wheelchair with mechanical lift.On 2/2/2026 at 10;34AM, V14, CNA stated V3, CNA is going upstairs to get a battery for the lift as the battery is dead. V4, CNA stated the mechanical lifts are not broke. V4 stated the facility does not have enough batteries for the lift.On 2/5/26 at 11:20 AM, V12, CNA left the floor to get a battery for the full body mechanical lift device that was sitting in front of R1's room. V12 stated Most of the time there is only 1 or 2 batteries available to use. A couple of weeks ago, no one could find a battery, and I think there was only 1 or 2 for all the halls to share.R154's face sheet dated 2/9/2026 documents a diagnosis in part end stage renal disease, dependence on renal dialysis and congenital complete absence of left lower limb. R154's Care plan dated 1/27/2026 documents R154 has an Activity of Daily Living (ADL) self-care performance deficit related to weakness, absence limb, End stage renal disease (ESRD), fractured ulna. R154's care plan documents the intervention dated 1/26/2026; transfer: the resident requires Hoyer lift to transfer between two surfaces. R154's Minimum Data Set (MDS) dated [DATE] documents R156 is cognitively intact. On 2/10/2026 at 10:58AM V1 Administrator stated the facility has 14 mechanical lifts and 12 batteries. V1, stated 2 of the 12 batteries need fuses. V1 stated she would expect the facility to have enough batteries for the mechanical lifts. V1 stated the facility does not have a specific policy for maintenance of equipment, but would expect the facility to follow manufacturer guidelines.

Based on interview, observation, and record review, the facility failed to safely transfer a resident to prevent falls in 1 of 4 residents (R2) reviewed for falls in the sample of 4. This failure resulted in R2 falling and receiving a laceration which required suture repair. Findings Include:On 10/16/25 at 9:17 AM, R2 was observed in her bed with an approximately 1 1/2 inch moon shaped scabbed, healing laceration to the right/center of her forehead. R2 is alert to self only.R2's Minimum Data Set (MDS), dated [DATE], documents R2 has a BIMS (Brief Interview for Mental Status Score) of 2, indicating R2 has severe cognitive impairment and is dependent with transfers. R2's Care Plan, dated 8/27/19, documents R2 is at risk for falls related to: Impaired mobility, memory loss/dementia, difficulty standing up, unsteady, fear of falling, history of falls, history of fractured left hip and clavicle with an intervention dated 10/6/25, to remove the floor mat from bedside as resident doesn't attempt to sit on the side of the bed any longer. R2's Care Plan, dated 5/30/23, documents R2 has impaired ability to independently transfer and requires a full mechanical lift with 2 assist to transfer.R2's Progress Note, dated 10/4/25 at 7:19 PM, documents the following: Certified Nursing Assistant (CNA) notified writer that patient had fallen while being transferred in the (full mechanical lift). States that the machine tipped over as she was attempting to put patient into the bed. Patient has laceration to forehead. Writer notified POA (Power of Attorney), and physician and patient transferred to local ER (Emergency Room).R2's Progress Note, dated 10/6/25 at 10:27 AM, documents the following: IDT (Interdisciplinary Team) met to review fall from 10/4/25. Root Cause: Resident injured during transfer. Intervention: Remove fall mat from bedside as resident does not sit on side of bed any longer.R2's Progress Note, dated 10/6/25 at 9:27 PM, documents the following: Resident has a new skin concern. Type of skin concern: Laceration, no new orders will follow up with hospital for further treatment plan. Located to Face - forehead: stitches r/t (related to) fall. Resident does not complain of pain.The Hospital ER Discharge summary, dated [DATE], documents the following: [AGE] year-old female presenting from the nursing home due to a fall. Patient had an unwitnessed fall, staff then tried to lift her from the floor with a (full mechanical lift) and she fell from this. Patient sustained a laceration to her forehead. CT (Computed Tomography) of the head impression: small right frontal scalp hematoma. Superficial laceration approximately 5cm (centimeters) in length, closed with 10 sutures.The Facility's IDPH (Illinois Department of Public Health) Final Report, dated 10/10/25 by V2, Prior DON (Director of Nurses), documents the following: on 10/4/25 at 10:35 PM. R2 was being assisted into bed using a full mechanical lift. While cares were being provided and the lift was being used, the wheel became caught on the fall mat in place and caused the lift to tip resulting in a laceration to R2's forehead. She was assessed and the MD (Medical Doctor) and POA were notified. R2 was transported to the ER for evaluation. R2 returned from the ER with sutures. An investigation was conducted, and it was determined that the mechanical lift tipped due to a fall mat being in place while the lift was being used. The resident was being cared for at time of injury and is care planned to be transferred with an assist of 2 utilizing a mechanical lift. The IDT team reviewed the incident, and the care plan was reviewed and updated. Resident is being monitored for pain. Staff were educated on using the mechanical lifts as well as room preparation prior to using the lifts. Maintenance inspected the machine to ensure good working order. MD and POA were notified of plan of care and agreeable. On 10/1625 at 12:40 PM, V7, LPN (Licensed Practical Nurse), stated she was working when R2 fell from the Hoyer lift, but she was not in the room when it happened. V7 stated the aide came to her and stated they were putting R2 to bed and the full mechanical lift tilted over. V7 stated there was a floor (fall) mat in place next to R2's bed but it had been moved when she entered the room, so she isn't sure if it was by the bed when R2 was being transferred. V7 stated R2 was sent to the hospital for evaluation. V7 stated if a resident has a floor mat in place, it should be moved during the transfer. On 10/16/25 at 12:48 PM, V9, CNA, stated on 10/4/25 between 7:00 PM and 7:30 PM, she noticed R2 was in her wheelchair slouching down, so she was going to put her in bed. V9 stated she got R2 hooked up in the full mechanical lift, walked out of the room to get another CNA, she didn't see one, so she did the transfer by herself and has done them by herself several times. V9 stated she had lifted R2 up in the lift, was moving the wheelchair while her other hand was on the full mechanical lift moving it towards the bed and over the floor mat. V9 stated she should've moved the mat but didn't, she tried moving the lift over the mat, the lift caught on the mat and tipped over completely. V9 stated R2 hit her head, and it was busted open. V9 verified there were no other staff in the room during the transfer, and she did not move the floor mat prior to the transfer. On 10/16/25 at 1:05 PM, V1, Administrator, stated when using the Hoyer lift, there should be 2 staff present and she would expect that if a floor mat was in place, it be moved prior to the transfer. The Fall Prevention Program Policy, dated 11/2012, documents the following: The purpose of the policy is to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The resident's environment will be kept clear of clutter which would affect ambulation and remove hazards. Transfer conveyances shall be used to transfer residents in accordance with the plan of care.The Transfers - Manual Gait Belt and Mechanical Lifts Policy, dated 11/2012, documents the following: In order to protect the safety and well-being of the staff and residents, and to promote quality care, this facility will use mechanical lifting devices for the lifting and movement of residents. Mechanical lifting devices shall be used for any resident needing a two person assist, or who cannot be transferred comfortably and/or safely by normal transfer technique.

Based on interview, observation, and record review the facility failed to provide pain medications to a newly admitted resident for 1 of 3 (R2) residents investigated for medications in the sample of 20. R2's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility on [DATE].R2's EMR dated 4/18/25 documents a diagnosis of aftercare following joint replacement surgery and presence of right artificial hip joint.R2's Care Plan dated 5/18/25 documents The resident is at risk for pain r/t (related to) Osteoarthritis and RTHA (Reverse Total Hip Arthroplasty).R2's Physician Order dated 4/18/25 documents Hydrocodone-Acetaminophen Oral Tablet 7.5-325 MG (Hydrocodone-Acetaminophen); Give 1 tablet by mouth every 6 hours as needed for Pain.R2's Physician Order dated 4/18/25 documents tramadol HCl Oral Tablet 50 MG (Tramadol HCl); Give 1 tablet by mouth every 6 hours as needed for pain.R2's MAR (Medication Administration Record) dated April 2025 does not document that R2 received Hydrocodone-Acetaminophen 7.5/325 mg, or Tramadol 50 mg on the evening of 4/18/25.R2's Controlled Substance Proof of Use sheet dated 4/18/25 documents that R2 did not receive a Hydrocodone/APAP tablet 7.5/325 mg until 4/19/25 at 11:40 am.R2's Controlled Substance Proof of Use sheet dated 4/18/25 documents that R2 did not receive a Tramadol 50 mg until 4/19/25 at 11:40 AM.On 7/30/25 at 9:03 AM, V17, LPN (Licensed Practical Nurse) stated that she is pretty sure that R2's medication did not get here until late. She stated that the pharmacy runs late and that only certain people have access to the (Medication Distribution Machine).On 7/30/25 at 9:54 AM, R2 stated that he did not get his medication until Saturday morning (4/19/25). He stated that his pain medication was not available Friday (4/18/25) evening, and he was in a lot of pain. He stated that he did not sleep well because of the pain.On 7/30/25 at 10:30 AM, V2, DON (Director of Nursing) stated that she would expect a newly admitted resident to get their medication on time. She stated that staff can pull medication from the (Medication Distribution Machine).Facility's Pain Management Program dated 4/2025 documents To establish a program which can effectively manage pain in order to remove adverse physiologic and physiological effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness.

Based on observation, interview and record review the facility failed to prevent injury for 1 of 3 (R3) residents investigated for accidents in a sample of 3. R3's Undated Face sheet documents initial admission date 11/27/2023 diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, iron deficiency anemia unspecified, unspecified osteoarthritis, unspecified site and unspecified hearing loss, unspecified ear.R3's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15 out of 15.R3's MDS dated [DATE] documents resident needs substantial/maximal assistance with sit to lying, lying to sitting onside of bed, assistance to sit to stand, chair/bed to chair transfer and toilet transfer.R3's Care Plan addresses Resident is at a (moderate risk) for abuse/neglect as noted from Abuse screening r/t (related to) depression symptoms and right sided hemiparesis. Goal: Resident will be free for abuse/neglect through next review. Interventions: Resident has right-sided hemiparesis, extra caution when transferring/adjusting resident.R3's Care plan addresses The Resident needs assistance with ADL's (Activities of Daily Living). Goal: [NAME] will receive assistance as needed to safely perform ADLs through review date. Interventions: Toileting: Assist of 1 with gait belt. Transfers: Stand Pivot Assist x 2 with gait belt- SPT (stand pivot transfer) only.R3's Progress note dated 7/26/2925 at 2:00 PM documents During routine shower, Aide noted a bruise to residents right posterior hand below her thumb. Bruise noted to be deep purple in color. When asked how it happened, resident stated the CNA (certified nursing assistant) was kind of rough and impatient with her. Bruise was reported to on call nurse along with residents' statement about the situation. After beginning the investigation and getting statements from all staff members and resident, the aide assigned to her was suspended pending further investigation. All parties were made aware of all.R3's Progress note dated 7/26/2025 at 10:17 AM documents IDT (interdisciplinary teams) met to discuss fall from today. Resident was lowered to floor with staff assist while ambulating in room. Root cause- Weakness Intervention- Refer to therapy services r/t transfers.On 7/29/2025 at 10:49 AM R3 observed sitting in wheelchair, reading her book. R3 states V6, Certified Nursing Assistant, (CNA) tried to get her up for breakfast a couple days ago. R3 states her right side is paralyzed, but she R3 still does have some feeling. R3 states (V6) was forceful and pulled her right side. R3 states (V6) then grabbed her bad right hand and put her fingernail into her right hand. R3 states her right hand has a bruise under her thumb and a fingernail mark. R3 showed this writer her right hand, has a quarter size dark purple bruise along with a small fingertip size scab above it. R3 states her right hand is still sore. R3 states (V6) did not use the gait belt. R3 states most of the agency CNA's don't listen to her, but the staff CNA's know her very well and take good care of her. R3 states staff mostly help when she (R3) goes to restroom and will use a gait belt with 1 staff to assist. R3 states she (R3) has been here a long time and most staff know her needs well. R3 states she (R3) can make her needs well known.On 7/29/2025 at 10:58 AM, V3, CNA, states (R3) need one assist and gait belt for assistance.On 7/29/2025 at 11:00 AM V4, Licensed Practical Nurse, (LPN) states she was here the day (R3) got her injury to right hand. V4 states during medication pass, (R3) was about to get a shower and told her she didn't feel comfortable with the (V6) giving her a shower. (R3) requested V7, Restorative Aide, to give her a shower, as (R3) feels more comfortable with her. V4 states (R3) is very particular with staff that she wants to give her care and who she trusts. V4 states she looked at (R3's) right hand and saw very little bruising at that time.On 7/29/2025 at 11:18 AM V5, Police Officer, states staff V8, Nurse Manager/Wound Nurse at Arc at Sangamon Valley contacted police department regarding (R3). V8 states (R3) told him (V6) went to get her (R3) up. V8 states (R3) told (V6) she is paralyzed on her right side, and (V6) did not listen. V8 states (R3) stated her right foot slipped into the chair and hit her right hand. V8 states (V6) admitted she was in a hurry, and couldn't find the gait belt, so she used the back of (R3's) bra strap to lift her and lost balance and slipped. V8 stated (R3) told her it was okay to use the back of her bra strap. V8 states (R3) did not want to press charges and did not want to get (V6) in trouble. On 7/29/2025 at 11:48 AM V6, Certified Nursing Assistant, (CNA) states on 7/26/2025 at 7:43 AM, (R3) was still asleep, so she gave her five more minutes. V6 states at 8:09 AM she got (R3) up for breakfast, but (R3) wanted to do her exercises, although she knew (R3) needed to get up now and her son was coming today. V6 states she could not find (R3's) gait belt, so she used (R3's) bra strap to grab and lift her up. V6 states (R3) told her she could use her bra strap. V6 states when she lifted (R3) up, then back down, she hit her right arm and tensed up. V6 states she then saw (R3's) gait belt in another chair under clothes. V6 states she was later told that (R3) requested V7 to give (R3) a shower. V6 states she approached (R3) and asked why she requested (V7) to assist with a shower, (R3) told her that she felt she didn't like her and felt more stable and comfortable with (V7). (R3) told her, We don't have a connection. V6 states she apologized to (R3).On 7/29/2025 at 1:00 PM V2, Director of Nursing, (DON) states a bra strap is not acceptable to use if gait belt is not available. She states there are no alternatives to a gait belt.On 7/30/2025 at 10:52, V10, Director of Therapy states (R3) needs one assist with gait belt with transfers.R'3 written statement on 7/28/2025 by V7, Restorative Aide documents Nurse asked me to give a resident a shower. Went to go get resident. While in the shower room I assisted the resident. Where I discovered a bruise on rt hand thumb area. I asked what happened. She stated V6 did it. She (R3) would not state anything else.R3's Preliminary 24-hour Abuse Investigation Report documents On 7/26/2025 at approximately 2pm administrator was informed of a bruise on residents right hand. Resident stated it happened during care with a CNA (certified nursing assistant) Investigation was initiated immediately. The staff member indicated by the resident was immediately suspended pending investigation.Facility's Transfers- Manual Gait Belt and Mechanical Lifts Policy last revised 08/2023 documents Purpose: In order to protect the safety and well-being of the Staff and Residents, and to promote quality care, this facility will use Mechanical lifting devices for the lifting and movement of Residents. The transferring needs of residents will be assessed on an ongoing basis and designated into one of the following categories: 0 = Independent 1 = 1 person transfer (25% or less assistance from the caregiver) with gait belt 2 = 2 person transfer with gait [NAME] (ONLY when use of mechanical lift is not possible) 6. Resident transferring and lifting needs shall be documented in care plans and reviewed via care plan time frame and as needed. Assessment of the resident's transferring needs shall include a. Mobility status b. Weight bearing ability c. Cognitive status 8. Failure to comply with lifting guidelines may result in disciplinary action as deemed appropriate. 9. Use of gait belt for all physical assist transfers is mandatory.

Based on interview and record review the facility failed to provide medication on admission on 1 of 3 (R2) residents investigated for quality of care in a sample of 20.R2's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility on [DATE].R2's EMR dated 4/18/25 documents a diagnosis of aftercare following joint replacement surgery and presence of right artificial hip joint.R2's EMR dated 4/18/25 documents a diagnoses of unspecified asthma and chronic obstructive pulmonary disease with acute exacerbation (COPD).R2's Care Plan dated 5/18/25 documents The resident is at risk for pain r/t Osteoarthritis and RTHAR2's Care Plan dated 5/18/25 documents The resident has altered respiratory status/difficulty breathing r/t COPD.R2's Physician Order dated 4/18/25 documents Hydrocodone-Acetaminophen Oral Tablet 7.5-325 MG (Hydrocodone-Acetaminophen); Give 1 tablet by mouth every 6 hours as needed for Pain.R2's Physician Order dated 4/18/25 documents Apixaban Oral Tablet 5 MG (Apixaban); Give 1 tablet by mouth every morning and at bedtime for anticoagulation.R2's Physician Order dated 4/18/25 documents Doxycycline Hyclate Oral Tablet 20 MG (Doxycycline Hyclate); Give 1 tablet by mouth two times a day for infection.R2's Physician Order dated 4/18/25 documents tramadol HCl Oral Tablet 50 MG (Tramadol HCl); Give 1 tablet by mouth every 6 hours as needed for pain.R2's MAR (Medication Administration Record) dated April 2025 does not document that R2 received Apixaban 5mg, Doxycycline 20 mg, Hydrocodone-Acetaminophen 7.5/325 mg, or Tramadol 50 mg on the evening of 4/18/25.On 7/30/25 at 9:03 AM, V17, LPN (Licensed Practical Nurse) stated that she is pretty sure that R2's medication did not get here until late. She stated that the pharmacy runs late and that only certain people have access to the (Medication Distribution Machine).On 7/30/25 at 9:54 AM, R2 stated that he did not get his medication until Saturday morning (4/19/25). He stated that his pain medication was not available Friday (4/18/25) evening, and he was in a lot of pain. He stated that he did not sleep well because of the pain.On 7/30/25 at 10:30 AM, V2, DON (Director of Nursing) stated that she would expect a newly admitted resident to get their medication on time. She stated that staff can pull medication from the (Medication Distribution Machine).Facility's Medication Administration Policy dated 1/2015 documents Medications must be administered in accordance with a physician's order, e.g., the right resident, right medication, right dosage, right route, and right time.

Based on record review and interview the facility failed to notify a resident's responsible party of a resident injury for 1 of 4 residents (R3) reviewed for notification in the sample of 6.Findings Include:R3's medical diagnosis sheet, print date of 7/23/25, documented R3 has diagnoses including unspecified severe dementia with agitation, dysphagia, osteoporosis, crest syndrome, anemia, and congestive heart failure. R3's MDS (Minimum Data Set), dated 6/23/25, documented R3 is severely cognitively impaired and is dependent on staff for ADLS (activities of daily living). R3's progress note, dated 7/10/25 at 11:57 PM, documented CNA (Certified Nurse Assistant) made writer aware that resident had smashed her finger in the door. 4th digit of right hand observed to have the door indention print, redness and what look like a bruise forming. POA/MD (Power of Attorney/Medical Doctor) updated. On 7/22/25 at 10:27 AM V4, private caretaker for R3, stated last week on 7/11/25 during one of her visits to see R3 as she was washing R3's hands she noticed her right hand was bruised, swollen, and had a small skin tear. V4 stated she went to R3's nurse and CNA on the day shift and they both said they didn't know anything about R3's bruised hand. V4 stated then an evening shift CNA named (V5) came in at the beginning of her shift and said to her how is (R3's) hand, and that she was the one who found R3 with her hand stuck in the door across the hall from R3's room yesterday evening (7/10/25). V4 stated V5 told her that R3 was yelling help when she found her with her hand stuck in the door and that she took her to R3's nurse who was an agency nurse to have her hand looked at. V4 stated the next day R3 had an x-ray, and it was negative. V4 stated POA/daughter in California was not notified of the incident that evening nor did she know about it the next day when V4 first observed the injury. On 7/22/25 at 1:33 PM V9, daughter/POA for R3, stated she was never notified by the facility of R3's hand injury. V9 stated (V4) the personal caretaker she hired to look after her mom called her on 7/11/25 and informed her of the injuries she observed on her mom's right hand. V9 stated she then called the facility on 7/11/25 and asked her mom's nurse about the injury to her mom's hand. V9 stated her nurse did not know anything about the injury and the nurse said she didn't get anything in report from the night nurse about any injuries to her mom. V9 stated she then spoke to the DON (Director of Nursing) and the DON (V2) said the nurse documented she called and informed (V9). V9 stated she informed V2 she did not get any calls from the facility, she checked her phone, and did not have any missed calls from the facility. V9 stated she is a physician, and this concerned her due to the lack of supervision and monitoring of her mom.On 7/22/25 at 1:55 PM Surveyor asked V2, DON, if R3's skin condition report, dated 7/11/25 at 3:11 PM, was considered the incident report for R3's hand injury when she got her hand stuck in the door. V2 answered the night nurse did not complete an incident report on that. Surveyor asked V2 if the night nurse should have completed an incident on R3's hand injury and V2 replied yes. Surveyor asked if the night nurse called R3's family/contact person the night R3 injured her hand. V2 replied she charted she called but she said she got busy and didn't call. V2 stated I gave her a verbal warning for that.On 7/23/25 at 10:48 AM V1, Administrator, stated the facility nurses are expected to complete an incident report and call the POA when a resident sustains an injury.The facility's Incident and Accidents policy, dated 10/2024, documented the Incident/Accident Report is completed for all unexplained bruises or abrasions, all accidents, or incidents where there is injury or the potential to result in injury, allegations of theft and abuse registered by residents, visitors, or other, and resident-to-resident altercations. Procedure: An ‘incident' is defined as any happening, not consistent with the routine operation of the facility, that does not result in bodily or property damage. Physical or mental mistreatment of a resident is considered an incident whether or not actual injury has occurred. An ‘accident' is defined as any happening, not consistent with the routine operation of the facility that results in bodily injury other than abuse. An incident/accident report will be completed for: 1. All serious accidents or incident of residents. 2. All injuries of staff, families, and visitors. 3. All unusual occurrences. 4. All situations requiring the emergency services of a hospital, the police, fire department, or coroner. 5. Any type of resident abuse. 6. All unexpected events that occur that cause actual or potential harm to a resident or employee. 7. Suicide or attempted suicide. 8. Leaving premises without authorization. 9. Any condition resulting from an accident requiring first aid, physician visit, or transfer to another health care facility. 1. An incident/accident report is to be completed by a RN or LPN and is to include: a. Date and time of an incident/accident. b. Full written statement and possible cause of incident, physical assessment, injuries noted, vital signs, treatment rendered, and notification of appropriate parties. 2. An RN or LPN must notify the following if an actual injury occurs: a. Physician b. Legal representative, or interested family member within 24 hours.

Based on interview, observation, and record review, the facility failed to properly supervise 2 of 3 residents (R2, R3) reviewed for incidents and accidents in the sample of 6. This failure resulted in a resident (R2) to fall in an office rest room that was left unlocked after the office staff left for the day and R2 was not found for approximately 2.5 hours after staff noticed him missing. The facility also failed to complete an incident report per its policy after R3 sustained an injury when she got her hand stuck in a door and did not add an intervention to R3's care plan until 12 days after R3's incident. Findings Include:R3's medical diagnosis sheet, print date of 7/23/25, documented R3 has diagnoses including unspecified severe dementia with agitation, dysphagia, osteoporosis, crest syndrome, anemia, and congestive heart failure.R3's MDS (Minimum Data Set), dated 6/23/25, documented R3 is severely cognitively impaired and is dependent on staff for ADLS (activities of daily living).R3's progress note, dated 7/10/25 at 11:57 PM, documented CNA (Certified Nurse Assistant) made writer aware that resident had smashed her finger in the door. 4th digit of right hand observed to have the door indention print, redness and what look like a bruise forming. POA/MD (Power of Attorney/Medical Doctor) updated.On 7/22/25 at 10:27 AM V4, private caretaker for R3, stated last week on 7/11/25 during one of her visits to see R3 as she was washing R3's hands she noticed her right hand was bruised, swollen, and had a small skin tear. V4 stated she went to R3's nurse and CNA on the day shift and they both said they didn't know anything about R3's bruised hand. V4 stated then an evening shift CNA named (V5) came in at the beginning of her shift and said to her how is (R3's) hand, and that she was the one who found R3 with her hand stuck in the door across the hall from R3's room yesterday evening (7/10/25). V4 stated V5 told her that R3 was yelling help when she found her with her hand stuck in the door and that she took her to R3's nurse who was an agency nurse to have her hand looked at. V4 stated the next day R3 had an x-ray, and it was negative. V4 stated POA (Power of Attorney)/daughter in California was not notified of the incident that evening nor did she know about it the next day when V4 first observed the injury.On 7/22/25 at 1:33 PM V9, daughter/POA for R3, stated she was never notified by the facility of R3's hand injury. V9 stated (V4) the personal caretaker she hired to look after her mom called her on 7/11/25 and informed her of the injuries she observed on her mom's right hand. V9 stated she then called the facility on 7/11/25 and asked her mom's nurse about the injury to her mom's hand. V9 stated her nurse did not know anything about the injury and the nurse said she didn't get anything in report from the night nurse about any injuries to her mom. V9 stated she then spoke to the DON (Director of Nursing) and the DON (V2) said the nurse documented she called and informed (V9). V9 stated she informed V2 she did not get any calls from the facility; she checked her phone and did not have any missed calls from the facility. V9 stated she is a physician, and this concerned her due to the lack of supervision and monitoring of her mom.On 7/22/25 at 1:55 PM Surveyor asked V2, DON, if R3's skin condition report, dated 7/11/25 at 3:11 PM, was considered the incident report for R3's hand injury when she got her hand stuck in the door. V2 answered the night nurse did not complete an incident report on that. Surveyor asked V2 if the night nurse should have completed an incident on R3's hand injury and V2 replied yes. Surveyor asked if the night nurse called R3's family/contact person the night R3 injured her hand. V2 replied she charted she called but she said she got busy and didn't call. V2 stated I gave her a verbal warning for that.On 7/23/25 at 10:48 AM V1, Administrator, stated the facility nurses are expected to complete an incident report and call the POA when a resident sustains an injury.The facility's Incident and Accidents policy, dated 10/2024, documented the Incident/Accident Report is completed for all unexplained bruises or abrasions, all accidents, or incidents where there is injury or the potential to result in injury, allegations of theft and abuse registered by residents, visitors, or other, and resident-to-resident altercations. Procedure: An ‘incident' is defined as any happening, not consistent with the routine operation of the facility, that does not result in bodily or property damage. Physical or mental mistreatment of a resident is considered an incident whether or not actual injury has occurred. An ‘accident' is defined as any happening, not consistent with the routine operation of the facility that results in bodily injury other than abuse. An incident/accident report will be completed for: 1. All serious accidents or incident of residents. 2. All injuries of staff, families, and visitors. 3. All unusual occurrences. 4. All situations requiring the emergency services of a hospital, the police, fire department, or coroner. 5. Any type of resident abuse. 6. All unexpected events that occur that cause actual or potential harm to a resident or employee. 7. Suicide or attempted suicide. 8. Leaving premises without authorization. 9. Any condition resulting from an accident requiring first aid, physician visit, or transfer to another health care facility. 1. An incident/accident report is to be completed by a RN or LPN and is to include a. Date and time of an incident/accident. b. Full written statement and possible cause of incident, physical assessment, injuries noted, vital signs, treatment rendered, and notification of appropriate parties. 2. An RN or LPN must notify the following if an actual injury occurs: a. Physician b. Legal representative or interested family member within 24 hours.

Based on observation, interview, and record review, the facility failed to ensure wheelchairs were clean for 1 of 5 residents (R2), reviewed for safe/clean/comfortable/homelike environment in the sample of 5.Findings include:On 7/1/25 at 9:00 AM, R2 was observed in her wheelchair, in the dining room. The wheelchair had dried debris on the edges of the seat, wheels, and frame.On 7/1/25 at 12:45 PM, R2 stated the facility staff is to clean her wheelchair once a month, but she isn't sure if they do it.R2's Minimum Data Set, dated [DATE], documents R2 has a BIMS (Brief Interview of Mental Status) score of 14, indicating R2 is cognitively intact.On 7/1/25 at 4:00 PM, V1, Administrator, stated he will make sure R2's wheelchair is cleaned. The Cleaning & Sanitizing - Wheelchairs and Other Medical Equipment, dated 11/20/12, documents the following: Medical equipment/devices will be cleaned and sanitized weekly or more often if needed, when used by the same resident.

Based on observation, interview, and record review, the facility failed to ensure fall interventions were in place in 1 of 4 residents (R3), reviewed for falls in the sample of 5.Findings Include: R3's Face Sheet, undated, documents R3 has the following diagnoses: Dementia, History of Falling, and Chronic Kidney Disease.R3's Minimum Data Set, dated [DATE], documents R3 has moderate cognitive impairment, utilizes a wheelchair for mobility, and is dependent upon staff for chair/bed transfers. R3's Care Plan, dated 10/5/23, documents R3 is at risk for falls with the following interventions: Tilt Broda (reclining wheelchair) back in a reclining position when she is up and is not eating, keep furniture in locked position, and placement of a reminder sign to lock the Broda chair brakes when resident is sitting at the table due to resident pushing herself away from the table and is unbalanced and will lean forward causing unbalanced trunk movements.On 7/1/25 at 1:10 PM, R3's reclining wheelchair was observed with brakes to all four wheels and a sign on it documenting to make sure the brakes were locked and the chair was tilted backwards when R3 was in it. On 7/1/25 at 1:00 PM, V12, R3's family, stated the problems in the facility are ongoing. V12 stated R3 had a fall recently and had to go the ER/emergency room, she didn't have to get any stitches or have any bleeds. V12 stated when R3 is up in her chair, she is to have her wheelchair locked and she is to be leaned back. V12 stated R3 fell in the dining area, and she feels that staff didn't have her wheelchair locked or leaned back. V12 stated R3 used the table pushing herself backwards and fell out of her chair and smacked her head. V12 stated this was never confirmed or denied by the facility but she has requested the nurses report. V12 stated she doesn't believe there is enough oversight in the dining room, it is just dining staff and not enough CNAs (Certified Nursing Assistants) or nurses supervising. V12 stated R3 has fallen a few times, that is why she has signs all over her room reminding them to lock her wheelchair and tilt it backwards. R3's Progress Note, dated 6/24/25 at 10:23 AM, documents the nurse was called to the dining room by the activity aide. Resident was observed lying on the floor on her right side. Head laceration to the forehead. Complaints of pain to the head and right hip. Full mechanical lift sling lying on the floor with her. One wheel locked on the wheelchair. Resident transferred to local emergency room for further evaluation.R3's Progress Note, dated 6/23/25 at 10:53 AM, documents the interdisciplinary team met regarding recent fall. Resident was in the dining room when she pushed herself away from the table and fell. Resident unable to state what happened. Root cause: pushed self away from the table. Intervention: send to emergency room for evaluation and treatment. R3's Progress Note, dated 6/24/25 at 10:18 AM, documents the interdisciplinary team met regarding recent fall. Resident returned from the hospital with no major injury. Hematoma to the right forehead. Intervention: monitor bruising to forehead, add non-skid material to wheelchair and schedule acetaminophen for pain control. On 7/1/25 at 4:00 PM, V1, Administrator, stated he is aware of V12's concerns with R3's fall and has spoken with her about this. The Fall Prevention Program policy, dated 11/20/12, documents the purpose of the policy is to assure the safety of all residents in the facility when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary.

Based on interview, observation, and record review the facility failed to monitor a resident's enteral nutrition needs, monitor a resident's weight, identify severe weight loss of a resident, provide needed interventions to prevent further weight loss, and re-assess a resident's nutritional needs when the resident was not tolerating enteral nutrition for 1 (R11) of 3 residents reviewed for enteral nutrition. This failure resulted in R6 experiencing a 11.98% weight loss in 6 weeks of being admitted to the facility. Findings Include: R11's clinical census sheet, print date of 5/13/25, documented R11 was admitted to the facility on [DATE]. R11's medical diagnosis form, print date of 5/12/25, documented R11 has diagnoses including laceration of esophagus, history of anaphylaxis, gastrostomy status, hypertension, depression, anxiety, and anemia. R11's MDS (Minimum Data Set), dated 4/9/25, documented R11 is cognitively intact and dependent on staff for all ADLS (activities of daily living). R11's weights and vitals document, print date of 5/12/25, documented R11 was weighed 2 times between admission date of 4/2/25 through 5/8/25. R11's documented weights are 206.9 pounds on 4/2/25 and the next recorded weight is 182.1 pounds on 5/8/25. R11's gastroenterology progress note, dated 3/12/25, documented R11 presented to local hospital with concerns for angioedema (anaphylactic reaction) thought to be related to shellfish and found to have pneumothorax. Patient was intubated in the ED (Emergency Department) after multiple failed attempts in the field, ICU (Intensive Care Unit) concerned for possible traumatic esophageal perforation. CT (computed tomography) scan reveals diffuse accumulation of contrast in the right chest cavity believed to be caused from mid esophageal perforation. Underwent EGD (esophagogastroduodenoscopy) on 3/3/25 which confirmed diagnosis. Then underwent thoracotomy with decertification, repair of esophagus, and intersection of PEG (percutaneous endoscopic) tube on 3/11/25. R11's progress note, dated 4/2/25 at 1:40 PM, documented (local hospital) nurse called with report. Resident is an [AGE] year-old female. Resident had an allergic reaction to shrimp. It continues, IV (intravenous) ABT (antibiotic) for pneumonia. Resident is alert and oriented x4. NPO (nothing by mouth) G-tube with tube feeding 5x/times day. R11's provider progress note, dated 4/4/25, documented dietician to eval and treat free water flushes and tube feeds. R11's progress note, dated 4/5/25 at 12:44 PM, documented resident nauseated and declined feeding at this time. R11's progress note, dated 4/5/25 at 6:54 PM, documented enteral feed order, resident refused due to being nauseated and dizzy. R11's progress note, dated 4/6/25 at 5:46 AM, documented resident expressed clear refusal to receive morning G-tube medications, stating I don't want anything through my tube right now. Reported feeling extremely dizzy and nauseated since yesterday. No emesis or pain reported. Resident requested transfer via ambulance to local ER (Emergency Room) for further evaluation. Resident insisted on the need for a higher level of medical care. Notified POA (Power of Attorney) and charge nurse. EMS (emergency medical services) initiated, transported via gurney to local hospital at 0430 per wishes. R11's local emergency room progress notes, dated 4/6/25, documented reason for visit: vomiting, diagnoses: low sodium levels, dizziness, nausea and vomiting, medications given Antivert (for vertigo), Zofran (for nausea), and sodium chloride 0.9% (for low sodium). R11's progress note, dated 4/8/25 at 1:33 PM, documented resident complained to writer she is having loose stools after every tube feeding. Writer sent an email to the dietician to evaluate resident's tube feeding. R11's dietician recommendation, dated 4/8/25, documented recommend (enteral nutrition supplement) at 35 ml/hour continuous with water flushes every 4 hours to provide adequate nutrition. R11's progress note, dated 4/8/25 at 7:11 PM documented resident refused tube feeding due to having constant diarrhea. R11's progress note, dated 4/10/25 at 11:20 AM, documented resident refuses to have feeding through pump and would like to have feedings administered via bolus as previously ordered, will notify dietician as well. R11's progress note, dated 4/10/25 at 8:51 PM, documented resident states she doesn't want the feeding and would like to talk about other options. R11's progress note, dated 4/12/25 at 4:27 PM, authored by V25, R11's physician, documented patient states that she cannot tolerate tube feeding and frequently refuses continuous tube feedings she prefers boluses not only allows small amount of bolus. It continues, patient is NPO (nothing by mouth) and is getting tube feeding through G-tube not able to tolerate G-tube feeding well. Will ask dietician to see patient continue with fiber to prevent diarrhea, advised patient to do tube feeding as much as possible. R11's progress note, dated 4/12/25 at 8:29 PM, documented resident refused tube feeding. R11's progress note, dated 4/12/25 at 9:16 PM, documented resident refused her feeding this shift, stated it gives her diarrhea. Doctor (V25) aware. R11's physician progress note, dated 4/15/25 at 2:28 PM, documented patient is NPO (nothing by mouth) and is getting tube feeding through G-tube not able to tolerate G-tube feeding well. Will ask dietician to see patient, continue with fiber to prevent diarrhea, advised patient to do tube feeding as much as possible. C-diff (clostridium difficile) negative. R11's progress note, dated 4/16/25 at 10:09 AM, documented continues tube feeding at 35ml/hour, requests bolus feedings. R11's progress note, dated 4/17/25 at 2:27 PM, documented nurse practitioner in facility to visit resident. Dietician to eval for possible different tube feeding as this once causes her significant diarrhea. R11's provider progress note, dated 4/17/25, documented dietician to eval for possible different tube feeding as this one causes her significant diarrhea. R11's progress note, dated 4/17/25 at 9:28 PM, documented resident refused tube feeding this shift. Resident educated on the importance of her ordered feedings as well as the impact not receiving these feeding can have on her overall health. Resident is aware and acknowledges understanding. MD (Medical Doctor) and NP (Nurse Practitioner) are aware of this as well. Plan of care continues. R11's progress note, dated 4/18/24 at 10:42 PM, documented resident's feeding refused this shift. Resident expressed concerns to writer regarding her feeding order. Resident is currently NPO and has an order for (enteral nutrition) via g-tube however she has expressed to MD and NP (Nurse Practitioner) that the (enteral nutrition brand) gives her diarrhea and she would like order changed to a new type of feeding. As of now dietitian has been contacted and resident is awaiting word from dietitian about this matter. She states to writer that this has gone on for too long and she feels that her concerns are not being taken seriously by her MD at this time. She is asking to be seen by a new doctor. Writer explained that she will make managers aware of this. R11's progress note, dated 4/19/25 at 4:56 AM, documented resident continued to have an order for continuous tube feeding at 35ml/hour 24 hours a day. It continues, resident chose to take 60ml of (nutritional supplement) at this time, she stated that the (nutritional supplement) gives her severe diarrhea and wants to ease into talking the (enteral nutrition brand) feeding supplement. R11's progress note, dated 4/22/25 at 4:56 PM, documented received email from dietician regarding feeds. Continue (enteral nutrition brand), however, instead of being ran at 35 ml/hr she is requesting 45 ml/hr. Nursing staff as well as resident made aware; all agreeable to plan. R11's progress notes by V24, Registered Dietitian, dated 4/23/25 at 12:33 PM, documented current weight 206.9, diet: NPO, (enteral nutrition brand) at 45ml/hr x 24 hours. It continues, resident admitted [DATE], NPO with TF's (tube feeding) for nutritional support. TF's meeting low end of calorie needs. Unable to assess weight history as resident was recently admitted . Resident previously on (enteral nutrition supplement) however not tolerating it. Staff states resident tolerates (enteral nutrition brand). No pressure injuries, skin is intact. Plan: Recommend continuing current TF regimen. Will continue to monitor TF tolerance and weight changes. RD is available for consult PRN (as needed). R11's physician progress note authored by V26, thoracic surgeon, dated 4/24/25, documented patient may now start a full liquid diet. All further diet recommendations will come from (local) GI (gastrointestinal) clinic. R11's physician progress note authored by V25, dated 4/26/25 at 3:55 PM, documented based on last esophagogram there was not leak, started on CLD (clear liquid diet), does not do tube feeding any more, continue protein supplement and monitor weight. R11's provider progress note, dated 4/30/25, documented dietician eval as patient on liquid diet until 5/20/25. On 5/12/25 at 9:27 AM R11 stated she is no longer receiving nutrition through her g-tube and she is now on clear liquids with a protein supplement. R11 stated when she was first admitted she could not tolerate the feeding and feels the lactose was upsetting her stomach resulting in her to experience nausea and diarrhea. R11 stated she has lost over 30 pounds since she was admitted to the facility. On 5/12/25 at 9:38 AM V7 LPN stated R11 is receiving her medications and a protein supplement through her g-tube. V7 stated R11 started refusing her g-tube feeding because it caused her to have diarrhea, so the doctor put her on clear liquids and the protein supplement until she follows up with her surgeon. On 5/12/25 at 2:42 PM V7 LPN stated R11 could not tolerate the supplement, so the NP was notified and discontinued the supplement on 5/6/25 and started her on a protein supplement twice a day. V7 presented the protein supplement to surveyor and stated R11 gets 30ml of this twice a day. The supplement bottle documented 1 - 30ml dose of the protein supplement consists of 100 calories, 15 grams of protein, and 0 fat. On 5/12/25 at 2:46 PM V23 Unit Manager stated it is the facility policy to weigh residents every week for the first 4 weeks of admission, (R11) did get missed, we have no weights for her between 4/2/25 to 5/8/25. V23 then stated there is no documentation that the RD was notified of R11's weight loss nor was RD notified of (brand name) supplement being dcd. On 5/12/25 at 2:52 PM V24, Registered Dietitian, stated there was a miscommunication with the facility staff and her, that the facility was messaging her through a system that she does not have access to, and the facility nurses did not realize she was not receiving the messages. V24 stated she was not aware R11's (brand name) supplement was discontinued, was not notified of R11's 24.8-pound weight loss since admission to the facility until 5/8/25 and was not aware nor notified R11 had been placed on a liquid diet. V24 stated she recommended V24 be started on a fortified juice on 5/8/25 after she learned of her weight loss. V24 then stated, I also recommended they increase the (liquid protein supplement) from BID (twice a day) to TID (three times a day) on 5/9/25, and I see they have not increased it yet. On 5/13/25 at 9:55 AM R11 stated no facility staff including the Registered Dietitian have talked with her about her diet, that all she is receiving is a bowl of broth three times a day at meals. R11 stated she went over a month here at the facility without being weighed, she asked them to weigh her recently, and the has lost about 30 pounds. R11 stated she has not received any speech therapy since she was admitted to the facility. On 5/13/25 at 10:18 AM V25, R11's Medical Doctor, stated R11 had a perforated esophagus, it was repaired then developed a leak, she developed more complications including pneumonia, then inserted g-tube, she was receiving bolus feedings 6 times a day in the beginning of her stay. R11 refused the tube feeding because she said it was causing her to have diarrhea. Stated he personally had conversations with her regarding her weight and need for tube feeding, she was then put on clear liquid diet. Stated he was notified of her weight loss and made referrals to RD. On 5/13/25 at 2:55 PM V3, Regional Nurse, provided an email, dated 4/24/25 at 1:52 PM documenting the facility RD, V24, was notified of R11's new order to change her diet from NPO to clear liquid. V24 replied Thanks for the update on 4/24/25 at 2:07 PM. V3 stated the facility does not have any documentation from the RD, V24, regarding R11's diet change to clear liquid from enteral nutrition on 4/24/25 and she would have expected V24 to complete a new nutritional assessment. V3 stated the facility does not have any weekly weights documented for R11 between her documented weight of 206.9 on 4/2/25 and the next documented weight of 182.1 on 5/8/25. V3 stated R11 should have been weighed every week and V24 RD should have been monitoring R11's nutritional status. Surveyor requested a nutritional calculation of R11's daily caloric and protein needs and V3 stated the facility does not have anything documented. On 5/14/25 at 10:55 AM V3, Regional Nurse, stated the facility does not have any Registered Dietitian documentation for R11's daily nutritional needs other than the 3 dietitian recommendation notes dated 4/7/25, 4/8/25, and 4/22/25. V3 agreed that these 3 documents do not calculate R11's calorie, protein, and nutrient needs based on R11's current health condition. V3 stated the facility does not have any documentation showing the facility RD V24 received and responded to V25's referrals to RD on R11. On 5/14/25 at 12:02 PM V3, Regional Nurse, stated V26, R11's thoracic surgeon, is who ordered R11's clear liquid diet and she has a call out to his office for those progress notes. V3 stated she has no documentation showing the facility RD was notified and intervened of R11's ongoing enteral nutrition intolerance, weight loss, nor of R11 being placed on a liquid diet. V3 then provided surveyor with the progress note by V26 from R11's consultation with him on 4/24/25 and surveyor noted the order documented full liquid diet not clear liquid diet as the facility documented on R11's EMR physician orders. V26 also documented all further diet recommendations will come from (local) GI clinic. On 5/14/25 at 1:42 PM V3, Regional Nurse, agreed V26's order documented liquid diet on 4/24/25 and that the facility put R11 on a clear liquid diet rather than a full liquid. V3 stated there is a difference between those two diets and the facility will call for verification. Surveyor asked if V26 or R11's GI specialists were notified of R11 starting back on the continuous tube feeding yesterday, 5/13/25, and V3 stated there is no documentation noting this but R11's primary physician is aware of R11 being back on the continuous tube feeding. On 5/14/25 at 2:05 PM V7 LPN stated R11 was started back on her continuous tube feeding yesterday. Surveyor asked what physician gave the order and V7 replied you will have to ask the unit manager, V23, because she got the order. On 5/14/25 at 2:07 PM V23, Unit Manager, stated she received the order from the facility's RD, V24, yesterday for R11 to start the continuous tube feeding again. Surveyor asked if R11's primary physician, surgeon, or GI specialist approved that order and V23 stated she has no documentation showing they were notified or approved of the order. On 5/14/25 at 2:10 PM R11 stated she was started back on the continuous tube feeding yesterday, she does not know if a doctor approved it, the nurse just came in and said I was starting back on it. R11 stated the only issue she has had since it was restarted was one loose stool this morning, but the tube feeding has been shut off since 8 AM and not restarted. Surveyor observed the bottle of (enteral nutrition brand) hanging in R11's room, the bottle was labeled as being started on 5/13/25 at 12:30 PM, rate of 35ml/hr, observed 600ml remaining in bottle, not connected, and not running. Surveyor asked R11 if V26 (R11's thoracic surgeon) ordered a clear liquid diet or a liquid diet when she saw him on 4/24/25 and R11 replied I assumed it was clear liquid. On 5/14/25 at 2:17 PM V24, Registered Dietitian, stated she recommended R11 be started back on her continuous tube feeding yesterday, 5/13/25. Surveyor asked if she was aware R11's thoracic surgeon recommended R11 be on a liquid diet when she saw him on 4/24/25 and that all further dietary recommendations needed to come from (local) GI (gastrointestinal) specialist and V24 replied she was not aware of that and does not know if a physician approved for R11 to go back on full enteral nutrition. Surveyor then asked V24 if there is a difference between a full liquid diet (as noted by V26) and a clear liquid diet. V24 replied yes, and that a liquid diet would provide more nutrients and calories than a clear liquid diet. Surveyor asked if V24 was aware V26 ordered a liquid diet for R11 and not a clear liquid diet on 4/24/25 and V24 replied she was not aware. The facility's Significant Weight Gain or Loss Policy, dated 2/2024, documented Purpose: to ensure that insidious/significant weight gain or loss will be identified so that nutritional needs can be evaluated, and appropriate intervention provided. Guidelines: 1. Dietary/Nursing team will obtain weights from nursing, 2. Dietician/Nursing will determine significant weight changes: a. Gain or loss of 5% in the last month, b. Gain or loss of 7.5% in the last three months, 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 Dietitian Referrals and Recommendations policy, dated 2/2024, documented Purpose: To ensure high risk resident's nutritional needs/goals are met or maintained within acceptable parameter for resident. Responsibility: Dietitian/Licensed Nursing/Dietary Manager. Guidelines: Director of Nursing or designee will determine high risk residents and send referral to Dietitian. Dietitian will complete referrals in a timely manner. Dietitian will complete a nutritional assessment and document in the resident's EMR. Dietitian recommendations will be communicated to the medical provider on a timely basis to provide appropriate intervention if necessary. It continues, Dietitian will complete nutritional assessments on residents according to annual MDS or significant changes. Dietitian will complete assessment on all referrals and document in resident's EMR. High risk criteria examples but not limited to unintentional weight loss of more than 5% in one month, more than 7.5% in three months, and more than 10% in six months, and enteral feeding dependent residents.

Based on observation, interview, and record review the facility failed to provide enough nursing staff to adequately meet the needs for 4 of 4 (R2, R4, R7, and R11) residents reviewed for staffing in the sample of 16. These failures have the potential to affect all residents residing at the facility. Findings Include: 1.R2's diagnosis sheet, print date of 5/12/25, documented R2 has diagnoses including acute hematogenous osteomyelitis of left ankle and foot, type 2 diabetes mellitus, chronic kidney disease, hypertension, and heart disease. R2's MDS (Minimum Data Set), dated 4/18/25, documented R2 is cognitively intact and requires partial to moderate assistance with transfers to and from wheelchair. R2's care plan, undated, documented R2 has an ADL (activities of daily living) self-care performance deficit related to generalized weakness and requires assistance with all ADLS including bathing and toileting. On 5/7/25 at 9:15 AM V6, (husband of R2), step out of R2's room with a full bag of soiled laundry in a yellow isolation bag and placed the bag on the floor outside of R2's room. V6 then stated to V5, CNA, this is the 3rd day I have asked for this dirty laundry to be removed from my wife's room, I am tired of asking. Surveyor then interviewed R2 and V6. V6 stated oh my god they are very short staffed, (R2) called me at home one day because she couldn't get any employees to answer her call light, so I got ready and came to the facility, she waited 40 minutes to get help. R2 stated her initial stay at the facility was very difficult because she could not transfer herself after being in ICU (Intensive Care Unit) for 21 days and had a partial foot amputation during the hospital stay so there was no way for her to transfer herself to the bathroom and she had to wait for an average of 20 to 30 minutes to get her call light answered. R2 stated she was told by her doctors to drink lots of water to improve her kidney function so she was which resulted in her needing to go to the restroom frequently and she would have to wait for extended periods of time to get assistance. V6 stated R2 quit calling for assistance and now she just takes herself to the bathroom. V6 stated we have talked to the DON, (Director of Nursing), 3 times about it taking so long to get her call light answered. I am glad you are here because I was planning on calling state about the lack of staff, now I don't have to. On 5/13/25 at 10:12 AM R2 stated she has not been receiving showers on a regular basis since she was admitted to the facility on [DATE]. R2 stated she would like to get at least 2 showers per week, but she has only received 1 a week and sometimes none. R2 stated the facility does not have enough CNAs to get everything done. R2's CNA Skin Attention Forms documented R2 received showers on 4/17/25, 4/24/25, and 5/1/25. R2's Skin Attention Form, dated 5/8/25, documented R2 refused her shower. On 5/13/25 at 10:14 AM R2 stated she refused the shower on 5/8/25 because the CNA offered it to her late in the evening and that she was supposed to get a shower the following day on 5/9/25 but no staff ever came to give her one. 2.R7's diagnosis sheet, print date of 5/7/25, documented R7 has diagnoses including recent left artificial shoulder joint replacement, fibromyalgia, hypothyroidism, sleep apnea, atrial fibrillation, morbid obesity, hypertension, depression, anxiety disorder, and spinal stenosis. R7's MDS (Minimum Data Set), dated 5/6/25, documented R7 is cognitively intact and is dependent on staff for her toileting needs. R7's care plan, undated, documented R10 has an ADL (activities of daily living) deficit related to left shoulder replacement. On 5/7/25 at 10:28 AM R7 stated it takes a while to get my call light answered, sometimes 15-30 minutes, I wet the bed once because they didn't come in time to put me on the bedpan. They are so understaffed. On 5/7/25 Surveyor observed R7's call light on from 12:04 PM until it was answered by V16, transportation CNA (Certified Nurse Assistant), at 12:32 PM. The daily nursing department schedule dated 5/7/25 documented 1 nurse (V10) and 1 CNA (V9) CNA were assigned to R7's unit (300) on the day shift. V10 and V9 were not observed on the 300 unit during this observation. On 5/7/25 at 12:35 PM V9 CNA (assigned to 300 unit) stated she passes the 4 room trays on the 300 unit and then she goes to the dining room. V9 stated she does not know how she is supposed to pass trays in the dining room and answer call lights on the 300 unit. V9 stated no specific staff are assigned to answer hall lights while the CNAs are in the dining room including on 300 unit where she is the only CNA. On 5/7/25 at 12:43 PM V16, transportation CNA, stated she answered R7's call light and that she took R7 off the bed pan. On 5/8/25 at 7:45 AM R7 stated she was left on the bedpan for over 20 minutes yesterday afternoon because her call light was not getting answered. R7 stated it was not comfortable being on the bed pan for so long. 3.R4's diagnoses sheet, print date of 5/8/25, documented R4 has diagnoses including multiple sclerosis, quadriplegia, depression, osteoporosis, hypertension, and urgency of urination. R4's MDS, dated [DATE], documented R4 is cognitively intact. R4's care plan, undated, documented R4 needs total care with ADLS, is totally dependent on staff for bed mobility, dressing, eating, personal hygiene, transfers with assistance of 2 via a full body mechanical lift, and is incontinent of both bowel and bladder. On 5/7/25 at 9:52 AM R4 stated the facility does not have enough staff, the average length of time to get her call light answered is 30 minutes, it is especially bad in the evenings, and the staff rush in and out because they are so short staffed. On 5/8/25 R4's call light on at 7:26 AM and it was answered at 7:38 AM. On 5/8/25 at 2:40 PM R4 stated I cannot move anything, so it takes about 45 minutes to complete all my tasks when getting up and going to bed. There have been times when it has taken 2 hours to get my call light answered, it was at shift change from days to evenings. There have been days when 1 CNA had to transfer me in the lift because she didn't have any help. I have lived here for about 2 years and have always been on the 300 unit, we had 2 CNAs on this unit until the last month and then the company cut the second one. My quality of care has declined, it has caused me more anxiety from having to wait longer for help, I am totally dependent since I can't move anything. I have been desperate a few times because no staff answered my call light, so I asked my (hands free smart speaker) to call the front desk and my husband to get help. The CNA must cut corners now since there is only one, I could tell my CNA was stressed yesterday because she said oh, I have all these call lights on so I felt like I asked for too many tasks and I needed to cut out some tasks so she could get out and help the other residents. We need 2 CNAs on this unit, I feel bad because I take so much time to get ready for the day and bedtime. 4. R11's medical diagnosis form, print date of 5/12/25, documented R11 has diagnoses including laceration of esophagus, history of anaphylaxis, gastrostomy status, hypertension, depression, anxiety, and anemia. R11's MDS, dated [DATE], documented R11 is cognitively intact and dependent on staff for all ADLS. On 5/12/25 at 9:27 AM R11 stated the facility is short staffed and they are not providing her and the other patients the services they need. R11 stated she was ready to get out of bed and dressed at 7:30 this morning but was unable to get any staff to help her dress until 9:15 AM. R11 stated last Thursday, 5/8/25, she was left on the bedpan for over 2 hours, her call light was on, and no one would answer it. R11 stated I was scared because no one would come, my left does not work, so I was trying to figure out how to get myself out of the bed without with out help since no one was coming. R11 stated she has not had a shower in over 2 weeks. On 5/12/25 at 12:56 PM R11 stated she needs to go to the rest room, but she doesn't want to push her call light during lunch because she has to use the sit to stand to transfer onto the toilet and she is afraid she will get left in the bathroom for a long time because the facility does not have enough CNAs. On 5/12/25 at 2:15 PM surveyor requested R11's shower record documentation from 4/1/25 to 5/12/25 and R11's last documented shower was on 4/29/25. On 5/7/25 at 9:12 AM V5 CNA stated the facility is very short staffed, they do not have enough CNAs, and the family members of the residents are complaining. On 5/7/25 at 9:27 AM V7 LPN stated that the new company who recently bought this facility cut staff and now the facility does not have enough CNAs. V7 stated the residents are not getting the care they need since the new owner cut staff, residents are having skin issues, and they are especially not getting the care they need on the night shift. On 5/7/25 at 10:02 AM V10 LPN stated the new company who took over the facility cut staff including nurses and CNAs. V10 stated for several weeks there was just 1 nurse assigned to the 300 and 400 units. V10 stated they are still only allowed to have 1 CNA on the 300 unit and 1 CNA is not enough. V10 stated the floor staff have informed management that the 300-unit CNA does not have any CNAs to cover that unit when they go on break if the nurse is unable to and that management stated the 300-unit CNA has to find a CNA to cover their break, so they have to go searching for help when they go to break or lunch. V10 stated residents and family members have been upset about the lack of staff, resident falls have increased, and nursing staff have quit since the new owner took over and started cutting staff. On 5/7/25 at 10:22 AM V11 CNA stated she was normally routinely scheduled on the 300 unit, but she recently requested a break from the 300 unit because they just assign 1 CNA to that unit and there is too much to do for 1 CNA. V11 stated there are usually about 15 residents on the 300 unit, R4 is a quadriplegic, and it takes 45 minutes to get her ready, then you have to search for someone to assist with R4's transfer because she requires a mechanical lift. V11 stated it was really bad when the company cut a nurse, and the 300-unit nurse had to cover 400 also. V11 stated it is scary working by yourself on the 300 unit. On 5/7/25 at 10:45 AM V13 CNA stated, we don't really have enough staff, it has been overwhelming, residents and their families are complaining a lot about not having enough help, and we don't always have time to give all the residents showers as assigned. On 5/7/25 at 10:52 AM V14 LPN stated she has worked at the facility for the last 7 years and she recently stepped down from the wound care nurse position because the new owner of the facility cut staff and wanted her to work the floor in addition to being the wound care nurse. V14 stated CNAs and residents are complaining about the staff cuts, and resident pressure ulcers have increased. On 5/7/25 at 12:02 PM V15 LPN stated she has worked at the facility for the past 20 years, the new company cut nurse and CNAs, and there has been an increase in resident complaints due to the lack of staff. On 5/7/25 at 12:35 PM V9 CNA stated she passes the room trays on the 300 unit and then she has to go to the dining room to pass trays and assist the residents. V9 stated she does not know how she is supposed to pass trays in the dining room and also answer call lights on the 300 unit. V9 stated no specific staff are assigned to answer hall lights while the CNAs are in the dining room. On 5/7/25 at 1:52 PM surveyor informed V2 DON (Director of Nursing) of the observation of R7's call light being on from 12:04 PM until 12:32 PM and V2 stated that is not an acceptable call light response time. On 5/13/25 at 12:40 PM V3, Regional Nurse, stated the facility follows CMS (Centers for Medicare and Medicaid Services) guidelines and does not have a staffing policy.

Based on observation, interview, and record review the facility failed to ensure that residents who require assistance receive a shower or bath for 3 of 4 residents (R2, R11, R14) reviewed for Activities of Daily Living assistance in the sample of 16. This failure has the potential to affect all 126 residents residing at the facility. Findings Include: 1.R2's diagnosis sheet, print date of 5/12/25, documented R2 has diagnoses including acute hematogenous osteomyelitis of left ankle and foot, type 2 diabetes mellitus, chronic kidney disease, hypertension, and heart disease. R2's MDS (Minimum Data Set), dated 4/18/25, documented R2 is cognitively intact and requires partial to moderate assistance with transfers to and from wheelchair. R2's care plan, undated, documented R2 has an ADL (activities of daily living) self-care performance deficit related to generalized weakness and requires assistance with all ADLS including bathing and toileting. On 5/13/25 at 10:12 AM R2 stated she has not been receiving showers on a regular basis since she was admitted to the facility on [DATE]. R2 stated she would like to get at least 2 showers per week, but she has only received 1 a week and sometimes none. R2 stated the facility does not have enough CNA'S (Certified Nurse Assistants) to get everything done. R2's CNA Skin Attention Forms documented R2 received showers on 4/17/25, 4/24/25, and 5/1/25. R2's Skin Attention Form, dated 5/8/25, documented R2 refused her shower. On 5/13/25 at 10:14 AM R2 stated she refused the shower on 5/8/25 because the CNA offered it to her late in the evening and that she was supposed to get a shower the following day on 5/9/25 but no staff ever came to give her one. 2. R11's medical diagnosis form, print date of 5/12/25, documented R11 has diagnoses including laceration of esophagus, history of anaphylaxis, gastrostomy status, hypertension, depression, anxiety, and anemia. R11's MDS, dated [DATE], documented R11 is cognitively intact and dependent on staff for all ADLS. On 5/12/25 at 9:27 AM R11 stated she has not received a shower in over 2 weeks, and she is used to taking a shower every day when she is at home. On 5/12/25 at 2:15 PM surveyor requested R11's shower record documentation from 4/1/25 to 5/12/25 and R11's last documented shower was on 4/29/25. 3.R14's census sheet, print date of 5/13/25, documented R14 was admitted to the facility on [DATE]. R14's medical diagnosis sheet, print date of 5/13/25, documented R14 has diagnoses including acute kidney failure, hypertension, hyperlipidemia, type 2 diabetes mellitus, heart failure, anemia, and lymphedema. R14's MDS, dated [DATE], documented R14 is cognitively intact and requires partial to moderate assistance with ADLS including showers. On 5/12/25 at 10:10 AM R14 stated he has had 2 showers in 3 weeks and then stated, I just take what I can get. On 5/12/25 the facility provided R14's shower documentation and it documented R14 has only received 1 shower since admission. R14's shower was documented on 5/8/25 on the facility CNA skin attention form. On 5/13/25 at 10:30 V1, Administrator, confirmed the facility only has documentation of R14 receiving 1 shower between the admission date of 4/24/25 through 5/13/25. On 5/7/25 at 10:45 AM V13 CNA stated we don't really have enough staff, it has been overwhelming, residents and their families are complaining a lot about not having enough help, we don't always have time to give all the residents showers as assigned. On 5/12/25 at 9:40 AM V21 CNA stated, I don't know how I am supposed to work the split hall nor have time to do showers. On 5/13/25 at 10:31 AM V1, Administrator, stated the facility policy says residents should receive a shower or bath no less than once a week. Surveyor requested additional shower documentation for R2, R11, and R14. V1 replied I gave you what we have the shower documentation. On 5/13/25 at 2:15 PM V11, day shift CNA stated she was unable to complete her assigned showers today as she did not have time with all the other job duties she had to complete for the residents. On 5/13/25 at 2:52 PM V3, Regional Nurse, stated resident showers are only documented on the CNA skin impairment forms. The facility's Bathing - Shower and Tub Bath policy, dated 10/2024, documented Purpose: To ensure resident's cleanliness to maintain proper hygiene and dignity. Guidelines: A shower, tub bath or bed/sponge bath will be offered according to resident's preference, no less than once per week or according to the resident's preferred frequency and as needed or requested.

Based on interview and record review, the facility failed to develop a baseline care plan within the first 48 hours of admission to the facility and failed to provide the baseline care plan to the resident within 48 hours of admission for 1 of 4 residents (R11) reviewed for baseline care plans in the sample of 16. Findings Include: R11's clinical census sheet, print date of 5/13/25, documented R11 was admitted to the facility on [DATE]. R11's medical diagnosis form, print date of 5/12/25, documented R11 has diagnoses including laceration of esophagus, history of anaphylaxis, gastrostomy status, hypertension, depression, anxiety, and anemia. R11's [NAME] Data Set/MDS, dated [DATE], documented R11 is cognitively intact and dependent on staff for all ADLS (activities of daily living). On 5/12/25 at 12:56 PM R11 stated no facility staff have discussed her care plan with her, she has not received a copy of it, and she has not been invited to a care plan meeting. R11's progress note, dated 4/25/25, documented baseline care plan has been completed. Resident/POA (Power of Attorney) have received a copy. On 5/14/25 at 12:00 PM V3, Regional Nurse, stated the facility Social Service department is supposed to give residents a copy of their baseline care plan within 48 hours of admission to the facility. V3 confirmed that R11's progress note dated 4/25/25 documented R11 was given her baseline care plan on 4/25/25, 23 days after admission. The facility's Baseline Care Plan policy, dated 11/2012, documented Purpose: to develop a baseline care plan within 48 hours of admission to direct the care team while a comprehensive care plan is developed that incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Guidelines: Upon admission, the admitting nurse will initiate the development of the baseline care plan as part of the admission assessment. The baseline care plan will continue to be developed by the interdisciplinary team and be completed within 48 hours of admission. It continues, the resident and/or their representative shall receive a summary of the baseline care plan prior to completion of the comprehensive care plan that includes: the initial goals of the resident, a summary of the resident's medications and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility, any updated information based on the details of the comprehensive care plan, as necessary. As a best practice, the interdisciplinary team should attempt to schedule an initial meeting with the resident and/or resident representative within 5 days of admission to review the baseline plan of care and make updates or revisions as indicated based on feedback and input of the resident and/or representative prior to the development of the comprehensive care plan.

3.R9's Care Plan, dated 10/23/2024, documents that R9 has the potential for alteration in skin condition r/t (related to) impaired mobility/incontinence. It continues Goal: The Resident will not develop a skin injury through next review. Interventions: Administer medications as ordered and monitor for adverse effects. Administer Treatments as ordered. Weekly skin checks. It also documents the resident has the potential for pressure injury development r/t (related to) immobility / incontinence. It continues Administer medications as ordered and monitor for adverse effects. Administer treatments as ordered. R9s Minimum Data Set, dated [DATE], documents that R9 is cognitively intact, has 2 stage III pressure ulcers, and does not reject care. R9's Medication/Treatment Administration Record (MAR/TAR), dated January 2025, documents Cleanse coccyx with generic wound cleanser, pat dry, skin prep periwound, allow to dry, apply hydrocolloid 3 x (times) weekly, MWF (Monday, Wednesday, Friday), and PRN (as needed). every day shift every Mon, Wed, Fri for wound -Start Date 12/06/2024 0700 -D/C (discontinue) date 02/11/2025. There is no documentation on the TAR that R9's treatment was completed on 1/20, 1/27 and 1/29/2025. R9's Progress Notes, dated 2/11/2025 10:31 PM, documents Skin/Wound Note Text: Resident was seen on 2/10/25 by V24, Wound Nurse, for her wounds. She has a stage 3 on her coccyx with moderate serosanguinous drainage noted. It has 100% gran (granulation) tissue. Tx (treatment). of collagen and bordered gauze dressing daily and PRN (as needed). Prealbumin to be done by next visit. R9's Medication/ Treatment Administration Record, dated February 2025, documents Cleanse coccyx with generic wound cleanser, pat dry, skin prep periwound, allow to dry, apply hydrocolloid 3x weekly, MWF, and PRN. every day shift every Mon, Wed, Fri for wound -Start Date 12/06/2024 0700 -D/C Date 02/11/2025 2146. There is no documentation on the MAR/TAR that this treatment was completed on 2/5/25. R9's Medication/Treatment Administration Record, dated February 2025, cleanse coccyx with generic wound cleanser, pat dry, skin prep periwound, allow to dry, apply collagen and bordered gauze daily and PRN. every day shift for wound. -Start Date 02/12/2025 0700. There is no documentation R9 received this treatment on 2/19, 2/21, and 2/22/25. R9's Progress Note, dated 2/19/2025 at 8:36 PM, documents Skin/Wound Note Text: Resident was seen on 2/17/25 by (V24), Wound Nurse, for her wounds. She has a stage 3 on her coccyx with moderate serosanguinous drainage noted. It has 100% necrotic tissue. Tx. (treatment) of Santyl, calcium alginate and bordered gauze dressing daily and PRN. IDT, PCP, and resident updated. R9's Medication/Treatment Administration Record, dated February 2024, documents Santyl Ointment 250 UNIT/GM (Collagenase) Apply to coccyx topically everyday shift for wound Cleanse coccyx with generic wound cleanser, pat dry, skin prep periwound, allow to dry, apply Santyl, calcium alginate and bordered gauze daily and PRN. -Start Date 02/18/2025 0700 -D/C Date 02/23/2025 1802. There was no documentation that R9 received this treatment on 2/19 and 2/22 and 2/23/25. On 4/3/25 at 2:20PM, V4, (Regional Nurse Consultant), stated there have been changes since the change of ownership. V4 stated staffing is a problem, they have gotten 2-3 admissions, and management doesn't come out to help. V4 stated the wounds have gone downhill. V4 stated they have a full-time wound nurse, but she only does rounds with the wound doctor once a week, she doesn't do the wound care any other time, not even the pressure ulcers, which would help. V4 stated that with short staff this causes things to be missed. On 4/9/2025 at 4:05 PM V1, Administrator, stated that she would expect the nurses to sign off the medication/treatment record when the treatment is completed. The facility's Medication Administration policy, dated 5/2025, documents that Policy I. LEVEL OF RESPONSIBILITY: Licensed nurse (RN, LPN) may: a) prepare, b) administer, and c) record the administration of medications (prescription ointments are considered medicines) Medications shall always be prepared, administered, and recorded by the same licensed nurse or CMA. Documentation of medication administration is recorded on the Medication Administration Record (MAR.) or Treatment Record and includes the date, time, time, and initials of the licensed nurse or CMA who administered the medication. II. ADMINISTRATION OF MEDICATIONS: Medications must be administered in accordance with a physician's order, e.g., the right resident, right medication, right dosage, right route, and right time. The facility's Pressure Ulcer Prevention policy, dated 5/2025, documents that the purpose is to prevent and treat pressure sores/pressure injury. Based on interview and record review, the facility failed to assess and identify a residents impaired skin integrity, failed to document weekly skin assessments, and failed to follow physician orders for pressure ulcer treatment for 3 of 4 residents (R7, R9, R14) reviewed for pressure ulcers in a sample of 29. This failure resulted in R7 developing pressure ulcer that upon identification was classified as an unstageable/stage 4, required significant debridement on multiple occasion, osteomyelitis and 7-day hospital stay. The Immediate Jeopardy began on 2/27/25 when the facility failed to assess and treat a high-risk resident who was readmitted on [DATE] without any pressure injuries, resulting in R7 developing a facility acquired unstageable/stage 4 pressure ulcer that was identified on 02/27/25 on her ischial tuberosity with infection present. V6, Crisis Administrator, V32, Mobile Administrator, and V2, Director of Nurses was notified of the Immediate Jeopardy on 4/30/25 at 2:16 PM. The surveyor confirmed by record review and interview that the Immediate Jeopardy was removed on 5/2/2025 but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: 1.R7's Face sheet documents R7 was admitted on [DATE] with a readmission date of 4/7/25 with diagnoses of Type 2 Diabetes, other symptoms and signs involving cognitive function and awareness, hydronephrosis, enterococcus, pulmonary embolism, sacrococcygeal disorders, not elsewhere classified, and presence of urogenital implants. R7's Braden scale dated 9/20/2022 obtained during admission assessment, documented a score of 17 indicating R7 is at risk for developing pressure ulcer. R7's Minimum Data Set (MDS) dated [DATE] documented that R7 is moderately cognitively impaired, no pressure ulcer/injury on admission. The MDS further documents R7 is at risk of developing a pressure ulcer with skin treatments recommended including a pressure reducing device for chair and for bed. R7 is at risk for developing a pressure injury and had no pressure ulcers present. R7's MDS dated [DATE] documents R7 remains at risk for pressure injury but currently has no unhealed pressure wounds. R7's MDS dated [DATE] documented that R7 is severely cognitively impaired, dependent on staff for all activities of daily living (ADL)'s. The MDS documents R7 is incontinent of bladder and bowel and is at risk for pressure ulcers and has one stage 4 pressure ulcers. R7's MDS dated [DATE] documents R7 as moderately impaired cognition and dependent on staff for all ADL's, including turning and repositioning. The section regarding skin conditions documented yes to the question resident has pressure ulcer/injury, a scar over bony prominence, or non-removable dressing, unhealed pressure ulcer. R7's MDS dated [DATE] documents R7's cognition as (left blank), short-term memory ok, no behaviors or inattention, disorganized thinking or altered level of consciousness. R7's MDS further documents R7 is dependent on staff for ADL's, including turning and repositioning. R7's Social Service Note dated 3/6/25 documented R7 has clear speech, understands verbal content with severe impairment memory to recall after 5 minutes. R7's Care Plan dated 10/4/22 documented R7 has the potential for pressure injury development related occasional incontinence and decreased mobility. The goal is the resident will have intact skin, free of redness, blisters, or discoloration. Interventions include to apply skin barrier as needed, educate the resident and family on the causes of skin breakdown, educate the resident/family on the importance of change in position for prevention of pressure injuries, encourage appropriate hydration, encourage increased activity, if the resident refuses positioning, talk with the resident regarding the importance of positioning, maintain clean and dry skin, monitor nutritional status, and document/report changes in skin appearance and color. R7's care plan dated 12/11/2024 documents a potential for pressure injury development. The goal is that she will have intact skin and be free of open areas related to pressure. The interventions include air loss mattress with safety cover bolsters, air pressure redistribution, administer treatments as ordered, assist with position changes on rounds, barrier cream as directed, elevate/float heels while in bed, encourage to avoid lying or sitting on affected area, offer toileting assistance before and after meals, requires pressure relieving reduction devices on bed and chair. R7's Shower sheet dated 2/3/25 documented dry flaky skin but no wounds. R7's Shower sheet dated 2/9/25 documented no wounds. There is no other documentation in R7's Clinical records of R7's skin assessment. R7's progress notes dated 2/27/25 at 10:57 am documented a Certified Nursing Assistant (CNA), came to nurse this morning, and notified nurse of a right-side coccyx wound/ulcer. Nurse went in to see the coccyx, cleaned it, and covered it. wound nurse notified and informed to look at it. change in condition assessment completed and doctor as well a family updated. R7's progress notes dated 2/27/25 The Change in Condition (CIC) documented a skin wound. The skin status evaluation documented a pressure ulcer/injury. R7 was reported to have pain with the wound. Nursing observations, evaluation, and recommendations are open wound/ulcer on coccyx. R7's Situation, Background, Assessment, Recommendation (SBAR) Summary for Providers dated 2/27/25 at 10:25 AM documents Situation: The Change in Condition/s reported on this CIC Evaluation are/were Skin wound or ulcer. R7's Wound Assessment Details dated 2/27/25 documents: site left ischial tuberosity, active, pressure, ulceration, facility acquired, unstageable, tissue: necrotic soft, adherent 100%, probable decline, size: 5.5 centimeters (cm) x 6.5cm x 0cm, area: 35.75cm, exudate: moderate serosanguineous, odor: yes, signs of infection present: unable to determine. R7's Specialized Wound Management Physician Notes dated 3/3/25 document Wound Evaluation and Management Summary. Chief complaint: R7 has a wound on her left ischium and a rash. At the request of the referring provider, a thorough wound care assessment and evaluation was performed today .Past Medical History: atherosclerotic heart disease of native coronary artery with angina pectoris, essential(primary) hypertension, anemia, hyperlipidemia, Type 2 Diabetes mellitus with diabetic neuropathy. Genitourinary- intermittent incontinence, appetite fair, supplements none, no medication found to be affecting wound healing in clinical context. Oriented to person, place, time, and situation, calm and cooperative. Etiology- pressure, MDS 3.0 stage: 4, Duration: greater than one day, Wound size: 9.5 x 7 x not measurable cm, Depth: unmeasurable due to presence of nonviable tissue and necrosis, Surface area: 66.50 cm, Peri wound radius: odor, Exudate: heavy serous, Thick adherent devitalized necrotic tissue: 80%, Granulation tissue: 20%. Additional Wound detail: R7 states she has some type of cancer, dg(diagnosis) not found, not enough information in R7 chart; pending notes from PCP (primary care physician) or oncology; on exam today, no mass noticed on her back, sacrum, or legs. Expanded Evaluation Performed: The development of this wound and the context surrounding the development were considered in greater detail today. Relevant conditions including anemia, malnutrition, infection was considered and addressed through treatment changes or investigations. Thorough review of history performed, including speaking with Nursing staff for further information. Coordination of care and plan for this wound discussed with Nursing staff for further information. Dressing Treatment Plan: Primary dressing(s): sodium hypochlorite solution (Dakin's) and apply twice daily for 30 days; Dakin's sol (solution) ¼ strength; gauze apply twice daily for 30 days. Secondary Dressing(s) Gauze Island with border apply twice daily for 30 days. Plan of care reviewed and addressed: Recommendations Off load wound; reposition per facility protocol; air cell wheelchair cushion; low air loss mattress. Indication for Procedure: Remove necrotic Tissue and Establish the margins of Viable tissue. Procedure Note: The wound was cleansed with normal saline, and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade, pick-ups were used to surgically excise 26.60cm of devitalized tissue and necrotic muscle level tissues were removed at a depth of 1.2cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 80% to 40%. Hemostasis was achieved and a lean dressing applied. Post operative recommendations and updates to the plan of care are documented in the Assessment and plan section below. Deep swab technique performed on stage 4 pressure wound of the left ischium on 3/3/25. Procedure Today: surgical excisional debridement was performed today on this wound. Additional Recommendations related to performed expanded evaluation: lab name: white blood count (WBC), Deep wound culture, prealbumin. R7's Skin/Wound Note dated 3/3/25 documents: Resident was seen by V24, Wound Physician on 3/3/25 r/t (related to) her wound. R7 has a stage 4 to her left buttock with heavy serous drainage noted. It has 80% necrotic tissue and 20% gran tissue. Treatment of Dakin's moistened kerlix lightly packed in wound, abdominal (ABD) pad and secure with tape twice daily (BID) and as needed (PRN), glycated hemoglobin (HBA1C), prealbumin, complete blood count (CBC), hemoglobin (HGB) and [NAME] Blood Count (WBC) to be done for next visit. Interdisciplinary team (IDT), primary care physician (PCP), power of attorney (POA) and resident aware. R7's Skin/Wound Note dated 3/3/25 documents: Tetracycline 500 milligrams (mg) 1 tab PO twice BID for 14 days and wound culture to be done. R7's Physician orders dated 3/3/25 documented treatment of Dakin's moistened kerlix lightly packed in wound, ABD pad and secure with tape BID and PRN, tetracycline 500mg BID and labs including a wound culture. R7's Physician order dated 3/3/25 at 9:44 PM documented orders also to apply Santyl ointment to left buttock topically every day and evening shift for wound to left buttocks. Cleanse with normal saline apply Santyl ointment, calcium alginate and bordered gauze BID and PRN. R7's March Treatment Administration Record (TAR) did not document R7 received treatments on 3/6/25(evening), 3/7/25 (morning), 3/8/25 (evening), 3/12/25 (morning) and 3/13/25 (evening). Treatment orders consisted of Apply Dakin's ¼ strength to left buttock topically every day and evening shift for wound. Cleanse left buttock with generic wound cleanser, pat dry, skin prep peri wound, allow to dry, pack wound lightly with Dakin's moistened kerlix, ABD pad and secure with tape BID and PRN. R's Physician orders dated 3/3/25 documented an order for a wound culture. R7's Wound Assessment Details dated 3/7/25 documents: site: left ischial tuberosity, active, pressure, ulceration, facility acquired, date identified: 2/27/25 healed stage 4, tissue: bright beefy red; 20%, necrotic soft, adherent 80%, has been debrided: no, probable decline, size: 9.5cm x 7.0cm x 0cm, area: 66.5cm, exudate: heavy serosanguineous, odor: yes, signs of infection present: yes. Is patient on antibiotic: no. Although R7's physician Order Sheet documents R7 was on antibiotic. R7's Specialized Wound Management Physician Notes dated 3/10/25 document Wound Evaluation and Management Summary. Chief complaint: R7 has a wound on her left ischium and a rash. At the request of the referring provider, a thorough wound care assessment and evaluation was performed today .Past Medical History: atherosclerotic heart disease of native coronary artery with angina pectoris, essential(primary) hypertension, anemia, hyperlipidemia, Type 2 Diabetes mellitus with diabetic neuropathy. Genitourinary- intermittent incontinence, appetite fair, supplements none, no medication found to be affecting wound healing in clinical context. Oriented to person, place, time, and situation, calm and cooperative. Focused Wound Exam (Site 1) Stage 4 Pressure wound of the left ischium full thickness: Etiology- pressure, MDS 3.0 stage: 4, Duration: greater than 8 days, Wound size: 9.5 x 6.5 x not measurable cm, Depth: unmeasurable due to presence of nonviable tissue and necrosis, Surface area: 62.70 cm, Exudate: heavy serous sanguinous, Thick adherent devitalized necrotic tissue: 70%, Granulation tissue: 30%. Additional Wound detail: Recommend increase protein intake with each meal and addition supplements three times a day, pending notes from PCP or oncology, importance of performing the dressing as per order discussed with rounding nurse. Expanded Evaluation Performed: The development of this wound and the context surrounding the development were considered in greater detail today. Patient not following reposition or offloading recommendations and counseling provided. Impaired nutritional status discussed with patient, family, nursing staff and/or dietician. Recommend consult/reconsult with dietician to review current nutritional status. Reviewed offloading surfaces and discussed surfaces care plan. Thorough review of history performed, including speaking with Nursing staff for further information. Coordination of care and plan for this wound discussed with Nursing staff for further information. Dressing Treatment Plan: Primary dressing(s): sodium hypochlorite solution (Dakin's) and apply twice daily for 23 days; Dakin's sol (solution) ¼ strength; gauze apply twice daily for 23 days. Secondary Dressing(s) Gauze Island with border apply twice daily for 23 days. Plan of care reviewed and addressed: Recommendations Off load wound; reposition per facility protocol; pillow cushion; low air loss mattress. Site 1: Surgical Indication Debridement Procedure: Indication for procedure: Remove necrotic Tissue and Establish the margins of Viable tissue. Procedure Note: The wound was cleansed with normal saline, and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade, pick-ups were used to surgically excise 25.08cm of devitalized tissue and necrotic muscle level tissues were removed at a depth of 1.5cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 70% to 30%. Hemostasis was achieved and a clean dressing applied. Post operative recommendations and updates to the plan of care are documented in the Assessment and plan section below. Investigations: Recommended and/or Reviewed: Deep wound culture pending on pressure wound of the ischium as of 3/10/25. R7's Skin/Wound Note dated 3/10/25 documents: Resident was seen by V24 on 3/10/25 r/t (related to) her wound. R7 has a stage 4 to her left buttock with heavy serous drainage noted. It has 70% necrotic tissue and 30% gran tissue. It has improved. Tx. Of Dakin's moistened kerlix lightly packed in wound, ABD pad and secure with tape IDT, PCP, and POA and resident aware. There is no documentation regarding the wound culture. R7's Wound Assessment Details dated 3/13/25 documents: site: left ischial tuberosity, active, pressure, ulceration, facility acquired, date identified: 2/27/25 healed stage 4, tissue: bright beefy red; 30%, necrotic soft, adherent 70%, has been debrided: no, probable improvement, size: 9.5cm x 6.6cm x 0cm, area: 62.7cm, exudate: heavy serosanguineous, odor: yes, signs of infection present: yes. Is patient on antibiotic: no. R7's shower sheet dated 3/13/25 documents R7 did not have any wounds. R7's Specialized Wound Management Physician Notes dated 3/17/25 documented Wound Evaluation and Management Summary. Chief complaint: R7 has a wound on her left ischium and a rash. At the request of the referring provider, a thorough wound care assessment and evaluation was performed today .Past Medical History: atherosclerotic heart disease of native coronary artery with angina pectoris, essential(primary) hypertension, anemia, hyperlipidemia, Type 2 Diabetes mellitus with diabetic neuropathy. Genitourinary- intermittent incontinence, appetite fair, supplements none, no medication found to be affecting wound healing in clinical context. Oriented to person, place, time, and situation, calm and cooperative. Focused Wound Exam (Site 1) Stage 4 Pressure wound of the left ischium full thickness: Etiology- pressure, MDS 3.0 stage: 4, Duration: greater than 15 days, Wound size: 9.5 x 6.3 x not measurable cm, Depth: unmeasurable due to presence of nonviable tissue and necrosis, Surface area: 59.85 cm, Exudate: heavy serous sanguinous, Thick adherent devitalized necrotic tissue: 50%, Granulation tissue: 50%. Additional Wound detail: Wound culture not performed yet, discussed with rounding nurse . Dressing Treatment Plan: Primary dressing(s): sodium hypochlorite solution (Dakin's) and apply twice daily for 16 days; Dakin's sol (solution) ¼ strength; gauze apply twice daily for 16 days. Secondary Dressing(s) Gauze Island with border apply twice daily for 16 days. Plan of care reviewed and addressed: Recommendations Off load wound; reposition per facility protocol; air cell wheelchair cushion; low air loss mattress. Site 1: Surgical Indication Debridement Procedure: Indication for procedure: Remove necrotic Tissue and Establish the margins of Viable tissue. Procedure Note: The wound was cleansed with normal saline, and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade, was used to surgically excise 17.96 cm of devitalized tissue and necrotic periosteum and bone were removed at a depth of 1.6cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 50% to 20%. Hemostasis was achieved and a clean dressing applied. Post operative recommendations and updates to the plan of care are documented in the Assessment and plan section below. Investigations: Recommended and/or Reviewed: Deep wound culture pending on pressure wound of the ischium as of 3/17/25. R7's progress note dated 3/17/25 at 9:31 pm documented resident was seen by V24 on 3/17/25 related to her wound. She has a stage 4 to her left buttock with heavy serous drainage noted. It has 50% necrotic tissue and 50% granulated tissue. It has improved. Treatment. of Dakin's moistened kerlix lightly packed in wound, ABD pad and secure with tape BID. There is no documentation for the wound culture. R7's Wound Assessment Details dated 3/20/25 documents: site: left ischial tuberosity, active, pressure, ulceration, facility acquired, date identified: 2/27/25 healed stage 4, tissue: bright beefy red; 50%, necrotic soft, adherent 80%, has been debrided: no, probable improvement, size: 9.5cm x 6.3cm x 0cm, area: 59.85cm, exudate: heavy serosanguineous, odor: yes, signs of infection present: yes. Is patient on antibiotic: no. R7's Dietary note dated 3/21/25 documents Diet: Low Concentrated Sweet (LCS), Regular, Thin; fortified ice cream four times per day (QID); liquid protein Intake: 50-100% Skin: Stage 4 wound on left ischial tuberosity Review: Resident is eating 50-100%of meals. Stage 4 wound noted, receiving liquid protein and fortified ice cream for wound as of 3/21/25. R7's Specialized Wound Management Physician Notes dated 3/24/25 document Wound Evaluation and Management Summary. Chief complaint: R7 has a wound on her left ischium and a rash. At the request of the referring provider, a thorough wound care assessment and evaluation was performed today .Past Medical History: atherosclerotic heart disease of native coronary artery with angina pectoris, essential(primary) hypertension, anemia, hyperlipidemia, Type 2 Diabetes mellitus with diabetic neuropathy. Genitourinary- intermittent incontinence, appetite fair, supplements multivitamins, protein, no medication found to be affecting wound healing in clinical context. Oriented to person, place, time, and situation, calm and cooperative. Focused Wound Exam (Site 1) Stage 4 Pressure wound of the left ischium full thickness: Etiology- pressure, MDS 3.0 stage: 4, Duration: greater than 22 days, Wound size: 9.5 x 8 x not measurable cm, Depth: unmeasurable due to presence of nonviable tissue and necrosis, Surface area: 76.00 cm, Peri wound radius: odor, Exudate: heavy serous sanguinous, Thick adherent devitalized necrotic tissue: 40%, Granulation tissue: 40%. Other viable tissues: 20% (bone) Additional Wound detail: Wound culture report never received. Performed another one today. Expanded Evaluation Performed: The progress of this wound and the context surrounding the progress were considered in greater detail today counseling offered to optimize wound healing and relevant conditions (or possible conditions) were addressed through management changes or investigation regarding conditions including anemia, noncompliance, malnutrition. Patient not following reposition or offloading recommendations and counseling provided. Impaired nutritional status discussed with patient, family, nursing staff and/or dietician. Recommend consult/reconsult with dietician to review current nutritional status. Medications affecting wound healing reviewed and considered. Reviewed offloading surfaces and discussed surfaces care plan. Coordination of care and plan for this wound discussed with Nursing staff for further information. Dressing Treatment Plan: Primary dressing(s): sodium hypochlorite solution (Dakin's) and apply twice daily for 9 days; Dakin's sol (solution) ¼ strength; gauze apply twice daily for 9 days. Secondary Dressing(s) Gauze Island with border apply twice daily for 9 days. Plan of care reviewed and addressed: Recommendations Off load wound; reposition per facility protocol; air cell wheelchair cushion; low air loss mattress. Site 1: Surgical Indication Debridement Procedure: Indication for procedure: Remove necrotic Tissue and Establish the margins of Viable tissue. Procedure Note: The wound was cleansed with normal saline, and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade, pick-ups were used to surgically excise 7.60cm of devitalized tissue and necrotic periosteum and bone were removed at a depth of 1.6cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 40% to 30%. Hemostasis was achieved and a clean dressing applied. Post operative recommendations and updates to the plan of care are documented in the Assessment and plan section below. Investigations: Recommended and/or Reviewed: Deep wound culture technique cancelled on stage 4 pressure wound of the left ischium on 3/24/25 (R7's record did not document the 3/3/25 orders result and thus cancelled on 3/24/25) Prealbumin recommended on 3/24/25. Deep swab technique performed on stage 4 pressure wound of the left ischium on 3/24/25. R7's progress note dated 3/24/25 at 9:57 pm documented R7 was seen by V24 on 3/24/25 related to her wound. She has a stage 4 to her left buttock with heavy serous drainage noted. It has 40% necrotic tissue, 20% bone and 40% granulation tissue. It has exacerbated. R7 is noncompliant with off-loading wound and with wound care. Treatment of Dakin's moistened kerlix lightly packed in wound, ABD pad and secure with tape BID and PRN. Prealbumin and a deep swab performed and collected to be done for next visit. R7's progress notes dated 3/26/25 documents R7 received intravenous infusion of Derma IV-DRIPT IV therapy infusion (500.9% normal saline with 5 gm Vitamin C, B Complex, biotin 10 mg, Arg 300 mg, Om150mg, [NAME] 150mg, Cit 150 mg and zinc 10 mg.) due to Acute/Chronic Wounds It continues to document R7 received intravenous (IV) infusion d/t acute/chronic wounds. No adverse reaction noted upon post IV infusion. no bruising noted at IV site. R7's Wound Assessment Details dated 3/29/25 documents: site: left ischial tuberosity, active, pressure, ulceration, facility acquired, date identified: 2/27/25 healed stage 4, tissue: bright beefy red; 50%, necrotic soft, adherent 50%, has been debrided: no, probable improvement, size: 9.5cm x 7.0cm x 0cm, area: 66.5cm, exudate: heavy serosanguineous, odor: yes, signs of infection present: yes. Is patient on antibiotic: no. R7's shower sheet 3/31/25 documents shower given and no wounds present. R7's Specialized Wound Management Physician Notes dated 3/31/25 document the patient visit had been rescheduled. R7 not in the facility currently. R7's Specialized Wound Management Physician Notes dated 4/7/25 document the patient not seen due to wound related hospitalization since last visit. R7's Wound Assessment Details dated 4/10/25 documents: site: left ischial tuberosity, active, pressure, ulceration, facility acquired, date identified: 2/27/25, unstageable, tissue: slough non adherent 10%, necrotic soft, adherent 90%, has been debrided: yes, probable decline, size: 10cm x 6.0cm x 0cm, area: 60.00cm, exudate: heavy purulent and malodorous , odor: yes, signs of infection present: yes. Is patient on antibiotic: no. R7's Laboratory Report dated 4/1/25 documents a wound culture with gram stain was collected on 3/25/25 with final report of heavy growth of proteus mirabilis and light growth of enterococcus faecalis. The Sensitivity report to medications does not indicate tetracycline, that was ordered for R7 on 3/3/25, as medication of choice sensitive to organisms. R7's Progress notes dated 3/25/25 document R7 making loud moaning sound. Upon entering room, observe pt lying in bed with pillows surrounding her, lifted slightly off left hip. Call bell in reach. R7 stated Why won't anyone help me? Writer instructed that R7 has not used her call bell to alert any staff that she wanted or needed any help. R7 looked directly at call bell that was laying by her right hand on the bed and stated, I'm so weak Offered pain medication and R7 opened her mouth as in wanting pill dropped in. Asked R7 why she wasn't holding the pill cup and R7 stated I'm so weak in my legs. R7's Progress notes dated 3/26/25 documents R7 continues to hold on to call bell but instead is hollering out and becomes agitated that no one answers her. Writer has explained on each occasion that she should be using call bell because staff cannot always hear her yells. R7's Progress note dated 3/26/25 documents R7 received IV infusion d/t acute/chronic wounds. No adverse reaction noted upon post IV infusion. no bruising noted at IV site. R7's Follow up assessment post fall note dated 4/1/25 documents R7 is alert and orientated. R7 has sad worried facial expression. Pain scale 3 of 10, R7 has chronic pain though nights d/t hip wound. R7 has preexisting wound to hip. R7's IDT note dated 4/1/25 documents Late entry: Root cause for fall on 4/1: R7 restless in bed due to pain. R7 sent to hospital per R7 and family request for pain control brief Interview for Mental Status (BIMS) 12. Care plan updated. Medical Doctor (MD) and POA aware. R7's Nursing Note dated 4/1/25 documents R7 grandson came to writer and reported that he overheard a female not talking very k[TRUNCATED]

Based on interview, observation, and record review, the facility failed to answer call lights in a timely manner for 3 of 10 residents (R17, R58, R102) reviewed for dignity in the sample of 51. This failure resulted in R58 feeling less than a person, R102 feeling humilated, and R17 fell ing terrible. Findings include: 1. On 09/23/24 at 11:27 AM, R58 stated, It can take up to 1 hour for them to come and get me to the bedpan. They have to (full mechanical lift) me into bed and then get the bed pan. With waiting that long, I have accidents. I have lost a lot with my disease and being put in a nursing home. I am continent still and I don't want to lose that. When I have accidents, I feel like less of a person. R58's Admission Record, Print date of 9/24/24, documents that R58 was admitted on [DATE] and has diagnoses of Multiple Sclerosis and functional Quadriplegia. R58's Minimum Data Set,(MDS), dated [DATE], documents R58 is cognitively intact, is totally dependent on staff for all care and mobility, is occasionally incontinent, and that bowel continence was not rated. 2. On 09/23/24 at 11:10 AM, R102 was questioned about how timely staff assist with answering the call light, R102 stated, This morning I was in the dining room, I asked to be taken back to my room because I had to go to the bathroom. The aide in the dining room said, Ok I will be back. If I ever write a book about this place that is going to be the title because that is all they ever tell you. They never took me to the bathroom. I had a number 2 in my pants because I couldn't hold it during breakfast and exercise class. When they finally brought me back to my room, I got cleaned up. It makes me humiliated when I have an accident because I have to wait so long. R102's Nurses Note, dated 9/12/2024 10:15 documents, The staff member informed this writer that they were going to go on break and when they come back they are going to get up the resident. The staff member left on her break, the resident put on her light. This writer went to check on the call light and see what the resident needed. Resident stated that she needed the aid. This writer informed the resident that it was be just one moment and left the room to go get help. This writer walked down the hall to see if staff had returned, when resident put back on her light. Staff went back down to her room to check on the resident. Resident stated that she had soiled herself and she still need to go some more and wanted to get up to go to the restroom. This writer informed her it would be just one moment and went to go to get the aid. This writer left the floor to get the other staff member. However, did not see the staff member outside and returned to the floor. This writer could hear noise down the hall and resident call light was back on. This writer went back to the resident room with wipes and a depend. Resident was crying and very upset. She stated that it wasn't fair and that she always has to wait, and she is sick of it all. This writer and a different staff member assisted getting the resident up. She was placed on a sit-to-stand and transfer to the restroom. We were in the process of cleaning up the resident, when the aid returned to the floor and saw that the two of us were in the resident room. The different staff member and this writer finished cleaning up the resident while the aid went to get another resident up. R102's Admission Record, print date of 9/24/24, documents that R102 was admitted on [DATE] and has diagnoses of Polyarthritis and a history of falls. R102's MDS, dated [DATE], documents R102 is cognitively intact, has bilateral leg range of motion issues, dependent on staff for transfers and toileting hygiene, always continent of bowel, and frequently incontinent of urine. 3. On 09/23/24 at 11:40 AM, R17 stated, I am continent but it can take an hour before they come and answer the light. When it takes that long, I have accidents. I then feel terrible about it. R17's Admission Record, print date of 9/24/24, documents that R17 was admitted on [DATE] and has diagnoses of Type 2 Diabetes and Schizoaffective Disorder. R17's MDS, dated [DATE], documents that R17 is cognitively intact, dependent on staff for toileting, chair to bed transfer, uses a wheelchair, is occasionally incontinent of urine, and always continent of bowel. The Resident Council Minutes, dated 9/3/24, documents, New Business: Nursing: A lot of complaints about CNA's (Certified Nurses Aide) not coming to calls. The Resident Council Minutes, dated 7/2/24, documents, New Business: Nursing: call light/ won't give to resident. Long wait times. The Illinois Long Term Care Ombudsman Program Resident Rights', dated 11/18, Your rights to dignity and respect. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.

Based on interview, observation, and record review the facility failed to implement interventions to prevent weightloss, monitor weightloss, encourage resident eating for 2 of 7 residents (R7, R46) reviewed for weight loss in the sample of 51. This failure resulted in R7 and R46 both experiencing significant weight loss. Findings include: 1. On 9/24/24 at 11:58 AM, R7 was served her lunch tray. During the meal, R7 sat still and looked at her food. At 12:20 PM, the Chaplin came and removed her from the dining room to take her back to her room. During the meal, R7 was not offered help with cutting up her turkey, encouragement to eat, or offered something else to eat. R7's Admission Record, print date of 9/25/24, documents that R7 was admitted on [DATE] and has a diagnosis of Dementia. R7's Minimum Data Set (MDS), dated [DATE], documents that R7 is severely cognitively impaired and requires set up or clean up assistance with dining. R7's Diet Order, dated 9/18/24, documents, Sodium precautions diet, Regular texture, Thin consistency. R7's Dietary Note, dated 8/15/2024 08:58, documents, WEIGHT WARNING: Value: 134.2 Vital Date: 2024-08-06 11:27:00.0 MDS: -5.0% change over 30 day(s) [ 9.5% , 14.0 ] -7.5% change [ 8.2% , 12.0 ] RD (Registered Dietician) evaluation for unplanned wt (weight) loss. Wt (8/6) 134.2# BMI (body mass index) 28 (overweight). Sodium precautions. PO (oral) intakes had been varied/poor over the past month, but more meals >76% consumed recently per documentation. Continue to encourage intakes and fluids. Offer alternatives and snacks as desired. No pressure wounds reported as present. Continue to monitor PO (oral) intakes and wt trends. RD to f/u prn (follow up). R7's Weight Summary documents on 6/10/24 R7 weighed 147.2 pounds, on 8/6/24 134.2 pounds resulting in a 8.83% weight loss in one month, and on 9/10/24 133.2 pounds resulting in a 9.5% weight loss in 3 months. R7's Meal Intake Percentages Summary documents that from 9/1/24 - 9/24/25, 14 days were documented on and 20 entries made documented that R7 ate 0 - 25%. 2. R46's Admission Record, print date of 9/25/24, documents that R46 was admitted on [DATE] and has diagnoses of Senile Degeneration of the Brain, anorexia, Dementia, skin cancer of the nose and right lower leg. R46's MDS, dated [DATE], documents that R46 is severely cognitively impaired and requires supervision or touching assist for eating. R46's Diet Order, dated 6/5/24, documents, Regular diet, Regular texture, Thin consistency. R46's Electronic Medical Record fails to document any other dietary orders. R46's Dietary Note, dated 9/16/2024 11:07, documents, WEIGHT WARNING: Value: 121.6 Vital Date: 2024-09-10 15:15: 00.0-3.0% change over 30 day(s) [ 4.3% , 5.4 ] -7.5% change [ 12.1% , 16.7 ] RD (Registered Dietician) evaluation for wt (weight loss) loss x 3 mo (months). Insignificant 4/3% wt loss x 1 mo. Anticipated wt loss r/t (related to) hospice. Wt (9/10)121.6# BMI 19.6 (low based on age). Regular diet. Most meals 51-100% per documentation. Continue to encourage intakes and fluids as desired. See Skin & Wound Evals (evaluations) for cancer lesions details. Chart reviewed. Declines including poor intakes and wt loss r/t hospice. RD to plan to f/u (follow up) monthly/prn (as needed). R46's Weight Summary documents that R46's weight on 6/6/24 was 138.3 pounds, 7/10/24 was 138.1 pounds, 8/6/24 127 pounds (8.03% loss in one month), and on 9/10/24 it was 121.6 pounds (4.25% weight loss in one month). R46 had a 11.94% loss from July to September. R46's Care Plan,dated 9/9/2024, (R46) is at nutritional risk related to Admit to hospice for senile degeneration of brain and anorexia 6/5/24 History of weight loss Impaired skin integrity r/t CA (cancer) lesions to nose/R (right) thigh. Interventions: Nutrition Interventions to encourage adequate intakes r/t underweight per BMI (body mass index) and altered skin integrity 9/9/24 - Fortified Juice BID (twice a day) (B/D meals)(breakfast and dinner). Serve diet as ordered, weight as ordered, record meal intake, encourage appropriate intake of food and fluids, offer substitutes for dislikes. 6/5/24 Regular diet. On 9/24/24 at 4:05 PM, V1, Administrator, stated, We do not have a feeding assistance policy, but staff should be assisting those that need help. On 9/25/24 at 2:20 PM, V2, Director of Nurses, stated that even though she (R46) is on hospice some intervention should be put into place to at least try to keep the weight loss at a minimum. V2 further stated that residents should be encourage to eat, receive assistance from staff if they need it, and offered something else to eat if they are not eating.

Based on interview, observation, and record review, the facility failed to identify, monitor, provide education to resident and family, and implement interventions to prevent pressures ulcers for 2 of 3 residents (R2, R3), reviewed for pressure ulcers, in the sample of 6. This failure resulted in R2 and R3 sustaining facility acquired pressure ulcers while residing in the facility. Findings include: 1. R2's Admission Record, print date of 4/3/24, documented that R2 was admitted on [DATE] with a diagnosis of a left femur fracture. R2's Minimum Data Set, (MDS), dated [DATE], documented that R2 was cognitively intact and required substantial to maximum assistance for all mobility. R2's Physician Orders, documented, Specialized turning schedule every two hours for turning and repositioning to maintain skin integrity. Start date of 2/20/24. R2's Physician Orders, documented, Anasept Antimicrobial External Gel 0.057 % (Sodium Hypochlorite) Apply to L (left) heel topically everyday shift for Wound healing Cleanse with WW (wound wash), then apply anasept, then calcium alginate, cover with dry dressing. start date of 2/27/2024 07:00. R2's Physician Orders, documented, Cleanse R (right) heel with WW, then apply skin prep every day shift. Start date of 2/27/2024 07:00. R2's Nurses Note, dated 2/17/2024 21:26, documents, Nursing Note Text: Writer observed wound to L heel and DTI (deep tissue injury) to R (right) lateral heel. MD (Medical Doctor) aware, and wife aware. Writer cleansed and applied dry dressing and elevated heels. Resident expresses no pain at this time. R2's Progress Note from Orthopedic MD, dated 2/20/2024 at 09:27, documented, Resident cannot be in bed for more than 8 hrs (hours) at time to decrease worsening of L heel ulcer. Wife with resident at appt (appointment) and is updated. R2's Braden Scale, dated 2/15/24, documented that R2 was a high risk for developing pressure ulcers. R2's Skin & Wound Evaluation, dated 2/17/24, documented that R2 had a new facility acquired Left heel Stage 3 Pressure ulcer that measures 3.7 cm (centimeters) x (by) 3.7 cm x 2.2 cm. This pressure ulcer had light serous drainage. R2's Initial Wound Evaluation & Management Summary, dated 2/19/24, documented, (R2) had 2 Pressure Ulcers; Site 1 a Unstageable Pressure Deep Tissue Injury of the right lateral heel measuring 1 x 1.5 cm Recommendations: Off - Load wound; Reposition per facility protocol; float heels in bed; prevalon boot. Site 2 a Stage 3 Pressure Ulcer of the left posterior heel Full Thickness which measures 3.5 x 2 x 0.2 cm. Recommendations: Off - Load wound; Reposition per facility protocol; float heels in bed; prevalon boot. R2's Care Plan did not address current pressure ulcers. On 4/2/24 from 10:20 AM until 2:10 PM, R2 remained in his wheelchair based on 15 minute interval checks without benefit of meaningful turning, repositioning, or offloading of pressure. R2 also wore normal shoes and not prevalon boots. On 4/2/24 at 2:10 PM, R2 was questioned if he preferred to stay in the wheelchair all day, R2 stated that he does not prefer to sit in the wheelchair all day because it hurts his bottom. He stated that he does have a sore on his bottom and one on his heel. On 4/2/24 at 2:15 PM, V5, Certified Nurses Aide (CNA), stated that R2 likes to sit up in his wheelchair all day. On 4/4/24 at 8:39 AM, V2, Director of Nurses, (DON), and V8, Registered Nurse (RN) entered R2's room. R2 was in his wheelchair with normal shoes on. V2 held the leg up and V8 did the treatments. R2's bilateral shoes were removed. The left heel dressing removed. The left outer heel has an approximate 1 cm x 1cm pressure ulcer the wound bed is red the edges were white, V8 cleansed area with wound cleanser, put anasep gel, calcium alginate and a dry dressing on the pressure ulcer. The right heel has a small intact necrotic area which had skin prep applied. On 4/4/24 at 8:45 AM, V2, DON, and V8, RN, were both asked why R2 does not wear the prevalon boots during the day instead of his shoes, V8 stated that he does not like the boots because it hurts his leg with the fracture. Both were questioned why he doesn't lay down throughout the day to offload, V2 stated his wife does not want him to. V2 stated that he brought in a recliner for him and R2 refused to sit in it. R2 stated that he does not like to sit in the recliner. V2 and V8 both stated that they have educated R2 and the wife and they still don't want off loading or prevalon boots during the day. On 4/4/24 at 12:10 PM, V2, DON, stated that he has documentation that R2 and his wife were educated on the importance of offloading and pressure relief. V2 stated that it was documented that R2 and R2's wife does not want him in bed during the day or wearing the boots and he would supply that information. On 4/4/24 at 1:07 PM, R2's Physician Orders, Nurses Notes, Social Service Notes, Care Plans were reviewed. Documentation that R2 and R2's wife have been educated on the importance of pressure relief was not found. At time of exit on 4/8/24, documentation of R2 or R2's wife being educated on the importance of offloading or pressure relief was not provided by the facility. 2. R3's Admission Profile, print date of 4/3/24, documented that R3 was admitted on [DATE] with diagnoses of aftercare for pacemaker placement, Diabetes Mellitus and Atrial Fibrillation. R3's MDS, dated [DATE], documented that R3 was cognitively intact, required substantial to maximum assistance with rolling, was dependent upon staff for all mobility, and was frequently incontinent of bowel and bladder. R3's Braden Scale for Predicting Pressure Sore Risk, dated 3/12/24, documented that R3 was at risk for developing pressure ulcers. R3's Braden Scale for Predicting Pressure Sore Risk, dated 3/31/24, documented that R3 was at risk for developing pressure ulcers. R3's Nurses Note, dated 3/17/2024 at 2:35 PM, documented, DTI (deep tissue injury) to bilateral heels. Skin prep and foam dressing applied. Heel protector boots in place. No edema noted. Continues with skilled therapy. Resident/Family Education and Teachback: wound interventions R3's Skin and Wound Evaluation, dated 3/17/24, documented that staff have identified a new Pressure Ulcer Deep Tissue Injury on the right medial heel. This Evaluation did not measure the pressure ulcer. R3's Skin and Wound Evaluation, dated 3/17/24, documented that staff have identified a new Pressure Ulcer Deep Tissue Injury on the left heel. The pressure ulcer measured 4.5 cm x 3.1 cm x 2.0 cm. R3's Skin and Wound Evaluation, dated 3/18/24, documented that staff have identified a new Pressure Ulcer Deep Tissue Injury on the right heel. The pressure ulcer measured 6.7 cm x 3.1 cm x 2.7 cm. R3's Wound Note, dated 3/22/2024 07:32, documented, Skin/Wound Note Data: Writer spoke with resident and family in regard to wounds. Informed them that resident would benefit from having in house Wound MD eval and tx (evaluation and treatment) wounds for optimal healing Action: Resident and family gave verbal and written consent for Wound MD to eval and tx. R3's Initial Wound Evaluation and Management Summary, dated 3/25/24, documented that R3 had an unstageable pressure ulcer to the right heel measuring 3cm x 3cm, an unstageable pressure ulcer to the left heel measuring 0.5cm x 1cm, and a stage 3 pressure ulcer to the left buttocks measuring 2.5cm x 0.5cm x 0.2cm with Light Sero- Sanguinous exudate. R3's Wound Evaluation and Management Summary, dated 4/1/24, documented that there were no changes in R3's pressure ulcers to the left and right heel or the left buttocks. On 4/2/24 R3 remained in bed from 8:25 AM until 1:30 PM with 15 minute interval checks without benefit of meaningful turning, repositioning, or offloading of pressure areas. On 4/2/24 at 9:06 AM, R3 stated that she does have heel and buttock pressure ulcers. R3 stated that she isn't turned and reposition often. On 4/2/24 at 10:47 AM, V6, RN, entered R3's room to check R3's heels. R3 was lying on her back the same position she was in at 9:06 AM. R3's bilateral heel boots were removed. R3's right heel had a black necrotic area the approximate size of a quarter. The left heel had a darkened area approximately 1 cm long. The heel boots were replaced. R3 was not repositioned or offered / encouraged to repositioning. On 4/2/24 at 12:07 PM, R3 and V3, R3's daughter, both stated that no one has been in the room to provide repositioning for R3. On 4/2/24 at 12:45 PM, V6, RN, and V4, CNA entered R3's room. V6 removed the soiled pressure ulcer dressing to the sacrum buttock area. The right buttocks had MASD (moisture associated dermatitis) which was bleeding slightly, the sacrum had a dime size area pressure ulcer that was bleeding, the left buttocks had a pressure ulcer area approximately the size of a quarter, the wound bed was bleeding, the peri wound was whitish pale pink. The area was cleansed with ww, and a hydrocolloid dressing was placed. On 4/4/24 at 2:55 PM, R3 was lying in bed with her heel boots on. R3 stated that the staff have been coming in and turning her every 2 hours from side to side since yesterday. On 4/4/24 at 2:55 PM, V9, R3's Granddaughter, stated that she was the one that found the heel pressure ulcers. She stated that she found them on 3/14/24 and that she did tell the nurse about it. On 4/4/24 at 3:15 PM, V2, DON, stated that he would look for documentation related to why the wound doctor saw R3 on 3/25/24 for a pressure ulcer located on the buttocks when there was not any other documentation of the pressure ulcer. V2 also stated that the nursing staff should measure any new pressure ulcer when they notice it and document on it. On 4/8/24 upon exit, there was no documentation of when R3's buttock pressure ulcer developed or if R3's right heel pressure ulcer was measured when first noted. The facility provided pressure ulcer policy, Skin / Pressure Ulcer Risk Evaluation, policy, dated 1/16/14, it did not document how to treat actual pressure ulcers.

Based on interviews and record reviews the facility failed to treat and assess one of three residents (R2) after an injury of unknown origin to R2's head. This failure resulted in a delay in treatment for R2's odontoid fracture and significant bruising to face primarily around bilateral eyes. Findings include: R2's face sheet, dated 3/5/2024, documented an admitted [DATE] and diagnoses of Dementia, Hypertension, GERD and hearing loss. R2's Minimal Data Set, dated 2/9/2024, documented that R2 was severely cognitively impaired and that R2 is dependent on staff for mobility, Toileting, transfers, sitting and maximum assistance for bed mobility. R2's progress notes, dated 2/24/2024 at 8:00 am, V4, Registered Nurse (RN), documented that R2 had a bruised eye on left eye and partial bruising to right eye. On 3/2/2024 at 11:00 am, R2 was observed sitting up in wheelchair with bilateral eyes and cheeks dark purple in color extending up forehead into hair line. R2 had a cervical (C) collar in place. On 3/4/2024 at 2:30pm, V10, Certified Nurse Assistant (CNA), stated that she got R2 out of bed on 2/24/2024 around 7:00 am and noticed that both of R2's eyes were bruised and his forehead had a scrape on it by his hairline. V10 stated that she immediately took R2 to V4, RN, and showed V4 the bruises. V10 also stated that she did not know what had happened to R2 to cause the bruising. On 3/4/2024 at 2:30pm V4, RN, stated that V10, CNA, got R2 up around 7:00 am on 2/24/2024 and showed her that R2 had bruises around both eyes. V4 stated she figured R2 had fallen and no one told her about it. V4 states she did not call the doctor or family because she figured someone had just forgot to tell her that he had fallen. V4 stated she did not do neuros or any kind of assessment on R2. On 3/4/2024 at 3:30pm, V2, Director of Nurses, stated that V4, RN, reported to him on 2/26/2024 the bruising to R2's face. V2 continued to state that R2's doctor was notified on 2/26/2024 and wanted R2 sent to emergency room . V2 continued to state that V13, R2's Power of Attorney, did not want R2 sent out until 2/27/2024. V2 stated that R2 went to emergency roiagnom on [DATE] and was diagnosed with Odontoid fracture and significant bruising to face. V2 stated R2 returned with a C collar in place. V2 stated that the doctor and family were notified on 2/26/2024 of the bruising. V2 stated that neuro checks were started on 2/26/2024 and that he expects his staff to start neuro checks on head injuries immediately. On 3/4/2024 at 4:30pm, V1, Administrator, stated that she was notified of R2's bruises of unknown origin on 2/26/2024. V1 also stated that she instructed V4, RN to call the doctor on 2/26/2024 and to start neuro checks. V1 stated that she expects her staff to notify doctor and assess residents at the time of a noted head injury. The facility's, change of condition policy, dated 12/7/2011, documented that a resident assessment at time of condition change and ongoing assessment until condition stabilizes will occur.

Based on interviews, record reviews and observations the facility failed to notify doctor/family timely of change of condition for two of three residents (R2, R8) after R2 had an injury of unknown origin and R8 had facial bruising after an unwitnessed fall. This failure resulted in R2 being sent to the emergency room three days after the injury of unknown origin with a diagnosis of an odontoid fracture and R8 being taken to her primary doctor after family came into facility and saw R8 with facial bruising. Findings include: 1. R2's face sheet, dated 3/5/2024, documented an admitted [DATE] and diagnosis of Dementia, Hypertension, GERD and hearing loss. R2's Minimal Data Set, (MDS), dated [DATE], documented that R2 was severely cognitively impaired and that R2 is dependent on staff for mobility, Toileting, transfers, sitting and required maxium assistance for bed mobility. R2's Progress Notes, dated 2/24/2024 at 8:00 AM, written by V4, Registered Nurse, RN, documented that R2 had a bruised eye on left eye and partial bruising on right eye. It did not document that R2's doctor was notified of this finding. On 3/2/2024 at 11:00am R2 was observed sitting up in wheelchair with bilateral eyes and cheeks dark purple in color extending up forehead into hair line. R2 had a cervical (C) collar in place. On 3/2/2024 at 10:00am, V13, R2's Power of Attorney, stated that the facility called on 2/26/2024 and said that R2 had bruises from what they thought was a fall a few days ago, but no one from the facility had called to notify V13 of a fall. V13 stated that R2 went to ER a because of all the bruises on his face. V13 stated they still don't know how R2 got the bruises. On 3/4/2024 at 2:00 PM, V10, Certified Nursing Assistant, (CNA), stated that she got R2 out of bed on 2/24/2024 around 7:00 AM and noticed that both of R2's eyes were bruised and his forehead had a scrape on it by his hairline. V10 stated she immediately took R2 to V4, (RN), and showed V4 the bruises. On 3/4/2024 at 2:30 PM, V4, Registered Nurse, stated V10 got R2 up around 7 AM on 2/24/2024 and showed her that R2 had bruises around both eyes. V4 stated she figured R2 had fallen, and no one told her about it. V4 states she did not call the doctor or family because she figured someone had just forgot to tell her that he had fallen. On 3/4/2024 at 3:30 PM, V2, Director of Nursing, stated that V4 reported to him on 2/26/2024 bruising to R2's face. V2 stated R2's doctor was notified on 2/26/2024 and wanted R2 sent to emergency room . V2 stated that V13 did not want R2 sent out until 2/27/2024. V2 stated that R2 went to emergency roiagnom on [DATE] and was diagnosed with Odontoid fracture and significant bruising to face. V2 stated that R2 returned with a C collar in place. V2 stated that the doctor and family were notified on 2/26/2024 of the bruising. V2 stated that he expects the nurses to notify family and doctor at time of condition change. On 3/4/2024 at 4:00 PM, V1, Administrator, stated she was notified of R2's bruises of unknown origin on 2/26/2024. V1 stated that she instructed V4 to call the doctor on 2/26/2024. V1 states she expects her staff to notify doctor and assess residents at the time of a noted head injury. 2. R8's MDS, dated [DATE], documented that R8 was cognitively intact and required moderate assistance with toileting, dressing and transfers. R8's Post fall evaluation document, dated 1/22/2024 at 4:15 AM, documented that R8 had fall on 1/22/2024 at 0400 in room. The Evaluation documented R8 was sitting on her buttocks, R8 had injury of skin tear to left wrist and between 3rd and forth finger, neuro checks initiated and that Dr was notified and to follow facility's policy. The Evaluation documented R8 has sustained no head injury. R8's Transfer Form, dated 1/31/2024, documented that R8 had bruises to face related to recent fall. This was the only form of documentation R8's medical record that documented bruises to R8's face. On 3/14/2024 at 8:15am, R8 stated that she fell a few weeks ago and that her face was all bruised up from the fall. R8 states the staff came in after she fell and just put her back to bed, that she had a small cut on her wrist and that she told them she had hit her head. R8 states her sister took her to the doctor after her fall. On 3/14/2024 at 12:00pm, V2, Director of Nurses, stated that R8's doctor was not updated on the bruising to R8's face until R8's sister took her to the doctor on 1/29/2024. V2 continued to state that R8's clinical record does not document any monitoring of the bruises to R8's face. V2 also stated that R8 did have bruising to her face but staff did not asses or document it. On 3/14/2024 at 10:00am V14, R8's POA, stated that she was not notifed of the bruising on R8's face after the fall. V14 stated that she was concerned about a head injury for R8 so she took her home and called R8's primary doctor. R8's primary doctor saw R8 on 1/29/2024. Facility provided change of condition policy, dated 12/7/2011, documents that doctor and family will be notified of changes in condition at onset.

Based on interview and record review, the facility failed to provide timely monitoring/visual checks for 1 of 5 residents (R3), reviewed for changes in condition in the sample of 5. This failure resulted in R3 falling out of bed at an unknown time and being found deceased with face being disfigured and gash on the right side of his forehead. Findings Include: R3's Face Sheet, undated, documents R3 has the following diagnoses: Neurocognitive Disorder, COPD (Chronic Obstructive Pulmonary Disease), Atrial Fibrillation and Presence of a Cardiac Pacemaker. R3's Progress Note, dated [DATE] at 8:35 AM by V6, Licensed Practical Nurse (LPN), documents she was called to R3's room by a Certified Nurses Assistant (CNA). R3 was observed on the floor face down next to his bed. Resident had no response, pulse or respirations. Time of death was determined by two nurses at 8:20 AM. R3's Death Certificate, documents a date of death of [DATE], no time provided, and the cause of death was listed as Hypoxia with COPD. R3's Minimum Data Set (MDS), dated [DATE], documents R3 requires assistance with bed mobility, transfers, toileting and is frequently incontinent of bowel and bladder. R3's Care Plan, dated [DATE], documents R3 has an ADL (Activities of Daily Living) deficit and to assist with care. The Facility Investigation documents the following: Date of incident: [DATE] at 8:35 AM with a report date of [DATE]. Nursing staff found R3 deceased beside his bed on [DATE] at 8:35 AM. Per R3's plan of care, the resident preferred to stay in bed most of the time or refused to get out of bed and often liked to sleep until noon. R3's bed was in low position and the call light was within easy reach of the bed but had not been activated. The Facility's Timeline of Events documents the following: [DATE] at 12:00 AM: R3 was lying in bed; 1:15 AM - R3 was in bed watching TV, awake, yelled at staff; 8:30 AM 1st CNA (V11) passing breakfast drinks and found resident, 1st (V4, Former LPN)/2nd (V6, Registered Nurse (RN) nurse called/arrived to room; 8:36 AM - 3rd (V12) nurse arrived in room, 2nd (V13) CNA arrived went to get mechanical lift sling, 4th (V7) nurse arrived. The Facility Camera Footage Review from [DATE] - [DATE] for R3's room documents the following information: [DATE] at 5:52 PM: V14, Former CNA, entered R3's room, exited room at 5:54 PM, [DATE] at 8:03 AM: CNA (no name) observed entering R3's room. V4, Former LPN's, written statement, no date or time, documents the following: At approximately 12 AM, she opened the bathroom door, noted that R3 was sleeping and snoring. He showed no visible signs of pain. V4, Former LPN's, written statement, dated [DATE], documents the following: When doing her rounds at midnight on [DATE], R3 was lying in bed on right side. R3 was resting quietly with no signs or symptoms of distress. R3 has a preference not be disturbed during the night. V4 had no personal knowledge of the event until she was called to R3's room at 8:30 AM. On [DATE] at 12:54 PM, V4, Former LPN, stated she checked on R3 on [DATE] around 12 AM, he was in bed. V4 stated she did not check on him again through the night until she was called to his room that morning ([DATE]) around 8 AM. V4 stated when she entered the room, R3 was lying on the left side of his bed, face down and full rigor mortis had set in, when they turned him over it was the worst thing I've ever seen, his face was blue and smashed in. It was established that he could've fallen but you could tell he had been there a while. V4 stated he was incontinent at times and particular about what kind of care and when he wanted care. V4 stated R3 was not nice and didn't want messed with during the night. V4 stated she was suspended for a week and then fired because they (facility management) said she didn't do her rounds. V4 stated it was weird because it's normal protocol that the nurse notifies the coroner's office of a death, but V1, Administrator, and V2, DON, stated they were going to do it, but she doesn't think they did. V4 stated their normal standards of practice was that residents that needed assistance were checked on every 1 ,d+[DATE] to every 2 hours by the nurses and/or CNAs. V4's Separation Report documents the following: Date and time of incident: [DATE], last day worked: [DATE]; Termination date: [DATE]; nature of separation: violation of company policy, dishonesty with investigation; facts of the incident: employee was on shift the night that an incident happened. Employee was asked to write a statement of what happened and the statement that was wrote did not match video footage that was found on cameras. V6's, RN, written statement, undated, documents the following: V6 was passing medications to a resident in the dining room at 8:30 AM when a CNA approached her and said come to R3's room now. V6 observed R3 face down on the floor. V6 immediately called V2, Director of Nurses (DON) and V1, Administrator, to come to R3's room. On [DATE] at 9:15 AM, V6, RN, stated she was working when R3 was found deceased . V6 stated she began work at 7 AM, went to take care of another resident, which took a little while and then sometime between 8:30 AM and 9:00AM, she found R3 deceased on the floor. V6 stated he was found face down on his stomach with his arms above his head. V6 stated when she found him she assessed him with another nurse and found that he did not have a blood pressure or pulse. V6 stated when she tried to move him he was stiff. V6 stated she was written up for neglect and insubordination, she didn't agree with it but she signed it anyway because she needs her job. V6 stated she was told to write her nurse's note and then Administration handled the rest. V6 stated she is not aware of when R3 had been checked on last. V6's, RN, Disciplinary Report documents the following: Date of incident: [DATE] at 7:00 AM; nature of incident: carelessness/negligence of duties, insubordination; facts of incident: employee was on shift and failed to do her rounding at the appropriate times. V7's, LPN, written statement, dated [DATE] at 10:44 AM, documents the following: V7 was called into R3's room indicating that R3 was deceased and that they needed to get him off of the floor. Upon walking into R3's room, V7 saw R3 lying on his back next to the right side of his bed. R3 appeared to be deceased and his face was disfigured with blood and a gash on the right side of his forehead. On [DATE] at 10:35 AM, V7, LPN, stated when she entered R3's room, unsure of time, he had already been turned onto his back. R3 was incontinent, had a gash to the left side of his forehead and his face was disfigured, appeared smashed inward. V7 stated she assumed R3 had fallen due to the way he had been found. V7 stated she did not notice any other areas and his injuries were primarily to the left side of his head/face. V7 stated she did not normally take care of R3 so she isn't sure what his level of care was. V11, CNA's, written statement, dated [DATE], documents the following: she came into the building around 5:50 AM for her shift at 6:00 AM. She went through her group getting people up and ready for breakfast. While waiting for other third aid, she was passing drinks for the residents who eat on the hall and upon opening R3's door, she noticed R3 face down on the floor. She called out his name with no answer. She exited the room to look for the nurse. A nurse was notified on her way to find the nurse on his group. R3's nurse was notified around 8:30 AM. On [DATE] at 12:40 PM, V11, CNA, stated the morning R3 was found deceased , they were supposed to have three CNA's but only two showed up. V11 stated she got her group of residents ready and was passing out drinks. V11 stated R3 likes her so she decided to go in to see if he wanted to get up and get dressed for breakfast. V11 stated when she entered R3's room, he was on the floor face down, she called his name but he didn't answer so she went and got the nurse. V11 stated she went into the room with the nurse and helped to roll him over but forced herself not to look at his face because she knew it was bad. V11 stated when they rolled R3 over, he was stiff. V11 stated she is not aware of the last time R3 had been visually seen or checked on. V11 stated R3 was incontinent but they couldn't tell if it was because he would take himself to the bathroom, not pull his pants down all the way and would get it on him, but he would also be in bed and be incontinent on himself. Stated he would refuse care for certain people, he had his favorites and he liked her so she took care of him. V13, CNA's, written statement, dated [DATE], documents the following: V13 overheard the nurses say someone was unresponsive so she went to see if she could help. V13 saw R3 face down on the floor and went to get a mechanical lift sling, but once they rolled R3 over, she stepped back and let the nurses handle it. V14, Former CNA's, written statement, dated [DATE] at 9:42 AM, documents the following: worked 2 PM - 10 PM and 10 PM - 5 AM; worked the 200 hall, rooms ,d+[DATE]. ,d+[DATE] PM shift, V14 started rounds to put R3 to bed, about 8:30 PM, V14 changed R3 and he sat in his chair. R3 put himself to bed. On the 10 PM -5 PM shift at 1:15 AM, V14 started her rounds, went into R3's room, R3 was lying in bed, awake, the TV on and R3 was facing the television. R3 yelled at V14 to get out of his room, V14 left his room and had no further interactions with R3. On [DATE] at 8:40 AM, V1, Administrator, stated there were concerns with R3's death and the length of time that had passed before he was found deceased . On [DATE] at 9:05 AM, V1, Administrator, stated the last time R3 was checked on prior to being found deceased was at midnight by V4, Former LPN. V1 stated there were staff that were disciplined because of the incident. On [DATE] at 9:05 AM, V10, Regional Nurse Consultant, stated it varies as to how often residents are checked on. V10 stated it depends on if the resident is clinically stable, independent and what their preferences are. V10 stated if they are clinically unstable, they are checked on more often/frequently. On [DATE] at 11:10 AM, V1, Administrator, was asked what is the standard of practice with rounding/checking on the residents is in the facility. V1 stated it's determined through their plan of care, if someone was incontinent then the expectation would be to check them every 2 hours. V1 stated R3 required some assistance with ADLs but often refused assistance and didn't like to be disturbed at night. V1 stated she did not notify the coroner. V1 stated their normal practice is that the nurse on the hall notifies the coroner. On [DATE] at 12:35 PM, V16, CNA, stated R3 needed encouragement with ADLs but didn't like to be bothered. V16 stated he would normally check on R3 between 6 AM and 7:30 AM to see about breakfast and if R3 wanted to get up, then again when they picked up trays after breakfast, then again before lunch around 11 AM and 11:30 AM, then again when they picked up the lunch trays and then again before the end of his shift. V16 stated R3 was incontinent, was able to get out of bed on his own, but still needed checked on. V16 stated they check on all the residents at least every 2 hours. On [DATE] at 1:30 PM, V18, Deputy Coroner, stated their office was notified of R3's death by a nurse, unsure of whom, but not that there had been any recent falls, injuries, etc. When surveyor told him that V4, Former LPN, and V7, LPN, had confirmed that R3 was found face down on the floor with facial disfigurement and bloody, V18 stated the office was not notified of that information. On [DATE] at 2:35 PM, V17, Advance Practice Nurse (APN), stated she had concerns with the facility in regards to R3's death. V17 stated the facility did an investigation and R3 was found face down deceased , he had fallen at sometime and wasn't found right away, there were concerns on how long it had been since he had been checked on. V17 stated her biggest concern with the facility is regarding to the quality of care being provided to the residents. V17 stated the majority of her time during her visits are spent fielding complaints from residents and family on their care. V17 stated it has gotten worse over the past month. V17 stated all the residents that reside in the facility are there because they need care, and she agrees that the standard of practice is to check on all residents at least every couple (2) hours. V17 stated she signed R3's death certificate under the supervision of her attending, V19, Medical Director/R3's Physician, who was out of town at the time, and they agreed that R3's cause of death was Hypoxia related to COPD. V17 stated she was notified by the facility about the concerns with the length of time from when he was checked on last until he was found deceased and that he possibly had fallen but not full details of how he was found. On [DATE] at 10:05 AM, V1, Administrator, stated they do not have a formal policy on rounding/monitoring/supervision, it is determined according to the resident's plan of care.

Based on interview and record review, the facility failed to ensure residents were free from neglect by not providing as needed monitoring/visual checks for 1 of 5 residents (R3), reviewed for neglect in the sample of 5. This failure resulted in R3 falling out of bed at an unknown time and being found deceased with face being disfigured and gash on the right side of his forehead. Findings Include: R3's Face Sheet, undated, documents R3 has the following diagnoses: Neurocognitive Disorder, COPD (Chronic Obstructive Pulmonary Disease), Atrial Fibrillation and Presence of a Cardiac Pacemaker. R3's Progress Note, dated [DATE] at 8:35 AM by V6, Licensed Practical Nurse (LPN), documents she was called to R3's room by a Certified Nurses Assistant (CNA). R3 was observed on the floor face down next to his bed. Resident had no response, pulse or respirations. Time of death was determined by two nurses at 8:20 AM. R3's Death Certificate, documents a date of death of [DATE], no time provided, and the cause of death was listed as Hypoxia with COPD. R3's Minimum Data Set (MDS), dated [DATE], documents R3 requires assistance with bed mobility, transfers, toileting and is frequently incontinent of bowel and bladder. R3's Care Plan, dated [DATE], documents R3 has an ADL (Activities of Daily Living) deficit and to assist with care. The Facility Investigation documents the following: Date of incident: [DATE] at 8:35 AM with a report date of [DATE]. Nursing staff found R3 deceased beside his bed on [DATE] at 8:35 AM. Per R3's plan of care, the resident preferred to stay in bed most of the time or refused to get out of bed and often liked to sleep until noon. R3's bed was in low position and the call light was within easy reach of the bed but had not been activated. The Facility's Timeline of Events documents the following: [DATE] at 12:00 AM: R3 was lying in bed; 1:15 AM - R3 was in bed watching TV, awake, yelled at staff; 8:30 AM 1st CNA (V11) passing breakfast drinks and found resident, 1st (V4, Former LPN)/2nd (V6, Registered Nurse (RN) nurse called/arrived to room; 8:36 AM - 3rd (V12) nurse arrived in room, 2nd (V13) CNA arrived went to get mechanical lift sling, 4th (V7) nurse arrived. The Facility Camera Footage Review from [DATE] - [DATE] for R3's room documents the following information: [DATE] at 5:52 PM: V14, Former CNA, entered R3's room, exited room at 5:54 PM, [DATE] at 8:03 AM: CNA (no name) observed entering R3's room. V4, Former LPN's, written statement, no date or time, documents the following: At approximately 12 AM, she opened the bathroom door, noted that R3 was sleeping and snoring. He showed no visible signs of pain. V4, Former LPN's, written statement, dated [DATE], documents the following: When doing her rounds at midnight on [DATE], R3 was lying in bed on right side. R3 was resting quietly with no signs or symptoms of distress. R3 has a preference not be disturbed during the night. V4 had no personal knowledge of the event until she was called to R3's room at 8:30 AM. On [DATE] at 12:54 PM, V4, Former LPN, stated she checked on R3 on [DATE] around 12 AM, he was in bed. V4 stated she did not check on him again through the night until she was called to his room that morning ([DATE]) around 8 AM. V4 stated when she entered the room, R3 was lying on the left side of his bed, face down and full rigor mortis had set in, when they turned him over it was the worst thing I've ever seen, his face was blue and smashed in. It was established that he could've fallen but you could tell he had been there a while. V4 stated he was incontinent at times and particular about what kind of care and when he wanted care. V4 stated R3 was not nice and didn't want messed with during the night. V4 stated she was suspended for a week and then fired because they (facility management) said she didn't do her rounds. V4 stated it was weird because it's normal protocol that the nurse notifies the coroner's office of a death, but V1, Administrator, and V2, DON, stated they were going to do it, but she doesn't think they did. V4 stated their normal standards of practice was that residents that needed assistance were checked on every 1 ,d+[DATE] to every 2 hours by the nurses and/or CNAs. V4's Separation Report documents the following: Date and time of incident: [DATE], last day worked: [DATE]; Termination date: [DATE]; nature of separation: violation of company policy, dishonesty with investigation; facts of the incident: employee was on shift the night that an incident happened. Employee was asked to write a statement of what happened and the statement that was wrote did not match video footage that was found on cameras. V6's, (RN) written statement, undated, documents the following: V6 was passing medications to a resident in the dining room at 8:30 AM when a CNA approached her and said come to R3's room now. V6 observed R3 face down on the floor. V6 immediately called V2, Director of Nurses (DON) and V1, Administrator, to come to R3's room. On [DATE] at 9:15 AM, V6, RN, stated she was working when R3 was found deceased . V6 stated she began work at 7 AM, went to take care of another resident, which took a little while and then sometime between 8:30 AM and 9:00AM, she found R3 deceased on the floor. V6 stated he was found face down on his stomach with his arms above his head. V6 stated when she found him she assessed him with another nurse and found that he did not have a blood pressure or pulse. V6 stated when she tried to move him he was stiff. V6 stated she was written up for neglect and insubordination, she didn't agree with it but she signed it anyway because she needs her job. V6 stated she was told to write her nurse's note and then Administration handled the rest. V6 stated she is not aware of when R3 had been checked on last. V6's, RN, Disciplinary Report documents the following: Date of incident: [DATE] at 7:00 AM; nature of incident: carelessness/negligence of duties, insubordination; facts of incident: employee was on shift and failed to do her rounding at the appropriate times. V7's, LPN, written statement, dated [DATE] at 10:44 AM, documents the following: V7 was called into R3's room indicating that R3 was deceased and that they needed to get him off of the floor. Upon walking into R3's room, V7 saw R3 lying on his back next to the right side of his bed. R3 appeared to be deceased and his face was disfigured with blood and a gash on the right side of his forehead. On [DATE] at 10:35 AM, V7, LPN, stated when she entered R3's room, unsure of time, he had already been turned onto his back. R3 was incontinent, had a gash to the left side of his forehead and his face was disfigured, appeared smashed inward. V7 stated she assumed R3 had fallen due to the way he had been found. V7 stated she did not notice any other areas and his injuries were primarily to the left side of his head/face. V7 stated she did not normally take care of R3 so she isn't sure what his level of care was. V11, CNA's, written statement, dated [DATE], documents the following: she came into the building around 5:50 AM for her shift at 6:00 AM. She went through her group getting people up and ready for breakfast. While waiting for other third aid, she was passing drinks for the residents who eat on the hall and upon opening R3's door, she noticed R3 face down on the floor. She called out his name with no answer. She exited the room to look for the nurse. A nurse was notified on her way to find the nurse on his group. R3's nurse was notified around 8:30 AM. On [DATE] at 12:40 PM, V11, CNA, stated the morning R3 was found deceased , they were supposed to have three CNA's but only two showed up. V11 stated she got her group of residents ready and was passing out drinks. V11 stated R3 likes her so she decided to go in to see if he wanted to get up and get dressed for breakfast. V11 stated when she entered R3's room, he was on the floor face down, she called his name but he didn't answer so she went and got the nurse. V11 stated she went into the room with the nurse and helped to roll him over but forced herself not to look at his face because she knew it was bad. V11 stated when they rolled R3 over, he was stiff. V11 stated she is not aware of the last time R3 had been visually seen or checked on. V11 stated R3 was incontinent but they couldn't tell if it was because he would take himself to the bathroom, not pull his pants down all the way and would get it on him, but he would also be in bed and be incontinent on himself. Stated he would refuse care for certain people, he had his favorites and he liked her so she took care of him. V13, CNA's, written statement, dated [DATE], documents the following: V13 overheard the nurses say someone was unresponsive so she went to see if she could help. V13 saw R3 face down on the floor and went to get a mechanical lift sling, but once they rolled R3 over, she stepped back and let the nurses handle it. V14, Former CNA's, written statement, dated [DATE] at 9:42 AM, documents the following: worked 2 PM - 10 PM and 10 PM - 5 AM; worked the 200 hall, rooms ,d+[DATE]. ,d+[DATE] PM shift, V14 started rounds to put R3 to bed, about 8:30 PM, V14 changed R3 and he sat in his chair. R3 put himself to bed. On the 10 PM -5 PM shift at 1:15 AM, V14 started her rounds, went into R3's room, R3 was lying in bed, awake, the TV on and R3 was facing the television. R3 yelled at V14 to get out of his room, V14 left his room and had no further interactions with R3. On [DATE] at 8:40 AM, V1, Administrator, stated there were concerns with R3's death and the length of time that had passed before he was found deceased . On [DATE] at 9:05 AM, V1, Administrator, stated the last time R3 was checked on prior to being found deceased was at midnight by V4, Former LPN. V1 stated there were staff that were disciplined because of the incident. On [DATE] at 9:05 AM, V10, Regional Nurse Consultant, stated it varies as to how often residents are checked on. V10 stated it depends on if the resident is clinically stable, independent and what their preferences are. V10 stated if they are clinically unstable, they are checked on more often/frequently. On [DATE] at 11:10 AM, V1, Administrator, was asked what is the standard of practice with rounding/checking on the residents is in the facility. V1 stated it's determined through their plan of care, if someone was incontinent then the expectation would be to check them every 2 hours. V1 stated R3 required some assistance with ADLs but often refused assistance and didn't like to be disturbed at night. V1 stated she did not notify the coroner. V1 stated their normal practice is that the nurse on the hall notifies the coroner. On [DATE] at 12:35 PM, V16, CNA, stated R3 needed encouragement with ADLs but didn't like to be bothered. V16 stated he would normally check on R3 between 6 AM and 7:30 AM to see about breakfast and if R3 wanted to get up, then again when they picked up trays after breakfast, then again before lunch around 11 AM and 11:30 AM, then again when they picked up the lunch trays and then again before the end of his shift. V16 stated R3 was incontinent, was able to get out of bed on his own, but still needed checked on. V16 stated they check on all the residents at least every 2 hours. On [DATE] at 1:30 PM, V18, Deputy Coroner, stated their office was notified of R3's death by a nurse, unsure of whom, but not that there had been any recent falls, injuries, etc. When surveyor told him that V4, Former LPN, and V7, LPN, had confirmed that R3 was found face down on the floor with facial disfigurement and bloody, V18 stated the office was not notified of that information. On [DATE] at 2:35 PM, V17, Advance Practice Nurse (APN), stated she had concerns with the facility in regards to R3's death. V17 stated the facility did an investigation and R3 was found face down deceased , he had fallen at sometime and wasn't found right away, there were concerns on how long it had been since he had been checked on. V17 stated her biggest concern with the facility is regarding to the quality of care being provided to the residents. V17 stated the majority of her time during her visits are spent fielding complaints from residents and family on their care. V17 stated it has gotten worse over the past month. V17 stated all the residents that reside in the facility are there because they need care, and she agrees that the standard of practice is to check on all residents at least every couple (2) hours. V17 stated she signed R3's death certificate under the supervision of her attending, V19, Medical Director/R3's Physician, who was out of town at the time, and they agreed that R3's cause of death was Hypoxia related to COPD. V17 stated she was notified by the facility about the concerns with the length of time from when he was checked on last until he was found deceased and that he possibly had fallen but not full details of how he was found. The Prevention of Abuse, Neglect and Exploitation policy, dated [DATE], documents it is the policy to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Neglect means failure of the facility, it's employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on interview, observation and record review, the facility failed to identify and monitor a rash for 1 of 4 residents (R4) reviewed for a skin condition in the sample of 13. The failure left R4 with a red rash with peeling skin on his scrotum and gluteal folds. Findings include: On 10/17/23 at 3:19 PM, V17, V18 & V19 all Certified Nurse Assistants, (CNAs) entered R4's room to check for incontinence. R4 was asleep. V17 removed R4's incontinence brief. V20 Registered Nurse, (RN), entered the room to observe. R4's incontinence brief was slightly wet with urine. V17 provided incontinence care for R4 correctly and thoroughly. During the care R4 was rolled over to his side, so his buttocks could be cleansed. R4's lower buttock, gluteal folds, lower groin and scrotum had a red rash. The rash did not have any open areas, but there was a patch on his scrotum, that was peeling and an area on both gluteal folds that were peeling. V17 applied a preventive silicone barrier cream to R4's buttocks, scrotum and gluteal folds. V20 returned to the room and stated, that R4 did have an order for triamcinolone cream, and he applied the cream to R4's buttocks, gluteal folds and scrotum. On 10/17/23 at 3:23 PM, V17, V18 and V19 all stated that they were unsure of how long R4 has had the rash. V20 RN stated, that he did not know if R4 had any ordered cream for the rash and that he would go and check. On 10/17/23 at 3:30 PM - 3:45 PM, V26, CNA, stated, He (R4) has had that fungal rash for about a month. We put a barrier cream on him. On 10/19/23 V1 stated, (V20) should know if R4 has a cream for a rash he is always the Nurse down there. On 10/24/23 at 10:46, V35, Wound Nurse, stated, that she was unaware that R4 had a rash on his buttocks, gluteal folds, groin and scrotum. V35 stated, that she should have been notified so the rash could be monitored and treated correctly. R4's Admission Record, print date of 10/3/23, documents that R4 was admitted on [DATE] and has diagnoses of Dementia and COPD. R4's Minimum Data Set, dated dated [DATE], documents that R4 is cognitively intact, requires supervision for eating, exertive assistance of 2 staff members for incontinence, extensive assistance of 1 staff member for hygiene and is always incontinent of bladder. R4's October 2023 Treatment Administration Record, documents, 10/4/2022 10/4/2022 On Hand Triamcinolone Acetonide 0.1 % Cream apply topically to bilateral buttocks every day shift & every evening shift for the rash until resolved. Mix with Miconazole. R4's Clinical Summary, dated 10/17/23, documents, Skin Condition: No skin condition noted. The Skin/Pressure Ulcer Risk Evaluation, undated, documents, All residents will have a documented weekly review of skin condition by the Licensed Nurse.

Based on interview and record review, the facility failed to ensure timely care for 1 of 7 residents (R44) reviewed for quality of care in the sample of 53. This failure resulted in delay in treatment for 27 hours after a fall before R44 was transferred to the local emergency room and determined to have sustained 6 rib fractures. Findings include: R44's Undated Face Sheet, documents diagnoses include repeated falls, multiple fractures of ribs, left side subsequent encounter for fracture with routine healing, age-related osteoporosis without current pathological fractures, restless leg syndrome (RLS), Diabetes Mellitus (DM.) R44's Quarterly Minimum Data Set (MDS), dated [DATE], documents resident is moderately cognitively impaired, bed mobility and dressing supervision of 1-person physical assist, walking in room supervision and setup only. Yes pain interview should be conducted. Pain within last 5 days: yes occasionally. Pain has made it hard for resident to sleep at night and has limited resident's day to day activities. Worst pain within last 5 days is rated at 5/10 (rated as a 5 on a scale of 1-10). R44's Undated Care Plan documents resident has a potential for pain r/t (related to) diagnosis of DM, RLS, hx (history) of repeated falls, osteoporosis. Interventions: administer medications as ordered, anticipate the resident's needs for pain relief and respond to any complaint of pain. On 1/19/2023 at 2:05 AM, V31, Licensed Practical Nurse (LPN), documents, Res (resident) observed sitting on the floor in her room on her buttocks with legs stretched out in front of her. walker was next to her. Stated she was getting her clothes ready. Had been rummaging through her closet. ROM (range of motion) x 4 WNL (within normal limits). No c/o (complaint of) pain or discomfort. Neuro-checks WNL. MD (physician) aware with NNO (no new orders.) Cont (continue) to monitor. Call out to family. R44's Nursing Note, dated 1/19/2023 at 7:06 AM, V31, LPN, documents, Res c/o soreness/tenderness to left ABD (abdomen.) No bruising, warmth or redness noted but tender to touch. L/S (lung sounds) clear bilat (bilateral.) No resp (respirations) distress noted. C/o pain with inspiration (breathing in.) SPO2 (blood oxygen saturation) 98% on O2 (oxygen)@ 2L (liters)/NC (nasal cannula). Call out to (V24, MD). R44's Nursing Notes have no documentation of physician response between 7:07 AM through 2:21 PM on 1/19/2023. R44's Nursing Note, dated 1/19/2023 at 2:22 PM documents, Phone call made to (V24's) nurse due to resident complaints of pain in abdomen on left side, inquiring if doctor wanting to order portable X-Ray. Nurse states give Tylenol 650 mg (milligrams) per standing order for now q (every) 6 hours PRN (as needed), will check w/ (with) doctor about X-Ray and call back. R44's Medication Administration Record (MAR) dated 1/19/2023 documents Tylenol 650 mg for pain 5/10 and was E effective at 2:30 PM. R44's FollowUp: Fall dated 1/19/2023 at 7:16 PM, documents most recent pain level: 1/19/2023 at 5:16 PM pain 1. R44's Nursing Note, dated 1/19/2023 at 8:43 PM, V36, LPN, documents (V24's) NP (Nurse Practitioner) received message regarding fall and abdominal pain, no X-Ray orders at this time. Continue to monitor resident for injury and any GI issues (black tarry stool/worsening abdominal pain/nausea/emesis). R44's SBAR (Situation, Background, Assessment, Recommendation), dated 1/20/2023 at 8:55 AM, V8, LPN, documents, Abdominal pain. Resident complained of severe pain to her left Rib/Abdomen area. Resident is holding her left rib area and is unable to sit up. R44's Change in Condition Evaluation, dated 1/20/2023 at 9:20 AM, V8, LPN, documents, Resident complained of severe pain to her left rib/abdomen area. Resident is holding her left rib area and is unable to sit up. Change in condition was reported to the primary care clinician on 1/20/2023 at 9:00 AM with recommendations to send to ER (emergency room ) for eval (evaluation) and tx (treatment.) R44's Nursing Note, dated 1/20/2023 at 9:30 AM, V8, LPN, documents, Family representative returned call. Aware of resident's change in condition and being sent to local ER for evaluation. R44's Nursing Note, dated 1/20/2023 at 9:43 AM, V8, LPN documents, Writer called for transport to local ER. R44's Nursing Note, dated 1/20/2023 at 10:00 AM, documents, Emergency Medical Services here to transport resident to local ER. Papers sent with EMT's (emergency medical technicians.) Report given to EMT's. R44's Nursing Note, dated 1/20/2023 at 8:17 PM, documents, Family representative called w (with)/ update. Resident has 4-9 left rib fx's (fractures.) Will be admitted . F/u (follow up) to be documented. R44's Hospital History & Physical dated 1/20/2023 at 1:14 PM, documents resident is a 87 y/o (year old) female who presented to the ED (emergency department) after a fall. Pt (patient) is confused at bedside so is unable to provide thorough history. Pt does report she had fallen at some point in the day after standing up. She then fell on to a nightstand. She denies hitting her head or LOC (loss of consciousness.) Pt report left upper quadrant abdominal pain extending to left chest wall. Of note pt reporting burning with urination. Pt denies SOB (shortness of breath.) No HA (headache), vision changes, N/V (nausea/vomiting), numbness/tingling. Pt noted to have a history of recent falls 2/2 to lightheadedness. Integumentary (skin) assessment: bruise to LUQ (left upper quadrant) abdomen. Resident is alert and pleasantly confused. CT (cat scan) chest, abdomen, pelvis: there are acute fractures of the left fourth through ninth ribs laterally coupled which are minimally displaced. On 6/22/2023 at 11:10 AM, V31, LPN, stated she was assigned to R44 on night shift from 11:00 PM on 1/18/2023 to 7:00 AM on 1/19/2023. V31 stated she wouldn't administer pain medication after a resident falls because she doesn't want to mask (cover up) the pain. She was waiting for (R44's) physician to call the facility back and give orders on how to proceed. She stated she gave the day shift nurse (name unknown) report and let them know (R44) fell and had complained of pain and awaiting a call back from the physician. On 6/21/2023 at 10:15 AM , V8, LPN, stated she was assigned to resident on 1/20/2023 day shift and recalled when she went to give (R44) meds and res complained of side pain and wasn't able to sit up in bed. V8 assessed R44 and didn't assess any bruising at that time. V8 didn't recall if a CNA (Certified Nursing Assistant) reported to her that the res had pain or not because the incident occurred over 6 months ago. On 6/22/2023 at 12:50 PM, V26, CNA, stated she was familiar with (R44) and took care of her often. V26 stated R44 transfers and dresses herself independently and walks with a wheeled walker. V26 stated she worked day shift on 1/19/2023 from 6:00 AM to 2:00 PM and was assigned to R44. V26 stated she couldn't recall what nurse told her R44 fell but they did and she always goes and checks to ensure her residents are OK when she arrives to the facility. V26 stated the initial check on R44 on 1/19/2023, she was asleep in bed. V26 stated when she went into R44's room at approximately 8:00 AM, R44 was sitting up on the side of the bed and was holding her left side and complained of pain. V26 stated she reported R44 complained of pain to the nurse (name unknown) and recalled R44 got out of bed and walked to the dining room for meals with her wheeled walker but as the day went on R44 was in increased pain because she started complaining of pain even more and told her she wanted to go to the hospital. V26 stated everyone knew R44 was in pain and she wanted to go to the hospital because she was telling everyone her left side hurts. V26 stated she was assigned to R44 again on day shift on 1/20/2023. V26 stated when she arrived she went straight to R44's room to check on her and she was lying in bed holding her left side and moaning. V26 stated on the morning of 1/20/2023, R44 asked V26 to help with getting dressed because she didn't want to move her arms due to increased pain and was holding her left side so she assisted R44 to get dressed and R44 asked her to assist her to stand from bed. V26 stated she reported it to the nurse (name unknown) and R44 was transferred to the ER a few hours later. On 6/22/2023 at 1:00 PM, R44 is lying in bed with her eyes open. R44 stated she recalled falling in January 2023 and stated her left side hurt so badly and no one did anything about it. R44 stated at one point after she fell , it hurt to breath in so she was no longer able to breath normally, she was taking short shallow breaths. R44 stated she wanted to go to the hospital way before the nurse sent her but no one would listen. R44 stated her left side didn't hurt if she wasn't moving but as soon as she would move, the pain sent to the moon. On 6/23/2023 at 11:45 AM, V2, Director of Nurses (DON), stated when a resident has a fall then complains of pain that is considered a change in condition and she expects the nurse to call the resident's physician during office hours, or the on-call physician during off hours and/or the telehealth company (depends on physician preference) to notify the new complaint of pain if no one responds within 30 minutes, she expects staff to call the physician again, follow up with the telehealth company or to call one of the 3 medical directors. On 6/23/2023 at 10:39 AM, V24, R44's physician, stated there was no communication documented to his office that (R44) complained of pain with inspiration and/or left side pain he would have ordered a STAT (immediate) chest X-Ray or send resident to the emergency room for further evaluation and treatment. V24 stated when the resident expressed pain during inspiration and had left side pain that was considered a change in condition and staff should have called either the physician's office or the on-call physician during off hours and he would have ordered a STAT chest X-Ray or ordered the resident to be transferred to the emergency room for further evaluation and treatment. V24 stated when staff call the physician's office or the on-call physician phone, if the physician doesn't call back or they can't get ahold of the physician, and the resident is complaining of pain post fall, the nurse can transfer the resident to the emergency room per nurse judgement. The Facility's Change in Condition policy, revised 12/7/2011, documents, It is the policy of (corporate name) that a licensed staff member will notify the attending physician and responsible party of change in the resident's condition. Procedure: the physician/responsible party will be notified when the change is sudden in onset or represents a marked changed in relation to usual signs and symptoms or the signs and symptoms are unrelieved by measure already prescribed. Notification parameters are based on interact II change in condition file cards referencing AMDA (American Medical Directors Association) Clinical guidelines - acute changes in condition in the long-term care setting 2003, as attached to the policy. Physician/responsible party notification is to include but is not limited to: any unusual occurrence resulting in injury and significant change in resident's physical status. If the physician cannot be reached, the Medical Director will be contacted to report the change in condition until the attending physician can be contacted. Calls will be made to the family/responsible party until they are reached. The nurse will document in the clinical record. Documentation and assessment will be ongoing until condition has stabilized.

Based on interview and record review the facility failed to assess a resident for pain for 1 of 7 residents (R44) in the sample of 53. This failure resulted in R44 receiving only one dose of Tylenol in the 27 hours after a fall until R44 was transported to the local emergency room and determined to have 6 rib fractures. Findings include: R44's Undated Face Sheet, documents diagnoses include repeated falls, multiple fractures of ribs, left side subsequent encounter for fracture with routine healing, age-related osteoporosis without current pathological fractures, restless leg syndrome (RLS), Diabetes Mellitus (DM.) R44's Quarterly Minimum Data Set (MDS), dated [DATE], documents resident is moderately cognitively impaired, bed mobility and dressing supervision of 1-person physical assist, walking in room supervision and setup only. Yes pain interview should be conducted. Pain within last 5 days: yes occasionally. Pain has made it hard for resident to sleep at night and has limited resident's day to day activities. Worst pain within last 5 days is rated at 5/10 (rated as a 5 on a scale of 1-10). R44's Undated Care Plan documents resident has a potential for pain r/t (related to) diagnosis of DM, RLS, hx (history) of repeated falls, osteoporosis. Interventions: administer medications as ordered, anticipate the resident's needs for pain relief and respond to any complaint of pain. R44's Physician's Order Recap Report, dated 1/19/2023 documents, Tylenol 325 milligrams give 2 tablets by mouth every 6 hours for pain PRN (as needed). On 1/19/2023 at 2:05 AM, V31, Licensed Practical Nurse (LPN), documents, Res (resident) observed sitting on the floor in her room on her buttocks with legs stretched out in front of her. walker was next to her. Stated she was getting her clothes ready. Had been rummaging through her closet. ROM (range of motion) x 4 WNL (within normal limits). No c/o (complaint of) pain or discomfort. Neuro-checks WNL. MD (physician) aware with NNO (no new orders.) Cont (continue) to monitor. Call out to family. R44's Post Incident Eval, dated 1/19/2023 at 2:09 AM, V31, LPN documents Incident: fall, sitting on her buttocks with legs out in front, most recent pain level 0 (zero) on 1/12/2023 at 6:10 PM. Pain: N/A (not applicable) (use N/A if no pain reported.) Actions taken: monitor resident. R44's Nursing Note, dated 1/19/2023 at 6:44 AM, V31, LPN, documents, POA (power of attorney) aware of fall. R44's Nursing Note, dated 1/19/2023 at 7:06 AM, V31, LPN, documents, Res c/o soreness/tenderness to left ABD (abdomen.) No bruising, warmth or redness noted but tender to touch. L/S (lung sounds) clear bilat (bilateral.) No resp (respirations) distress noted. C/o pain with inspiration (breathing in.) SPO2 (blood oxygen saturation) 98% on O2 (oxygen)@ 2L (liters)/NC (nasal cannula). Call out to (V24, MD). R44's Nursing Note, dated 1/19/2023 at 2:22 PM, documents, Phone call made to (V24's) nurse due to resident complaints of pain in abdomen on left side, inquiring if doctor wanting to order portable X-Ray. Nurse states give Tylenol 650 mg (milligrams) per standing order for now q (every) 6 hours PRN (as needed), will check w/ (with) doctor about X-Ray and call back. R44's Medication Administration Record (MAR) dated 1/19/2023 documents Tylenol 650 mg for pain 5/10 and was E effective at 2:30 PM. R44's FollowUp: Fall dated 1/19/2023 at 7:16 PM, documents most recent pain level: 1/19/2023 at 5:16 PM pain 1. R44's Nursing Note, dated 1/19/2023 at 8:43 PM, V36, LPN, documents (V24's) NP (Nurse Practitioner) received message regarding fall and abdominal pain, no X-Ray orders at this time. Continue to monitor resident for injury and any GI (gastrointestinal) issues (black tarry stool/worsening abdominal pain/nausea/emesis). R44's Neurological Assessment Flow Sheet, dated 1/19/2023 and 1/20/2023 documents R44 had an appropriate pain response but no documentation if she had complaint of pain was documented on the flow sheet. R44's SBAR (situation, background, assessment, recommendation), dated 1/20/2023 at 8:55 AM, V8, LPN, documents, Abdominal pain. Resident complained of severe pain to her left Rib/Abdomen area. Resident is holding her left rib area and is unable to sit up. R44's eInteract Change in Condition Evaluation, dated 1/20/2023 at 9:20 AM, V8, LPN, documents, Resident complained of severe pain to her left rib/abdomen area. Resident is holding her left rib area and is unable to sit up. Change in condition was reported to the primary care clinician on 1/20/2023 at 9:00 AM with recommendations to send to ER (emergency room ) for eval (evaluation) and tx (treatment.) R44's Nursing Note, dated 1/20/2023 at 9:30 AM, V8, LPN, documents, Family representative returned call. Aware of resident's change in condition and being sent to local ER for evaluation. R44's SNF (Skilled Nursing Facility)/NF (Nursing Facility) to Hospital Transfer Form, dated 1/20/2023 at 9:30 AM. Most recent pain level 1 1/19/2023 5:16 PM pain location: abdomen acetaminophen (Tylenol) administered 1/19/2023 at 2:30 PM. R44's Nursing Note, dated 1/20/2023 at 9:43 AM, V8, LPN, documents, Writer called for transport to local ER. R44's Nursing Note, dated 1/20/2023 at 10:00 AM, documents, Emergency Medical Services here to transport resident to local ER. Papers sent with EMT's (emergency medical technicians.) Report given to EMT's. R44's Nursing Note, dated 1/20/2023 at 8:17 PM, documents, Family representative called w/ update. Resident has 4-9 left rib fx's (fractures.) Will be admitted . F/u (follow up) to be documented. R44's Hospital History & Physical dated 1/20/2023 at 1:14 PM, documents resident is a 87 y/o (year old) female who presented to the ED (emergency department) after a fall. Pt (patient) is confused at bedside so is unable to provide thorough history. Pt does report she had fallen at some point in the day after standing up. She then fell on to a nightstand. She denies hitting her head or LOC (loss of consciousness.) Pt report left upper quadrant abdominal pain extending to left chest wall. Of note pt reporting burning with urination. Pt denies SOB (shortness of breath.) No HA (headache), vision changes, N/V (nausea/vomiting), numbness/tingling. Pt noted to have a history of recent falls 2/2 to lightheadedness. Integumentary (skin) assessment: bruise to LUQ (left upper quadrant) abdomen. Resident is alert and pleasantly confused. CT (cat scan) chest, abdomen, pelvis: there are acute fractures of the left fourth through ninth ribs laterally coupled which are minimally displaced. R44's IL (Illinois) Facility State Report, dated 1/22/2023 at 10:32 AM, V2, Director of Nurses (DON), documents (R44) is [AGE] years of age with a past medical history of dementia, amnesia, muscle weakness, unsteadiness on feet, age related osteoporosis and respiratory failure. (R44) was observed at 1:00 AM sleeping in her bed with her C-Pap (continuous positive airway pressure machine) on. At 2:00 AM (R44) was observed by the nurse sitting on her bedroom floor without oxygen or C-Pap on. When asked what she was trying to do (R44) stated that she was trying to rearrange the clothes in her closet. ROM (range of motion) was performed and patient tolerated without pain. (R44) was assisted from floor with help from staff, (R44's) room was dark, and walker was next to her. It appeared that (R44) walked to her closet door and lost her balance falling on the left side. (V24, R44's physician) and POA were called and updated. At 7:00 AM pt c/o pain to left side of abdomen, no bruising was observed area was tender. (V24's) team was called, nurse requested a portable X-Ray and it was declined and to monitor patient. 2:22 PM (V24's) office was called and X-Ray was declined, nurse was informed to monitor for GI issues. During this time, patient pain was managed with Tylenol, the following morning, patient presented with pain that was uncontrolled and (R44) was send to the local hospital. (R44) was admitted with left rib fractures 4-9 and a UTI (urinary tract infection.) POA called to update the facility and to inform that (R44) would be returning after her hospitalization . On 6/22/2023 at 11:10 AM, V31, LPN, stated she was assigned to R44 on night shift from 11:00 PM on 1/18/2023 to 7:00 AM on 1/19/2023. V31 stated she wouldn't administer pain medication after a resident falls because she doesn't want to mask (cover up) the pain. V31 stated she was waiting for (R44's) physician to call the facility back and give orders on how to proceed. She stated she gave the day shift nurse (name unknown) report and let them know (R44) fell and had complained of pain and awaiting a call back from the physician. On 6/22/2023 at 2:45 PM, V32, CNA, stated she was assigned to (R44) on the evening shift on 1/19/2023 from 3:00 PM to 11:00 PM stated she didn't recall R44 fell and didn't recall if resident complained of pain. On 6/21/2023 at 10:15 AM, V8, LPN, stated she was assigned to resident on 1/20/2023 day shift and recalled when she went to give (R44) meds and res complained of side pain and wasn't able to sit up in bed. V8 stated she assessed R44 and didn't assess any bruising at that time. V8 stated Aspirin 81 mg isn't for pain its more for hypertension. V8 stated she didn't recall if a CNA (Certified Nursing Assistant) reported to her that the res had pain or not because the incident occurred over 6 months ago. On 6/22/2023 at 12:50 PM, V26, CNA, stated she was familiar with (R44) and took care of her often. V26 stated R44 transfers and dresses herself independently and walks with a wheeled walker. V26 stated she worked day shift on 1/19/2023 from 6:00 AM to 2:00 PM and was assigned to R44. V26 stated she couldn't recall what nurse told her R44 fell but they did and she always goes and checks to ensure her residents are OK when she arrives to the facility. V26 stated for the initial check on R44 on 1/19/2023, she was asleep in bed. V26 stated when she went into R44's room at approximately 8:00 AM R44 was sitting up on the side of the bed and was holding her left side and complained of pain. V26 stated she reported R44 complained of pain to the nurse (name unknown) and recalled R44 got out of bed and walked to the dining room for meals with her wheeled walker but as the day went on R44 was in increased pain because she started complaining of pain even more and told her she wanted to go to the hospital. V26 stated everyone knew R44 was in pain and she wanted to go to the hospital because she was telling everyone her left side hurts. V26 stated she was assigned to R44 again on day shift on 1/20/2023 when she arrived she went straight to R44's room to check on her and she was laying in bed holding her left side and moaning. V26 stated on the morning of 1/20/2023 R44 asked V26 to help with getting dressed because she didn't want to move her arms due to increased pain and was holding her left side so she assisted R44 to get dressed and R44 asked her to assist her to stand from bed. V26 stated she reported it to the nurse (name unknown) and R44 was transferred to the ER a few hours later. On 6/22/2023 at 1:00 PM, R44 is lying in bed with her eyes open. R44 stated she recalled falling in January 2023 and stated her left side hurt so badly and no one did anything about it. R44 stated at one point after she fell it hurt to breath in so she was no longer able to breath normally, she was taking short shallow breaths. R44 stated she wanted to go to the hospital way before the nurse sent her but no one would listen. R44 stated her left side didn't hurt if she wasn't moving but as soon as she would move she was sent to the moon with pain. R44 stated a nurse (name unknown) gave her pain medication one time after she voiced complaint of pain after she fell and she didn't understand why it took so long to go to the hospital, it was as if she needed to be granted permission to go to the hospital and she didn't feel that was right. On 6/23/2023 at 11:45 AM, V2, Director of Nurses (DON), stated when a fall was not witnessed V2 expects staff to assess the resident's neuro checks which includes a pain assessment and if the resident complains of pain during a neuro check she expects the nurse to document a progress note including an accurate description of location of pain, pain scale 1-10, signs/symptoms of pain and if resident was experiencing pain. When a resident complains of pain the nurse is expected to administer PRN pain and not wait for the resident's physician to call back. When a resident has a fall then complains of pain the nurse should notify the physician of the new complaint of pain. On 6/23/2023 at 3:00 PM, V2, DON, stated, Staff had (R44's) pain stabilized as long as she was laying in bed and not moving. On 6/23/2023 at 10:39 AM, V24, R44's physician, stated when a resident falls at the facility he expects a nurse to assess the resident immediately and move all extremities to ensure there are no major injuries and to assess the resident more frequently for at least 24 hours after the fall per the facility post fall policy and to document the assessment in the resident's medical record. The nurse should notify the physician when a resident falls by calling the office or on call physician during non-office hours. V24 stated there is no documentation in his records that the facility staff called on 1/19/2023 regarding the resident falling. V24's office received a fax dated 1/19/2023 at 6:48 AM documents (R44) had a fall, ROM and neuro checks within normal limits, no complaint of pain documented on fax report. V24 stated the nurse shouldn't have faxed his office when a resident has a fall, they should have called the off hours number and reported the fall that way. V24 stated there was no communication documented to his office that (R44) complained of pain with inspiration and/or left side pain he would have ordered a STAT chest X-Ray or send resident to the emergency room for further evaluation and treatment. V24 stated when the resident expressed pain during inspiration and had left side pain that was considered a change in condition and staff should have called either the physician's office or the on-call physician during off hours and he would have ordered a STAT chest X-Ray or ordered the resident to be transferred to the emergency room for further evaluation and treatment. When staff call the physician's office or the on call physician phone if the physician doesn't call back or they can't get ahold of the physician, and the resident is complaining of pain post fall, the nurse can transfer the resident to the emergency room per nurse judgement. The Facility's Pain Management Policy, revised 6/19/2019, documents Policy: it is the practice of (corporate name) to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission, in part through an effective pain assessment and management program; providing our resident the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. We will achieve these goals through screening and accurately assessing pain in residents, encouraging residents to self-report pain and monitoring treatment efficacy and side effects. A standardized method for assessing, monitoring, evaluating and documenting pain in all residents will be utilized. Pain is defined as whatever the experiencing person says it is, existing whenever the experiencing person says it does Procedures: physician communication and involvement: a new onset, worsening intensity and/or in the absence of effective pain and/or side effect interventions. Nursing assessment responsibilities: when pain is identified, the nurse will implement the resident plan of care for appropriate management using pharmacological and/or non-pharmacological interventions. Administer order sets in the EMR (electronic medical record) will trigger an Admission Pain Assessment and Management order that require the nurse to document pain presence and rating every shift. The comprehensive pain assessment: will be triggered for completion 5 days after admission/readmission. Pain Rating Scale Selection: when gathering subjective and objective data for the pain assessments, the nurse will determine the most appropriate pain screening tool based upon resident presentation. When documenting pain, the nurse will identify the pain scale used and specify the parameters, so the meaning of the pain rating is clear, consistent and relevant for the resident. The following scales are accepted standards for use: numeric rating scale and FACE. Plan of care: the nurse will develop baseline and comprehensive plans of care addressing pain based upon information derived from the assessments. Appropriate resident centric pharmacological, non-pharmacological interventions will be utilized, and their effectiveness evaluated during established care plan reviews. Pain Management Documentation will be provided by the nurse in the EMR for the administration of scheduled and/or PRN medications. Effectiveness of PRN pain pharmacological interventions ordered by the physician/practitioner will be measured and recorded following administration and using the appropriate pain screening tool.

Based on interview and record review, the Facility failed to ensure residents were safely secured in the Facility vehicle prior to transport for 1 of 7 residents (R375) reviewed for accidents in the sample of 53. This failure resulted in R375 sustaining a right hip fracture and right tibia fibula (lower leg) fracture requiring surgical repair after falling to the floor on the bus. Findings include: R375's undated Face Sheet documents diagnoses including type 2 diabetes mellitus (DM) with diabetic neuropathy, essential (primary) hypertension, depression, peripheral vascular disease, acquired absence of left leg above knee, stage 2 pressure ulcer of right heel, and unstageable pressure ulcer to right ankle. R375's Face Sheet describes her hip fracture as displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing and her shin bone fracture as displaced oblique fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing. R375's Minimum Data Set (MDS) dated [DATE] documented R375 was cognitively intact, required extensive 2+ person assistance with bed mobility, required total dependence of 2+ persons for transfer, and used wheelchair mobility device. R375's Care Plan dated 3/27/2023 documents, The resident needs assistance with ADL's (Activities of Daily Living). (R375) has an ADL self-care performance deficit r/t (related to) left AKA (above the knee amputation), impaired balance and limited mobility. 4/14/23 res (resident) has a power chair which has a seatbelt on it. Res reports she does not use seatbelt. (R375) is at risk for falls. Balance issues d/t (due to) left AKA, DM, gait/balance, problems and impaired functional ability, osteoporosis, neuropathy, and takes medication that could have adverse reactions that could interfere with her safety. R375's Admission/Readmission Screener dated 7/23/2022 documented R375 was at risk for falls. R375's Incident Reportable dated 5/30/23 documents, (R375) is [AGE] years of age with a BIMS (Brief Interview for Mental Status score) of 15 (cognitively intact), who admitted to (Facility) in July of 2022 r/t post-surgical care after left above the knee amputation and sepsis. (R375) has a past medical history of Diabetes (Mellitus), PVD (Peripheral Vascular Disease), COPD (Chronic Obstructive Pulmonary Disease), Osteoporosis, Osteopenia, severe Osteoarthritis, Vitamin D Deficiency, current smoker, Alcoholism, RA (Rheumatoid Arthritis), and abnormal posture and a history of fractures. Recently (R375) requested a ride from transportation to go pick up new eyeglasses at (Optical Store). (R375) who uses a motorized w/c (wheelchair) was told by the driver that she needed to use the seat belt on her motorized w/c for this outing. (R375) refused and then agreed to the use of the seat belt for the outing. During the interview with the bus driver, (V16), he reported that when he put (R375) on the bus, she was refusing to wear her seatbelt that was attached to her motorized w/c. According to (V16), (R375) stated, I never wear it, I don't understand why you're making a big deal about me wearing it. (V16) stated, I told her that I couldn't transport her to the eye appt. (appointment) if she didn't wear it and that wearing the seatbelt was for her own safety. Finally (R375) agreed to wear the van seatbelt but would not put on the seatbelt to her motorized chair. (V16) reports that he felt everything was secure (four areas of harness on the van floor, and seatbelts) and they left for her appointment. While driving on (Local Street), several cars in front of him suddenly stopped and he had to put his breaks on abruptly, but he denies slamming his breaks. (V16) stated that he heard a noise and looked back, and (R375) was on the floor of the bus, laying on her stomach about 2 feet in front of her chair. The w/c remained upright in the four areas of harness on the bus floor. He says he immediately pulled over and asked her if she was ok. (R375) denied pain, but insisted that (V16) get her up. According to (V16), (R375) was insisting on smoking a cigarette and getting back to the facility. (V16) stated that he called his supervisor who asked if he needed to dispatch an ambulance and he said that (R375) said she was ok and did not have any pain. (V16) stated that he asked (R375) if she wanted to go to the hospital and she stated No, get me up so I can have a cigarette to calm my nerves. (V16) stated that he was so nervous and upset that he helped her out to smoke a cigarette and she said she was fine and had no pain. Once in the bus, (V18), the 2nd van driver, arrived and began talking to (R375), and (R375) told her that her right shoulder was hurting a little. (V18) transported (R375) to (Local Hospital) where she was admitted r/t right hip fracture. (V18) reports that before (R375) went to (Local Hospital) that she smoked a cigarette, stated, I really need to calm my nerves. Writer spoke with (V19), R375's Family, who reports that (R375) is just very fragile with all of her conditions, such as her RA, Osteoporosis, and Osteoarthritis. She reports that her mom came through the surgery ok and is being treated for pain control before she will return to (Facility). All safety harnesses and seat belts were checked on the bus and are in good working condition. The driver detail report does not show any hard breaking or stops during the trip in question. Van/Bus drivers were re-educated regarding safety/emergency procedures. (R375)'s plan of care will be updated upon her return to (Facility). R375's Progress Note dated 5/29/23 at 2:47 PM documents, Writer called (Local Hospital) for an update on resident. Resident was admitted to hospital with diagnosis of fx (fracture) R (right) hip. R375's Orthopaedic Surgery Consult Note from (Local Hospital) dated 5/26/23 documents, CC (Chief Complaint): Motor vehicle accident. HPI (History of Present Illness): The patient is a pleasant [AGE] year-old female who is wheelchair-bound after a left above-knee amputation. The patient is wheelchair-bound and has chronic right knee and right hip contracture. In addition, she has a right lower extremity ulcer that is being treated conservatively. The patient was riding in motor vehicle today when the driver slammed on the brakes and the patient went flying down the center of the van. Currently the patient reports pain in her right hip, right distal tibia, right shoulder, and neck. She denies numbness and tingling right lower extremity. XR (X-ray) pelvis demonstrates an acute right intertrochanteric femur fracture with subtrochanteric extension. XR right tib-fib (tibia-fibula) demonstrates an acute nondisplaced distal tibia metaphyseal fracture. The patient is a pleasant [AGE] year-old nonambulatory woman with significant flexion contractures of her right hip and right knee who sustained a right intertrochanteric femur fracture with subtrochanteric extension and a right nondisplaced distal tibia metaphyseal fracture. Plan for OR (Operating Room) Sunday with (V34, Orthopedic Surgeon) for right hip closed versus open reduction and cephalomedullary nailing. On 6/22/23 at 2:21 PM, R375 was sitting in her wheelchair in her room. When asked about the accident on the bus, she stated, No. I'd like to tell you, but it's too bad. On 6/21/23 at 3:17 PM, V16, Bus Driver's phone went directly to voicemail. Voice message with return contact information was left. Additional attempts were made to contact V16 on 6/22/23 at 8:54 AM, 10:05 AM, and 1:40 PM, and 6/23/23 at 9:50 AM, but all calls went directly to voicemail with no answer. On 6/23/23 at 9:15 AM, V33, Director of Transportation, stated, Residents are required to wear van seatbelts at all times. If they refuse to wear the van seatbelt, we will not transport them. We will transport them if they are not wearing their wheelchair seatbelts. They are not required, but are highly recommended. The van seatbelts are guaranteed, so I have no idea how (R375) ended up on the floor. The only thing I can come up with is maybe she loosened the belt. I wasn't there, but I talked to (V16) after it happened, and he thought everything was good. He didn't know how it happened either. On 6/22/23 at 10:29 AM, V2, Director of Nursing (DON), stated, I would expect residents to wear seat belts connected to their motorized wheelchairs. I was not aware of R375 refusing to wear her seat belt prior to that incident, but I would have expected the driver to tell me. I did not find out about that until after it happened. On 6/22/23 at 2:00 PM, V1, Administrator, stated, (R375) was not wearing her seat belt on her motorized wheelchair throughout the facility prior to the accident. When she got on the bus that day, she was refusing to wear the wheelchair seatbelt. She did allow the driver to put the van seatbelt on, but not the motorized wheelchair belt. She remembered the van seatbelt clicking, but did not remember what happened. It was the one and only time we have ever transported (R375). (V16) did not notify me prior to the accident that (R375) was refusing to wear her wheelchair band, but I think he thought she was safe and did not anticipate that there would be a problem. I understand it is our responsibility to keep her safe. If she would have been wearing the motorized wheelchair belt, it may have kept her from falling. She previously refused to wear her wheelchair belt in the facility but now she wears it all the time. On 6/22/23 at 11:15 AM, V24, R375's Physician, stated he would expect the facility to follow their policies and procedures, including bus safety. He stated, If (R375) would have been secured in the vehicle, the risk of injury would have been less. The Facility's Driving Safety Policy, not dated, documents, It is the policy of (Facility Company) that all Drivers are trained to foster safety in the performance of their duties. Drivers must be aware of the general and any special needs of passengers; ever prepared to assist them as may be required to provide for their safety and security upon entering, while riding, and upon exiting any vehicle. Employees and their passengers are required to wear seat belts at all times while they are passengers in any vehicle which is in motion. The Facility's Fall Prevention - Steady Steps Policy revised February 17, 2020, documents, It is the policy of (Facility Company) to provide each resident with an appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.

Based on observation, record review, and interview, the facility failed to ensure residents who admitted with no pressure ulcers, did not develop pressure related injury for 1 of 3 residents (R3) reviewed. This deficient practice resulted in R3 developing an unstageable (full thickness tissue loss with base covered by eschar (black, tan, brown dead tissue) pressure injury to the coccyx, left buttock and right buttock. This deficient practice also resulted in R3 being hospitalized for septic shock and surgical debridement including bone. R3's Care Plan, initiated date 8/30/2022, The resident has the potential for pressure injury development r/t, (related to), weakness and impaired mobility. It continues Goal: The resident will have intact skin, free of redness, blisters or discoloration through review date. Educate the resident/family/caregiver as to causes of skin breakdown including transfer/positioning requirements, the importance of taking care during ambulating/mobility and good nutrition. R3's Minimum Data Set, dated dated [DATE], documents that R3 requires extensive assist of 2 staff for bed mobility and totally dependent with transfers and toilet use. It also documents that R3 is always incontinent of bowel and bladder. R3's MDS also documents that R3 had 3 unstageable pressure ulcers upon admission. R3's Admission/Readmission Screener, dated 8/29/2022, documents that R3's skin condition was normal and does not have any skin impairment (includes MASD, (moisture associated skin damage), Pressure Injury, Surgical Incision, Bruises, Abrasions, Arterial/Vascular, etc ) R3's Braden Scale for Predicting Pressure Sore Risk, dated 8/29/22, documents that R3 is at moderate risk for pressure sores. It also documents that R3 has a problem with Friction & Shearing. It continues 1. Problem: Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. [CONDITION(S)], contractures or agitation leads to almost constant friction. It also documents that R3's ability to change and control body position was very limited. It continues Mobility 2. Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. R3's Continence Evaluation, dated 9/1/22, documents that R3 is always incontinent of urine and frequently incontinent of bowel. R3's Skilled Notes, dated 9/4/2022 at 12:19 PM, documents Note Text: (R3), a M, (male), resident, with a date of birth of (xxxxxxx) resides in (xxx). It continues Skilled Services / Special Instructions: Resident admitted to facility after hospitalization for hematoma s/p, (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . PMH, (past medical history): mild chronic pulmonary fibrosis, bronchiectasis, asthma, AFIB, [CONDITION(S)], HLD, [CONDITION(S)] & pacemaker exchange during hospitalization . Skilled nursing to monitor surgical site, cardio/respiratory status & recurrent infection. PT/OT for strength, balance, fall recovery skills & activity tolerance. It also documents Resident Assessment: patient is alert and oriented with confusion at times, he is able to make most needs known but is very quiet and doesn't ask for help. patient is unaware when he is incont, (incontinent). patient is up with x2 assist. no s/s (signs/symptoms) of infection at this time. Resident/Family Education and Teachback: push fluids. R3's Skin Check, dated 9/5, documents that R3 had No skin issues to the right buttock, left buttock or coccyx. R3's Skin and Wound Eval, dated 9/6/2022, documents an in house acquired unstageable pressure ulcer to R3's coccyx measuring 3.8cmx0.9cmx0.1cm. It also documents slough 100% wound filled with light serosanguineous exudate. It also documents 9/7/2022 as exact date of length of time present. R3's Alert Note, dated 9/7/2022 at 7:31 PM, documents Note Text: Skin condition observed during care - report to nurse Reported skin condition is not new. R3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . every night shift for wound It also documents 9/8/2022 Cleanse right buttock with generic wound cleanser, pat dry, skin prep peri wound, allow to dry, apply [MEDICATION(S)] every 3 days and PRN (as needed). It continues 9/8/2022 Cleanse left buttock with generic wound cleanser, pat dry, skin prep peri-wound, allow to dry, apply [MEDICATION(S)] every 3 days and PRN. R3's Skin and Wound Eval, dated 9/12/2022, documents an in house acquired unstageable pressure ulcer to R3's left buttock measuring 5.1cmx1.2cmx0.1cm with a total surface area of 4.4cm2. It documents that the exact date of area as 9/7/2022. It also documents the wound bed filled with 100% eschar. It continues to document that the wound has moderate serosanguineous exudate and a faint odor noted after cleansing. It also documents the progress of the wound as deteriorating. R3's Skin and Wound Eval, dated 9/13/2022, documents an in house acquired unstageable pressure ulcer to R3's coccyx measuring 1.8cmx0.5cmx0.1cm. It also documents slough 100% wound filled with eschar. It documented the presence light serosanguineous exudate with faint odor after cleansing. It also documents the progress of the wound as deteriorating. R3's Wound Documentation from wound physician, dated 9/14/22, documents a necrotic pressure ulcer to R3's left buttock measuring 5.1cmx1.2cm. Depth not measurable due to the necrosis to the wound bed. It continues to document Necrotic pressure ulcer to R3's Right buttock 5cmx2.3cm. Depth unmeasurable due to necrosis of wound bed with moderate drainage. It also documents a necrotic pressure ulcer to R3's Coccyx measuring 1.8cmx0.5cm. Depth unmeasurable due 100% slough to the wound bed. It continues to document that the pressure ulcers to the coccyx and left and right buttock were debrided at the bedside. Recommends: Off-load wound; Reposition per facility protocol; Turn side to side and front to back in bed every 1-2 hours if able; Low air loss mattress R3's Skin and Wound Eval, dated 9/19/2022, documents an in house acquired unstageable pressure ulcer to R3's coccyx measuring 4.6cmx0.5cmx0.1cm. It also documents the wound is filled 100% with eschar. It documents the presence moderate serosanguineous exudate with faint odor after cleansing. It also documents the progress of the wound as deteriorating. R3's Wound Documentation from wound physician, dated 9/21 documents the right and left buttock wound Resolved. Wound present. See Focused Wound Exam below. The pressure ulcer to R3's coccyx measures (L x W x D): 10 x 8 x Not Measurable cm, Surface Area: 80.00 cm^2, Odor Exudate: Heavy Purulent Thick adherent devitalized necrotic tissue: 100 % Wound progress: Deteriorate It also documents Recommendations Off-load wound; Reposition per facility protocol; Turn side to side and front to back in bed every 1-2 hours if able; Low air loss mattress; Roho cushion R3's Skin/Wound Note, dated 9/21/2022 5:43 PM, documents Data: patient was seen by (V6) today for Wound Care, new orders were obtained for [MEDICATION(S)] 500mg BID x 14 days, Probiotics daily x 30 days, Dakins wet to dry dressing to Coccyx wound that is being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] R3's Skin and Wound Eval, dated 9/26/2022, documents an in house acquired unstageable pressure ulcer to R3's coccyx measuring 9.7cmx7.0cmx0.1cm. It also documents the wound is filled 100% with eschar. It documents the presence of heavy amount of purulent exudate with a strong odor after cleansing. It also documents the progress of the wound as deteriorating. R3's Wound Documentation from wound physician, dated 9/28/22 documents The pressure ulcer to R3's coccyx measures (L x W x D): 14x 11.5 x Not Measurable cm, Surface Area: 161.00 cm^2 , Odor Exudate: Heavy Purulent Thick adherent devitalized necrotic tissue: 100 % Wound progress: Deteriorate It also documents Recommendations Off-load wound; Reposition per facility protocol; Turn side to side and front to back in bed every 1-2 hours if able; Low air loss mattress; Roho cushion R3's Skin and Wound Eval, dated 9/27/2022, documents an in house acquired unstageable pressure ulcer to R3's coccyx measuring 11.7cmx7.9cm. It also documents the wound is filled 100% with eschar. It documents the presence of a moderate amount of purulent exudate with moderate odor after cleansing. It also documents the progress of the wound as deteriorating. R3's Nursing Note, dated 9/29/2022 at 3:16 PM, documents Note Text: Patient being sent out to (local Hospital) per wound MD for possible [CONDITION(S)] R/T, (related to), wound infection. R3's interact SBAR Summary for Providers, dated 9/29/2022 at 3:56 PM, documents Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Abnormal vital signs (low/high BP, heart rate, respiratory rate, weight change) Other change in condition At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 80/44 - 9/29/2022 15:18 Position: Pulse: P 71 - 9/29/2022 15:18 Pulse Type: Regular RR: R 20.0 - 9/29/2022 15:18, Temp: T 98.4 - 9/29/2022 15:18 Route: Forehead (non-contact) R3's Nursing Note, dated 9/29/2022 at 7:02 PM, documents Note Text: Patient is being admitted to ICU for [CONDITION(S)]. R3's Hospital Infectious disease progress note, dated 10/5/2022, documents [AGE] year-old male with PMH, [CONDITION(S)], HLD, pacemaker placement, AFIB, who was admitted to (Local Hospital) on 9/29/2022 for septic shock. Has large decubitus ulcer that a significant amount of wet gangrene on exam. Went to the OR (operating room) on 9/30 for excision debridement including bone. There was a significant amount of purulence extending down adjacent to the bone. On 10/6/2022 at 2:30 PM requested documentation of education provided to R3 and wife regarding pressure ulcer prevention and or management and documentation of R3's refusal of care. As of 10/12/2022 at 2:05 PM the facility had not provided information. On 10/11/2022 at 3:30 PM requested the Pressure ulcer Prevention Policy. As of 10/13/2022 the facility had not provided the pressure ulcer prevention policy. On 10/5/2022 at 2:15 PM, V5 Licensed Practical Nurse, (LPN), stated that she admitted R3 to the facility. V5 stated, that R2 was quiet. V5 stated, that he was alert. V5 stated, that R3 was cooperative with care. V5 stated, that she is not aware of R3 refusing to turn and reposition. V5 stated, that R3 was weak and like to be in bed. V5 stated, that the staff would get R3 up in the chair for meals and then lay R3 back down in the bed. V5 stated, that she performed a skin assessment of R3 upon admission and stated that the pressure ulcers to R3's buttocks and coccyx were not there. V5 stated, that the area started as a slit and progressed into the necrotic wound. On 10/5/2022 at 11:01 AM V4, Wound Nurse, stated, that she became aware of the area on 9/6/2022. V4 stated, at that time R3 had red discoloration to both right and left buttocks and a necrotic slight on his coccyx. V4 stated, that the areas to R3's buttocks were deep tissue injury. V4 stated, that she notified the physician and received orders. V4 stated, that R3 was to be seen by the wound doctor the following day but was out of the facility. V4 stated, that R3 was seen the following week and the wound doctored began to follow. V4 stated, that she was not sure how R3 obtained the area but thought they were present on admission. V4 stated, that she requested an air loss mattress on 9/6/2022 when first becoming aware of the area. On 10/5/2022 and 11:32 AM V6, Wound Physician, stated, that she seen R3 for the first time on 9/15/2022. V6 stated, at that time he had multiple unstageable necrotic wounds to his buttocks and to his coccyx. V6 stated, that she performed debridement at the bedside on the areas. V6 stated, that the wounds continued to deteriorate. V6 stated, that she requested an [MEDICATION(S)] and R3's [MEDICATION(S)] was low and requested protein supplements. V6 stated, that during a debridement of the wound the wound had a large amount of puss and V6 was sure there was an infection. V6 stated, that at that time she orders [MEDICATION(S)] and a culture. V6 stated, that when the culture came back the [MEDICATION(S)] was not the appropriate drug and then changed the order to [MEDICATION(S)]. When asked how R3 would have obtained the area. V6 stated, it's a pressure ulcer and unrelieved pressure is what caused it. When asked why did the area continue to deteriorate? V6 stated that looking at the logistics. V6 stated, that to have a pressure ulcer you have to have pressure. V6 stated, that I can order all the supplements and medications I want but if the offloading is not occurring the pressure ulcer will not improve and it will continue to deteriorate as in this case. On 10/5/2022 at 12:00 PM V8, Physical Therapist, stated, that she had performed treatment with R3. V8 stated, that R3 was weak and required staff assistance with turning and repositioning. V8 stated, that R3 did refuse therapy at times because he was weak. V8 stated, that during her assessment and treatment she noticed a disconnect with R3. V8 stated, that when giving R3 specific directions R3 could not perform or would perform them different. V8 stated, that an example of this was she requested R3 to kick his feet out of the bed and R3 lifted his feet with his hands and moved his feet. V8 stated, that she put in a request for R3 to be screened by the speech therapist at that time for cognition. V8 stated, that shortly after that R3 went to the hospital and had not returned. On 10/5/2022 at 1:00 PM V7, LPN, stated, that she works at the facility 2x week. V7 stated, that when she works it is on R3's unit and that she did provide care for R3. V7 stated, that R3 was pleasant and cooperative with care. V7 stated, that she is not aware of R3 refusing to reposition. V7 stated, that he did stay in the bed a lot. V7 stated, that R3 was shy but was alert and oriented to 4. V7 stated, that the pressure ulcers to R3's coccyx were necrotic. V7 stated, that when the areas continued to decline R3 was only out of bed for meals and then placed back in bed. On 10/5/2022 at 1:37 PM V3, Assistant Director of Nursing, stated, that he was familiar with R3. V3 stated, that R3 came to the facility from the hospital due to a fall and surgical wounds related to pacemaker placement. V3 stated, that R3 initially presented with a red area and then the area progressed. When asked how R3 got the area, V3 stated, that it is a bedsore and if the pressure is not relieved it, (unrelieved pressure), caused it. When asked if R3 was being turned and repositioned? V3 stated, that he believes so. V3 stated, that R3 did have some problems with therapy, but this was all he was aware of. When asked if R3 could move about the bed independently? V3 stated, that he was not sure. V3 stated, that therapy would be able to answer more accurately. On 10/11/2022 at 12:50 PM V12, CNA, stated, that R3 was quiet. V12 state that R3 rarely used his call light. V12 stated that occasionally R3 would refuse care. V12 stated, that she charted this in the behavior tracking. V12 stated, that R3 wanted to stay in the bed. V12 stated, that R3 was incontinent. V12 stated, that R3 allowed staff to clean him and turn him. V12 stated, that R3 didn't want to get out of bed. On 10/11/1011 at 2:30 PM V2, Director of Nursing, (DON), stated, that R3's pressure ulcers to the coccyx and right and left buttocks occurred at the facility. When asked about the MDS charting areas were there upon admission and staff stating that the areas were there upon admission. V2 stated, that the areas were acquired at the facility. When does it mean when a resident is at moderate risk for pressure injury? V2 stated, that this means the resident is at more risk for obtaining a pressure sore than the normal resident. When asked what interventions would this require? V2 stated, that it depends on the resident and their history and comorbidities. V2 stated, that the turning and repositioning would be more frequent. V2 stated, that skin checks would be performed weekly, boots on feet, dietician review. V2 stated, that the facility obtained on 9/12/2022. V2 stated, that she had reviewed R3's chart. V2 stated, that the multiple necrotic pressure injuries occur at the facility. V2 stated, that she felt that R3 obtained the areas not from lack of care. V2 stated, that she does not have the documentation to prove that. V2 stated, that the facility had a pressure ulcer prevention policy. On 10/12/2022 at 11:53 AM V13, CNA, stated, that she worked with R3 prior to going to the hospital. V13 stated, that R3 was nice and quiet. V13 stated, that R3 refused care occasionally like getting out of the bed. V13 stated, that R3 was in pain and didn't like to move a lot. V13 stated, that this was after R3 got the pressure ulcer to his buttocks. V13 stated, that R3 was alert and confuse. V13 stated, that it would vary. V13 stated, that he was dependent on staff for repositioning and could not turn himself. The facility's Wound Management policy dated January 14, 2014, documents It is the policy of this facility to facilitate residents' independence, promote resident comfort, and preserve resident dignity through an effective wound management program. It also documents A. Pressure Ulcers A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue damage. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Managing Tissue Load: Tissue load will be managed and tissue tolerance to pressure, friction, and shearing forces will be improved. This will be accomplished through the use of appropriate positioning practices, positioning devices, and support surfaces.

Based on observation, interview, and record review, the facility failed to provide supervision and implement effective interventions for 1 of 4 residents (R2) reviewed for falls in the sample of 4. This failure resulted in R2 falling multiple times and sustaining a fracture to the right femur requiring surgical intervention. Finding includes: The Physician's Order Sheet (POS), dated 03/01/21, documented R2 was admitted to the facility with diagnoses of repeated falls, non-traumatic chronic subdural hemorrhage, dementia, Alzheimer's disease, [CONDITION(S)], chronic [CONDITION(S)], heart failure, [CONDITION(S)], obstructive sleep apnea and fracture of the neck of right femur (03/15/21). The Minimum Data Set (MDS), dated [DATE], documented R2 was severely cognitively impaired and required extensive assist of one person for bed mobility, transfers, dressing, toileting, hygiene, and bathing. It's documented R2 was frequently incontinent of bladder and could only stabilize while standing with assist. On 03/30/21 at 12:40 PM, R2 was sitting in a wheelchair in a small room with a television and a bedside table in front of him feeding himself. He was alert, but confused. R2 had an alarmed seat belt attached around his waist. The personal alarm light was lit indicating it was on. V3, Licensed Practical Nurse (LPN) was sitting at the nurse's station behind R2, separated by a partial wall and the nurse's station itself. V3 stated R2 removes his seat belt a lot and the alarm sounds. On 3/30/21, at 2:55 PM, V1, Administrator, V2, Director of Nursing (DON) and V9, Registered Nurse/Unit Manager were observed to demonstrate the alarming seat belt on R2's wheelchair. V9 clipped the belt together after V2 had turned the device on. V9 then pulled the seat belt apart and the alarm sounded. When V2 pulled the cord from the device the alarm did not sound. V1 and V2 stated that R2 was a very fidgety person and moved around a lot and could have dislodged the alarm. V1, V2, and V9 could not answer why the device would not sound if the cord was removed. V1 and V2 could not answer if the alarm not sounding was due to the cord being disconnected, or malfunctioning. The Care Plan, dated 09/25/18, documented R2 was identified as being high risk for falls related to impaired mobility, history of self transferring with calling for assist, reports of feeling unsteady when walking or standing. R2's Care Plan intervention, dated 1/21/19 documented bed alarm. R2's Care Plan Intervention, dated 3/6/19, documented Alarming seat belt placed 2/11/19. R2's Physician's Order, dated 2/11/19 documented R2 was to have alarming seat belt while up in wheelchair. On 02/12/20 at 3:03 PM, a Nurse's Note documented, Writer was notified that resident was observed on the floor in his room while trying to transfer self. He was assessed on the floor, no injury noted at the moment, he denied having pain. He moved all extremities without difficulty. MD's (Medical Doctor) office and the POA (Power of Attorney) were notified about the fall. Neuro checks were started and will continue to monitor. There was no fall investigation presented by the facility. R2's Care Plan was not revised with a progressive intervention to address this fall and to prevent him from having future falls. On 04/13/20 at 3:41 PM, a Nurse's Note documented, Resident was observed on back laying on ground (floor mat) on side of bed. Resident was observed wearing socks. Denies hitting head. Neurological assessment performed. Vitals obtained. When asking resident what happen, resident stated I was trying to get up to make some coffee. Resident was assisted by staff back into bed. The Occurrence Report documented the alarm was not sounding. The Occurrence Report documented the recommendation as check bed alarms q (every) shift to make sure working properly. R2's Occurrence Report, dated 06/23/20 at 10:00 AM, documented, Resident propelling self down the hall and took seatbelt off and stood up and fell on his side. Writer assessed resident he has two skin tears to left hand in-between his thumb, and pointer finger. Resident able to perform ROM (Range of Motion) WNL (Within Normal Limits). The Report documented the following recommendation for this fall Referral to therapy for evaluation. On 6/26/20 at 3:43 AM, a nurse's note documented R2 was found walking in the hallway independently and redirected back to bed. There was no documentation if an alarm was sounding. On 7/23/20 at 7:00 PM, a Nurse's Note documented, Resident found on floor by laying on floor by door. Resident unsure of why he got up when asked by writer. Writer assessed resident no injuries at this time. Resident able to perform ROM WNL. Resident reminded to use call light at all times. MD, and POA called, and Neuro checks initiated. The Occurrence Report, dated 7/23/20, documented no alarm sounded when R2 fell . The Occurrence Report Recommendation documented frequent rounding. There was no documentation on R2's Care Plan that the facility revised this care plan with progressive interventions after R2 fell on [DATE]. On 2/3/21 at 3:34 AM, a Nurse's Note documented, Resident found sitting on his bottom in the room's doorway, on the floor. Bed alarm on but not sounding. Assessed resident. Staff helped resident into wheelchair. Bruise noted to left forehead area. MD, and POA notified. Fall, and Neuro checks in place. The fall investigation documented R2's alarm was not sounding, and the bed alarm was replaced. R2's Care Plan Intervention, dated 2/3/21, documented that R2's bed alarm was replaced. On 03/15/21 at 7:20 PM, a Nurse's Note documented, Writer was notified by housekeeping staff that resident was on the floor, upon assessment resident observed sitting on his buttocks with back against the door of the 400 hall common area. Alarm wasn't sounding. I immediately noticed his right leg was inverted inward and he was complaining of pain to right hip/leg. I also observed a dime sized abrasion to left side of his head, with a small amount of blood coming from it. Nurse's note documented R2 was sent to the emergency department via ambulance with the diagnosis of fracture of the right femoral neck. R2's Hospital Record, dated 3/16/21 documented R2 had a fall and sustained a right femoral fracture. The Hospital Record documented Plan for pinning of the right femoral neck fracture today (3/16). The bed and seat belt chair alarm checks were reviewed for the months of February, and March 2021. There were multiple days with missing documentation of the alarms not signed off as being checked per shift as ordered. On 03/19/21 and 03/21/21, the self releasing alarm was documented as being checked and functioning when the resident was still in the hospital. R2's Care Plan, revision date 3/30/21, documented (R2) disassembles his alarms at times due to constant fidgeting. On 03/30/21 at 10:20 AM, V1, Administrator stated R2 had a history of falls and recently fell and fractured a hip. V1 stated he was a confused resident and required full assistance with Activities of Daily Living. V1 stated R2 can propel himself in his wheelchair and liked to keep a blanket up over his head most of the time. V1 stated R2 cannot answer questions appropriately and was confused most of the time. V1 stated R2 had fallen in the past with no injury and had multiple interventions in place at the time of this last fall. V1 continually stated that on 03/15/21, the alarm had been heard by multiple staff sounding due to R2 continuously removing the seat belt. On 03/30/21 at 10:30 AM, V2, Director of Nurse's (DON) stated R2 was always a busy body and would propel himself everywhere in the facility. V2 stated R2 was confused and could not let his needs be known at times. She stated that R2 had several interventions in place for falls. On 03/30/21 at 12:40 PM, V3, Licensed Practical Nurse (LPN) stated she did not have R2 on her hall currently, but knew he was very active while up in his chair. V3 stated staff try to keep an eye on him as much as possible. V3 stated R2 does undo the seat belt often and the alarm sounds. On 03/30/21 at 2:55 PM, V9, Registered Nurse (RN) stated R2 was always propelling self about the facility and liked to go into other's rooms at times. She stated R2 was known to remove the seat belt and it always sounded. On 03/31/21 at 10:05 AM, V6, Certified Nursing Assistant (CNA) stated on 03/15/21 at the time R2 fell , she was in another resident's room giving a bed bath. She did not witness the fall. She stated that R2 was acting his usual self that evening before the fall. V6 stated R2 sometimes gets anxious and propels fast down the halls and runs into things and people and goes into other resident's rooms. V6 stated about 45 minutes to 1 hour before the fall she toileted R2 and put him back into his wheelchair. V6 stated she was told R2 was down on the floor by the library. She stated there were no staff down there when he fell . V6 stated during that time of the night, staff are very busy with putting residents to bed. She stated that night they were short staffed. She stated they normally have 2-3 CNA's and one nurse on the evening shift and that night they only had 2 CNA's. She believed the other CNA was on break at the time of the fall. She stated R2 plays a lot with the seat belt, but she stated she had not seen or heard it not alarm. She stated R2 needed one on one more often, but they don't have the staff to do that. She stated R2 will sometimes fall asleep in the chair and they will lay him down, but he will sometimes try to get out of bed afterwards. She stated R2 needed more supervision at times, but that was impossible with the amount of staff they have on most shifts. She stated R2 cannot use a call light due to his cognitive deficit. On 04/01/21 at 2:00 PM, V8, RN stated she had only worked with R2 after he returned from the hospital with the fractured hip. She stated R2 tries to get up/stand up all the time. She stated R2 removed the seat belt a lot. She stated it was physically impossible for staff to watch R2 at all times. V8 stated when R2 is up in the wheelchair he is all over the place. V8 stated staff will try to keep him in their field of view, but they can't watch him at all times. V8 stated R2 would benefit from one on one from staff, but they do not have the staff to do that. She stated she had not heard or seen R2's alarm fail. She stated R2 does not use his call light due to his cognitive deficits. The manufacturer's guidelines titled, (Proper Name of Seatbelt) Alarmed Velcro Seatbelt Installation Instructions was reviewed. It documented The alarm box features a fail-safe circuit. In the event that the cord is accidentally removed while the unit is on, the alarm will sound. The manufacturer's guidelines titled, Drive Sensor Basic Alarm: Tamper-proof chair and bed patient alarm - Item # was reviewed. It documented This device is not a substitute for routine visual monitoring of patients. It will not prevent falls. Staff must make frequent routine visual inspections to ensure sensor pad is properly placed and alarm unit is powered on. Use of alarm unit may not be suitable for all High risk patients. Other safety measures may still be necessary to ensure patient safety. The policy and procedure titled, Fall Prevention - Steady Steps, revision date 2/17/2020, was reviewed. It documented under policy It is the policy of the facility to provide each resident with an appropriate assessment and intervention to prevent falls and to minimize complications if a fall occurs. Under Fall Prevention it documented, Residents identified as at risk for falls, will have clinically appropriate interventions put into place to reduce the risk for falls and/or to prevent recurrence of falls.

Based on observation, interview, and record review, the facility failed to provide adequate supervision, and implement progressive interventions to prevent falls for 1 of 4 residents (R2) reviewed for falls in the sample of 4. This failure resulted in R2 falling and requiring emergency medical care for a laceration to her nose, and fractured nasal bone. Findings include: R2's Electronic Medical Record (EMR) dated 3/11/21 documents R2's diagnosis includes, Dementia, Hypertension (HTN), Anxiety, Heart Failure, [CONDITION(S)] (CVA), Fractured Nasal Bones. R2's Minimum Data Set (MDS). Dated 2/9/2021, documents R2 has severely impaired cognition. R2 requires extensive assist of 2 for transfers. R2's MDS documents she has poor balance and is only able to stabilize with staff assistance when moving from seated to standing position, walking, turning around, moving on and off toilet, and during surface to surface transfers R2's Care Plan Focus, initiated 8/2/20, documents R2 has risk for falls related to (r/t) Impaired Mobility, takes medications that could have adverse reactions that could interfere with her safety, heart failure, and history of self-transferring. The facility initiated the following interventions on the following dates to address R2's fall risk: 8/20/20, anti- rollbacks to be placed on (wheelchair (w/c) to prevent rolling; 10/28/20, Placement of non-skid in front of toilet and bed. Offer assist to toilet before bed; 11/8/20, Occupational Therapy (OT) to evaluate for recliner safety; 1/3/21 staff to make sure she is wearing appropriate footwear when ambulating or transferring; Stop light program initiated; 1/4/21 Place concave mattress on bed; and 1/5/21 Begin frequent rounds on all shifts. The Care Plan Intervention dated 1/5/21 did not document how often frequent rounds should be conducted on all shifts to monitor R2. R2's Progress Note, dated 2/3/21 6:16 PM documented that a Certified Nurse's Aide (CNA) was passing by R2's room and saw R2 lying on the floor in front of the refrigerator. The Note documented R2 sustained a skin tear to her right 1st finger and right elbow. R2's Care Plan Intervention, initiation date of 2/4/21, documented Request schedule pain medications for adequate pain control along with PRN (as needed) for breakthrough pain. R2's Progress Note, date 2/15/2021 at 1:40 PM documents Resident very tearful & (and) fretful all of this shift. Resident attempting to transfer self out of recliner & onto toilet by self. The note documented that 1:1's provided for positive reinforcement and reassurance. R2's Progress Notes dated 2/15/21 at 9:30 PM documents Resident heard yelling, writer went to check on resident. Resident was laying on the floor next to dresser on the wall across from bed on her back with her head towards the door. Resident assessed while on the floor, and left leg was rotated inwards. Writer went and got another nurse to assess resident with the same conclusion. Resident covered up and pillow placed under head. (R2)'s medical doctor office called to update and get orders to send to emergency room (ER) for evaluation and x-ray's [sic]. (Power of Attorney/(POA) called and notified of fall. POA had concerns about sending resident to hospital because previous hospital visit. Hospice called and notified of fall and wanting resident sent to (ER) for x-ray's [sic] and evaluation. Ok given to send and be treated plus admitted if need be. Ambulance Service called to transport to (local hospital). R2's Progress Notes dated 2/16/21 at 6:15 AM document, Resident returned to facility per Ambulance Service back to room, falls with neuro checks continued. Resident changed and made comfortable, call light in reach. Will continue to monitor safety and needs. R2's Care Plan, revised on 2/17/21 documented Continues to attempt self-transfers/ambulation without calling for assist. The Care Plan interventions to address this fall documented the facility would obtain a UA (urinalysis) and labs). The Care Plan did not address how staff were going to monitor R2 for attempting to self-transfer/ambulation. R2's Progress Note, dated 2/19/21, documented Begin frequent round on all shifts to monitor for safety. Every 3 hours for increased falls initial rounding sheet in room q (every) 3 (hours). This intervention was not added to R2's Care Plan. R2's Progress notes dated 2/22/2021 at 7:49 AM, documented Writer alerted by staff at 3:55 AM that resident was bleeding on the floor in her room. Resident assessed had a large hematoma on her forehead and a bleeding laceration across her nose. Ambulance was called at 0400 (4:00 AM) to transport resident to Local Hospital to be evaluated and treated. POA and Hospice Nurse both notified. R2's Progress notes dated, 2/22/2021 at 8:39 AM document, Resident returned to facility per facility transport van. Resident noted to have bruising to nose, forehead hematoma & bruising to the right side of the hematoma, bilateral eyes above and below. Resident complains of (c/o) pain. [MEDICATION(S)] given for c/o. pain. R2's X-Ray Report from ER visit on 2/22/21 documents include, The images demonstrate a new acute nasal bone fracture with overlying soft tissue swelling. New right frontal soft tissue swelling. R2's Progress Note, dated 2/22/21 at 10:22 PM documented Hospice company to order floor mats, new mattress and chair/bed alarm. R2's Care Plan Interventions, initiated on 2/22/21, documented Allow for essential caregiver visits with daughter. The Care Plan Interventions, initiated on 2/23/21 documented Hospice was consulted re (regarding) alarm and floor mats. R2's [MEDICATION(S)] Steady Steps Fall Management Program dated 2/23/21 documents, Keep at nurse's station when not in bed or during cares provided by staff. The Interdisciplinary Team (IDT) Note, dated 3/4/21, documented IDT met to discuss fall interventions placed. Continued current interventions and follow up as needed. R2's Progress notes dated 3/7/21 at 1:40 PM document, Resident observed sitting on floor of bathroom. Floor was wet. Resident's pants noted to be soiled. Wheelchair was positioned behind resident in doorway. Hospice, and POA notified. No injuries noted. R2's Post Incident Evaluation Form, dated 3/7/21, documented R2 was attempting to self-transfer to the toilet. The Incident Evaluation did not document why R2 was in her wheelchair alone in her room. On 3/9/21 at 3:25 PM, R2 is in her wheelchair in her room. R2 had bruising and a hematoma to her forehead, both eyes were bruised, and her right and left cheeks were bruised. R2's bridge of nose had an opened dried laceration. A Red Traffic Light sign was on her wheelchair. There was no chair alarm on her wheelchair and there was no mat on the floor next to her bed. On 3/9/21 at 3:25 PM, V3 Registered Nurse (RN) Nurse Manager states, The alarm and floor mat need to come from Hospice and they have been notified. On 3/11/21 at 10:00 AM, V1 Administrator and V2 Director of Nurses (DON) both stated they did not know why R2 did not have her alarm on or bedside mat on the floor. On 3/11/21at 11:00 AM, R2 had no alarm on her bed and has no bedside mat on the floor. R2 was sleeping in her bed. On 3/11/21 at 11:10 AM, V9 Licensed Practical Nurse (LPN) stated, (R2) is supposed to have a chair alarm. I don't know why she doesn't. Still waiting on hospice to bring it in. On 3/11/21 at 2:38 PM, V13 Hospice Patient Care Manager stated, When the Hospice Nurse requested the alarm for (R2), (V13) had called the facility to make sure the facility uses alarms because some facilities do not. She left a message with (V1) the Administrator and with (V3) the Nurse Manager because neither one answered the phone call. No one got back to her. She called (V3) on 2/22/21 and left a message. She called (V1) on 2/25/21 and left a message. To this day no one has called her back. On 3/11/21 at 2:42 PM, V14 Hospice Nurse stated, I went to the facility to see (R2) when she got back from theER on [DATE]. I suggested an alarm and a mat for the floor. I contacted my boss (V13) (Patient Care Manager) I was told we needed to get approval from the facility for the chair/bed alarm because it is considered a restraint. My manager left a message with (V1) the Administrator and with (V3) the Nurse Manager and she has never heard anything back from them. The Facility's Fall Prevention-Steady Steps Policy, with revision date of 2/17/20 documents, Policy: It is the policy of this facility to provide each resident with an appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Additionally, all resident falls in this community are analyzed and trended through the Quality Assurance/Performance Improvement (QAPI) process to determine if additional measures are required by the community to decrease falls including but not limited to Performance Improvement Project. The Policy documents Fall Prevention: Residents identified as at risk for falls, will have clinically appropriate interventions put into place to reduce the risk for falls and/or to prevent recurrence of falls. The Interdisciplinary Team will review and modify the fall risk prevention plan of care at a minimum of quarterly, after each fall, and as clinically indicated. Interventions for the fall prevention plan will be modified following the interdisciplinary review and changes will be made to the plan of care accordingly. Fall Risk Analysis Intervention Tool will be completed on Admission/Readmission and a change in condition that could potentially affect the resident's fall risk by the Interdisciplinary Team. The Policy documented the following under the section Red Light Protocol: The Red Light Protocol is a community-based portion of the Fall Management-Steady Steps Program. The Purpose: To assist in identifying resident who are at the highest risk for falling. To ensure residents will benefit from participation. To distinguish residents with a visual identifier Traffic Light. To include staff and families in fall prevention strategies. Protocol: A resident qualifies for the Red Light Program if they are identified to be at highest risk for falls. The resident is placed in the program at the discretion of the Interdisciplinary Team. A Traffic Light is placed on the resident's room nameplate/door frame, bed, and various appliances-wheelchair, walker. etc. to indicate the resident is part of the Red Light Program. The Policy documents under the Section POST FALL INTERVENTION documents Attempt to determine appropriate fall intervention(s) and implement as soon as possible after the fall. Utilize the Patient Centered Intervention Tool to assist in determining potential interventions with input from appropriate associates. The resident will be screened by the Rehab Department after each fall. Care Plan will be reviewed and revised with additional/modified fall interventions as indicated.

Based on observation, interview, and record review the facility failed to provide supervision to prevent falls, failed to assess for root cause analysis of falls and implement interventions based on this assessment for 3 of 13 residents (R125, R127, R142) reviewed for falls in the sample of 46. This failure resulted in R125 falling and sustaining a fractured distal fibula (one of two bones that support the ankle joint). Findings include: 1. R125's Admission Record, dated 08/01/19, documents R125 was admitted on [DATE] with [DIAGNOSES REDACTED]. R125's Fall Risk Assessment Tool, dated 07/01/19, documents that R125's Fall Risk Score was 4, indicating R125 was at high risk for falling. R125's Fall Risk Questionnaire, dated 07/01/19, documents R125 documents that R125 stated that her knees give out on her and that she gets dizzy sometimes. R125's Care Plan, under the at risk for falls section, with an initiation date of 07/01/19, has an intervention which states, Be sure call light is within reach and encourage to use it for assistance as needed. Needs prompt response to all requests for assistance. There is no intervention in this Care Plan which details, in any way, how direct care staff members should attend to, or supervise, R125 while she is on the toilet, even with her statements about her knees giving out and her tendency to get dizzy within R125's initial Fall Risk Questionnaire dated 07/01/19. R125's Minimum Data Set (MDS), dated [DATE], documents R125's Brief Interview of Mental Status (BIMS) score is 15, meaning R125 is cognitively intact. This MDS documents R125 requires extensive assistance of 2 staff members for bed mobility, transfers, locomotion on the unit, locomotion off the unit, and toilet use. The MDS also documents that R125 requires supervision with support of 1 staff member for walking in her room. Regarding balance status, the MDS documents R125 is not steady and is only able to stabilize with staff assistance when moving from seated to standing position, when moving on, and off the toilet, and during a transfer between bed and chair or wheelchair. R125's Progress Notes, dated 07/08/19, states that resident is educated about her increased risk for dehydration due to her [MEDICAL CONDITION] and that common side effects of dehydration include increased weakness and dizziness. R125's Progress Notes, written by V15, Licensed Practical Nurse (LPN), dated 07/09/2019 at 5:35 PM, documents, CNA (Certified Nurse's Aide) yelled for writer to come to resident's rm (room). Upon entering residents bathroom noted resident lying on her left side with her head in the shower and legs outstretched in front of her in front of toilet. Non-skid socks noted on feet. CNA stated she just came back into the room as resident stood up and couldn't get to her before she fell . Resident stated she stood up to pull up her pants and her left leg gave out on her and she fell . Resident assessed for injury. This note continues, new orders received to obtain 2 view x-ray of (left) foot. The facility's Incident/Accident Report, dated 07/15/2019, documents that R125's fell on [DATE] in front of her toilet in her bathroom. The report states that upon being assisted up R125 complained of pain to the top of her left foot upon weight bearing. The report continues, stating that X-ray results showed a [MEDICAL CONDITION] fibula without significant displacement and an appointment to a local orthopedic clinic was ordered. On 08/01/2019, at 10:16 AM, V15, Licensed Practical Nurse, stated that V24, CNA, called to V15 at the time of R125's fall and told her that she had helped R125 to the toilet, but went out of R125's room to help another resident. V15 stated that when V24 came back into R125's room, she saw R125 trying to get up on her own from the toilet. V15 stated that R125 fell before V24 could get to her. On 08/01/19, at 11:19 AM, V2, Director of Nurses, stated that the facility does not have a policy on attending to residents in bathroom if they are independent. V2 stated that V24 is no longer employed at the facility. V2 stated that in writing the facility's incident report, she just relied on R125's verbal description of the incident, which was that V24 was in the room when R125 fell but just turned around to give R125's privacy while toileting. R125's Progress Notes, dated 07/10/2019, document that R125 slipped out of her wheel chair while being transported, from an orthopedic appointment, back to the facility in the facility's transport van. On 08/01/2019, at 10:15 AM, V2 stated that R125 did not have her seat belt on when she slipped out of her wheel chair in the van. She stated that she did not have a CNA attending her when this happened. V2 also stated that the facility does not have a van policy, or a policy related to wearing a seat belt, or restraining device, during transport within the facility's van. R125's Post Fall Analysis & Intervention Tool, dated 07/11/2019, documents, under the Predisposing Environmental Factors, that there were other factors; however, there is no explanation anywhere in this report what is meant by 'other'. This report even has an Other Info section but there is no documentation at all in this 'other' section. This report has no information about R125 not having a seat belt on when she slipped out of her wheel chair during this transport. This report does state that R125 did not have any injuries related to this fall. 2. R127's Admission Record, dated (MONTH) 30,2019, documents R127 was admitted on [DATE] with [DIAGNOSES REDACTED]. R127's MAHC 10 (Fall Risk Assessment Tool), dated 4/29/19, documents R127's Fall Risk Score is a 7 indicating a High Risk for Fall. R127's MAHC 10 (Fall Risk Assessment Tool), dated 6/20/19, documents R127's Fall Risk Score is an 8 indicating a High Risk for Fall. R127's Minimum Data Set (MDS), dated [DATE], documents R127 was admitted [DATE]. This MDS documents R127 has a Brief Interview of Mental Status of 8 indicating R127 is moderately cognitively impaired. The MDS documents R127 has no hallucinations, delusions, behaviors or rejection of care. This MDS documents requires limited assistance of 1 staff member for bed mobility, walking in room, locomotion on unit. The MDS documents R127 requires extensive assistance of 1 staff member for transfer, dressing and personal hygiene. This MDS documents R127 requires extensive assistance of 2 for toileting. The MDS documents R127 is not steady, only able to stabilize with staff for moving from seated to standing position, walking, turning around and facing the opposite direction while walking, moving on and off the toilet and surface to surface transfer. The MDS documents R127 may use a walker or a wheelchair. The MDS documents R127 is frequently incontinent. The MDS does not document that R127 uses a trunk restraint. R127's MDS, dated [DATE], documents R127 has a Brief Interview of Mental Status of 7 indicating R127 is severely cognitively impaired. The MDS documents requires extensive assistance of 1 staff member for bed mobility, transfers, locomotion on and off unit, toileting and personal hygiene. This MDS documents R127 is not steady, only able to stabilize with staff for moving from seated to standing position, walking, turning around and facing the opposite direction while walking, moving on and off the toilet and surface to surface transfer. The MDS documents R127 may use a walker or a wheelchair. The MDS documents R127 is frequently incontinent of urine and bowel. R127's Nurses Note, dated 5/7/2019 22:00, documents in part, CNA (Certified Nurse Aide) observed resident in her room sitting on the floor in front of her wheelchair with her feet straight out. Resident stated, 'I hope the boys are doing the right thing and that there is no trouble with (V8) outside. And I need a drink.' VS (vital signs) and full body check done. Full ROM (range of motion) and neuro (neurological) checks WNL (within normal limits). No complaints of pain or discomfort from resident at this time. No complaints voiced. R127's Care Plan, undated, documents, in part, Focus: (R127's) is a high risk for falls related to:[MEDICAL CONDITION] LT (left) sided weakness. Interventions/Tasks: 5/8/2019 keep in common areas while in w/c (wheelchair). R127's Nursing Note, dated 5/16/2019 04:54, documents in part, resident sitting in her wheelchair at nursing desk. she is very confused and fidgety. she worked her way to the front of her wheelchair and slid out onto the floor onto her buttocks. no changes in cognition. denies pain. assisted back into wheelchair with 2 assist. initial b/p (blood pressure) 181/89, pulse 70, temp (temperature) 97.2, respirations 18. follow up b/p 155/92 with pulse 77. R127's Post Fall Analysis & Intervention Tool, dated 5/16/2019, documents, Discussion of Event: Guest had been restless in bed until she got up to toilet at 3:00 AM and declined to go back to bed. Was sitting at nurses' station with nurse. Very restless and repeatedly scooting self to edge of w/c. repositioned numerous times. Guest finally wiggled self out of w/c and slid to floor witnessed by nurse. Root Cause Analysis/ Impression: Scooted self out of w/c due to confusion/ disease process. Problem List: scooted self out of chair. Individualized Intervention: [MEDICATION NAME] for sleep, non-skid in recliner. R127's IDT (Intradisciplinary Team) Note, dated 5/16/2019 13:19, documents, IDT met to discuss incident. New interventions put in place for anti-skid to his wheelchair. Will also contact MD (medical doctor) and inquire about adding [MEDICATION NAME] due to not sleeping well at night. R127's Physician Order, dated 5/17/2019, documents, in part, [MEDICATION NAME] Tablet 3 mg (milligram) by mouth 1 tablet PRN (as needed) every 24 hours. Indication for use: restless. R127's Post Fall Analysis & Intervention Tool, dated 6/17/2019, documents, [AGE] year old female resident found in floor of room. Resident unable to give description of the event. Prior to event resident was in bed sleeping. Root Cause Analysis/ Impression: confusion/ disease process. Resident self transferred in night and fell . Problem List: Restless. Individualized Intervention: Request to schedule [MEDICATION NAME] from PRN (as needed). Beveled mats. R127's Nurses Note, dated 6/18/2019 12:12, documents, in part, Writer spoke with (V9 nurse Practitioner) regarding PRN [MEDICATION NAME]. Requesting scheduled due to recent fall while up in middle of night. New orders received as follows: [MEDICATION NAME] 3mg PO (by mouth) Q (every) HS (hour of sleep) for inability to sleep. R127's Nurses Note, dated 6/20/2019 12:10, documents, in part, Staff notified that resident had fallen out of her wheelchair, in the dining room. Upon arriving at the table, resident was found laying on her left side with the wheelchair lying on top of the resident, resident's head hit another resident's wheelchair. When nurse assessed resident there were no injuries, redness or bruising at this time. Resident was confused but this is her baseline mentation. Resident, when asked what happened she was unable to tell us what happened. VS taken and they were elevated but resident was quite riled up, the second set of vital signs started coming down. R127's Post Fall Analysis & Intervention Tool, dated 6/21/2019, documents, Root Cause Analysis/ Impression: Resident fell from wheelchair while in common dining area waiting to eat. confused at baseline. Attempts to self transfer frequently. Problem List: w/c tipped over. Individualized Intervention: Anti-tippers to wheelchair. R127's Nurse Note, dated 6/21/2019 05:27, documents, in part, Resident was sitting in the hallway outside of 318. She repeatedly kept leaning over in her wheelchair, I asked her to sit back. After asking her to sit back for the 3rd time resident leaned too far and fell out of the wheelchair on to her left side. No injuries, no complaints of pain. R127's Post Fall Analysis & Intervention Tool, dated 6/21/19, documents Root Cause Analysis/Impression: confusion/disease process leaned forward in wheelchair and fell forward. Problem List: leaning too far forward in her w/c. Individualized Interventions: Alarming seat belt to wheelchair. On 7/30/19 at 1:14 PM, V2 stated, I don't know what else we could do but put a seatbelt on her to keep her from falling. The other interventions didn't work. On 7/30/19, at 2:55 PM, V1 Administrator, stated we do a fall risk evaluation after every fall. On 7/31/19 at 1:30 PM, V2 stated I am sure the nurses were doing other interventions, but it was not charted. We determined in team meeting that a seat belt was the best way to keep her from continuing to fall because she is confused, has delusions and has a [MEDICAL CONDITION]. The facility's fall Prevention - Steady Steps policy, dated 3/1/19, stated that it is their policy to provide each resident with an appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. in the Fall Prevention section it documents Residents identified as at frisk for falls, will have clinically appropriate interventions put into place to reduce the risk of falls and/or prevent recurrence of falls. The interdisciplinary Team will review and modify the fall risk prevention plan of care at a minimum of quarterly, after each fall, and as clinically indicated. Interventions for the fall prevention plan will be modified following the interdisciplinary review and changes will be made to the plan of care. The policy continues under Post Fall Intervention: Attempt to determine appropriate fall interventions and implement as soon as possible after the fall. Utilize the Patient Centered Intervention Tool to assist in determining potential interventions with input from appropriate associates. Post Fall Analysis will be completed by the Interdisciplinary Team. The resident will be screen by the Rehab Department after each fall. Care Plan will be reviewed and revised with additional/Modified fall interventions as indicated. 3. R142's Care Plan dated 10/4/16, revised 7/4/19 documents Resident is high risk for falls related to Gait/balance problems, Diabetes, [MEDICAL CONDITION]. Has decreased safety awareness and takes medication that could have adverse reaction and family has reported she is legally blind in left eye. 8/15/18 resident was noted to self-transfer and ambulate without calling for assist. 12/7/18 resident was noted to self-transfer and ambulate without calling for assist. The Care Plan Interventions documented Nonskid strips next to bed on floor. 7/11/19 therapy to eval for appropriate wheelchair (w/c) and proper w/c positioning, 8/16/18 Resident to be toileted as immediately upon arising in am for evacuation of bowels. Antibiotic recently changed to cover urinary tract infection [MEDICAL CONDITION] bacteria resistance, * Be sure call light is within reach and encourage To use it for assistance as needed. Needs prompt response to all requests for assistance. Ensure wearing appropriate footwear when ambulating or mobilizing walker. Keep furniture in locked position. Keep needed items, water, etc., in reach. Maintain a clear pathway in room, free of obstacles. On 07/29/19 at 10:55 AM, V23, R142's Daughter, stated, (R142) has had falls on, 5/31/19 and 7/10/19. V23 stated, The fall on the 10th, Mom had just gotten out of the hospital and was very weak, she was on the 500 hall, the CNA (unknown) left her unattended in her wheelchair in the doorway while she went to answer someone's call light. My Mom did not have her call light she was left in the doorway. My Mom fell hard, she had 2 black eyes and a hematoma on her forehead, she had to go to the emergency room (ER) and came back to the facility the next morning. R142's Progress notes dated 7/10/19 documents in part, Writer was called to resident's room by CNA. Writer found Resident laying face down in door way. Resident was visually assessed and appeared to be in pain. Vitals taken and doctor and daughter notified. Writer received orders to send resident to emergency room (ER) for Evaluation and treatment related to (r/t) head injury due to fall. R142's Post Analysis & Intervention Tool, dated 7/11/19, documents Root Cause Analysis/Impression fell forward out of wheelchair, secondary to poor core strength. R142's Hospital Computed [NAME]ography Scan (CT) Head Impression, dated 7/10/19 documents There is a hematoma of the frontal scalp just right of midline. B. Based on observation, interview and record review the facility failed to safely transfer residents using a full mechanical lift for 2 of 2 residents (R23, R44) reviewed for full mechanical lift transfers in the sample of 46. Findings include: 1. On 07/30/19 9:41 AM, V20 Certified Nurse Aide (CNA) and V21 CNA were transferring R44 using a full mechanical lift. R44 was sitting in a high back wheelchair, V20 and V21 attached the machine to the sling and raised her above the chair, moved her over and checked the straps between the chair and the bed above the floor, then over to the bed and lowered her down into the bed. V20 and V21 did not lock R44's high back wheelchair prior to the transfer. 2. On 07/30/19 10:45 AM, V20 and V21 were transferring R23 using a full mechanical lift. R23 was sitting in a high back wheelchair, V20 and V21 attached the machine to the sling and raised her above the chair, moved her over and checked the straps between the chair and the bed above the floor, then over to the bed and lowered her down into the bed. V20 and V21 did not lock R23's high back wheelchair prior to the transfer. On 8/1/19 at 2:50 PM, V2 stated, I would expect the brakes on the wheelchair to be locked prior to transferring a resident with a mechanical lift. The User Manual for the full mechanical lift, not dated, documents in part, Using the Sling WARNING: If the patient is in a wheelchair, secure the wheel locks in place to prevent the chair from moving forwards or backwards. When elevated a few inches off the surface of the stationary object (wheelchair, commode or bed) and before moving a patient, check again to make sure the sling is properly connected to the hooks of the hanger bar. If any attachments are not properly in place, lower the patient back onto the stationary object (wheelchair, commode or bed) and correct this problem.

Based on interviews, and record review, the facility failed to prevent an avoidable incident from occurring, failed to provide adequate supervision and appropriate use of a mechanical lift to ensure safety for 3 of 3 residents (R3, R4 and R5) reviewed for falls/incidents in a sample of 5. This failure resulted in a fall from a mechanical lift, with an avulsion to the leg requiring medical evaluation/treatment for [REDACTED]. Findings include: 1. Electronic Health Record (EHR) Progress notes dated 6/1/19 entered by V3 Licensed Practical Nurse (LPN) document R3's orders on admission from the hospital included special instructions for a full body mechanical lift. A Physical Therapy Daily Treatment Note dated 6/19/19 written by V7 Physical Therapy Assistant (PTA) documents PT (patient) performed sit to stands with minimum to maximum assist and was sometimes unable to complete sit to stands. Writer encouraged pt. bringing her feet back among other suggestions throughout session, however pt. unwilling to listen or attempt suggestions. Pt requested to be changed to a sit to stand machine from a (full body mechanical lift) and request writer put her back to bed with sit to stand machine. Writer agreed to assess safety. Pt safe with sit to stand, plan on changing pts transfer status to sit to stand machine. The Occupational Therapy (OT) Daily Treatment Note dated 6/19/19 entered by V8, Certified Occupational Therapy Assistant (COTA) also documents R3 demonstrates good safety on the sit to stand with machine. Provided education for staff on proper positioning of the patient in the power chair during the sit to stand lift transfer. Progress notes dated 6/20/19 at 6:15pm entered by V6, LPN documents CNA (certified Nurse aide) V4 and V5 - here with instructor (V9), came from the room and states that resident was being transferred per the sit to stand and her knees buckled during the transfer. Resident started to shift her body to the right and her feet went out from underneath her. She was holding on to the handles of the sit to stand when this happened. V4 was also behind her and was holding on to her. V4 then positioned herself underneath the resident. They lowered the rails of the sit to stand to be able to remove the sling off the sit to stand. They then 2 person assisted her to the bed. They noticed a laceration on her left lower leg that was bleeding. The note documented the physician was notified and orders were received to send R3 to the emergency department (ED) for evaluation of the laceration of the leg. The progress notes also document R3 sustained a bruise right upper and lower arm in the incident. ED notes dated 6/20/19 documents 8cm L-shaped wound to the anterior lateral left lower leg which is predominately a skin avulsion to the superior portion and a skin tear to the inferior. The ED note also documents R3 to have bruising to the right upper arm which she reports as minimally tender. Treatment orders were given for wound care with the steri-strips to remain until they fell off. The Drugs.com Medical Dictionary describes an avulsion wound as a wound that happens when skin is torn from your body during an accident or other injury. The torn skin may be lost or too damaged to be repaired; A wound of this type cannot be stitched closed because there is tissue missing. The Sharecare.com site describes it as a serious soft-tissue injury often damages deeper tissue, causing significant bleeding. A facility Skin and Wound Evaluation dated 6/20/19 at 11:15pm documents R3's right lower leg wound as measuring 11.5cm x 4.1 cm x 3.5cm with non-attached edges: edges appeared as a cliff. A Skin tear or Bruise Investigation completed by the facility dated 6/21/19 documents R3's predisposing physiological factors include gait imbalance but fails to identify the root cause of R3's fall during a transfer and put forth recommendations so the incident did not occur again. On 7/3/19 at 8:45am, V1 Administrator stated R3 was being transferred by a facility employed CNA and a CNA here for recertification when the incident occurred. V1 stated they didn't identify it as a fall but as a laceration/skin tear and didn't report it because although R3 went to the emergency department, only steri-strips were applied. V1 confirmed the CNA instructor was standing in the hallway with the door closed. To her understanding when the incident occurred and didn't hear anything going on at the time. The manufacturers booklet entitled Stand Up Patient Lift documents under Using the sling for stand assist slings, the belt MUST be snug, but comfortable on the patient, otherwise the patient can slide out of the sling during transfer, possibly causing injury. It documents Transfer Slings - Before lifting the patient, make sure the bottom edge of the transfer sling is at the base of the spine and the patient's arms are outside the transfer sling. The booklet documents under lifting the patient - before lifting a patient from a stationary object (wheelchair, commode or bed), slightly raise the patient off the stationary object and check that all sling attachments are secure. If any attachment is not correct, lower the patient and correct the problem, then raise the patient and check again. Under Warnings in the booklet, it documents again Before lifting the patient, make sure the bottom edge of the transfer sling is at the base of the spine and the patient's arms are outside the sling. The booklet documents staff are to ensure the patient's knees are secure against the knee pad and the feet are properly positioned on the foot plate instructing the patient to lean back into the standing or transfer sling. The facility's policy/procedure entitled Mechanical Lift Transfers dated 7/8/16 documents under Sit to Stands, Apply harness around the resident's waist and secure. Assure the resident arms are on the outside of the harness with the front strap at or just below the sternum. On 7/5/19 at 1:10pm, V9 CNA Instructor stated he had a student, V5, who was with a facility employed CNA in R3's room doing the transfer with a sit to stand mechanical lift while he was standing outside the door. V9 stated R3 was anxious because she had been asking to go to bed for quite some time and the CNA's were still in the dining room assisting others with their meals at the time. V9 stated he heard the fall but it wasn't like a big boom or anything and when he opened the door, R3 was already on the bed and there was blood all over. V9 stated he went and got the nurse, V6 LPN to came to assess R3's leg. V9 estimated the wound as about a 4-inch skin tear on her left lower leg. When asked about whether the sling was applied appropriately to R3 prior to the fall, V9 stated yes, as he was looking through a crack in the door. When asked how this incident could happen if the sling was properly applied and her feet positioned accordingly, V9 stated he thought her foot must have slipped off the platform during the transfer. V9 stated he thought they should have used a full body mechanical lift at the time because he didn't think R3 was ready for the sit to stand lift transfer but was informed by V6, LPN, that R3 had been released by Physical Therapy to use it so that's what the CNA's did. V9 stated after telling the nurse, V6, what happened, he started to clean up all the blood the CNA's had tracked through. On 7/5/19 at 2:09pm, V6 recalled the evening of R3's fall and stated she never had a conversation with V9 regarding using a full body mechanical lift instead of the sit to stand and that R9 stood in the hallway with the door closed during the time the CNA's were transferring R3. V6 stated R3 had been cleared the day before to use the sit to stand and the sign behind her door had been changed to reflect that earlier in the day. V6 stated R3 was upset at the time of the transfer because she was wanting to go to bed and the CNA's were still in the dining room assisting with meals. On 7/5/19 at 2:35pm, V1 Administrator stated that during transfer, R3 shifted to the side but the sling did not come off her nor did she slide out of it. On 7/5/19 at 10:57am, R3 stated the sling was not snug when the two CNA's applied it and that the non-certified nurse aide was running the controls. R3 stated she told the aides she was starting to slide and fall but the non-certified aide continued to lift her up despite her repeatedly asking them to go get help. R3 stated she thinks her foot fell off the side of the lift and she slid sideways adding that the aides then just pushed her onto the bed after that. R3 stated she didn't realize her leg had been injured until she was on the bed and saw all the blood. R3 stated her shoulder is still sore and her leg wound is still not healed. R3 stated she had just seen the physician that morning and he told her if her leg isn't healed by the next visit, he will have to send her to a Wound Clinic. R3 stated she hurt to where she couldn't go to her therapy for probably a week after. On 7/5/19 at 2:45pm, V7 PTA stated R3 had been doing the sit to stand transfers for a week or so and doing them quite safely when he and the COTA both determined she was ready to use it with the CNA's in her room. V7 stated the transfer is improper is when the arms are outside the sling, the feet are not planted correctly positioned on the platform or the sling is not applied appropriately with the bottom edge almost down to their hips. V7 stated he discussed the incident with R3 numerous times and that she repeatedly refused therapy and to get out of bed due to the soreness for at least a week following the incident. V7 stated his best guess on how it happened was that the sling was either positioned too high or not low enough to support the torso when lifting. V7 also stated the sling must be cinched snug after applied before lifting and is also too high if it is positioned over the breasts. V7 stated he would consider this an avoidable incident since R3 had been cleared to safely use the sit to stand for transfers. On 7/10/19 at 1:05pm, V15 Nurse Practitioner stated the incident with R3 was avoidable and the facility must have not had R3 secured correctly in the sit to stand lift. V15 stated she definitely does consider R3's leg wound as harm as it was deep and was a significant injury that has not healed yet. V15 stated she saw R3 in the office and did order an antibiotic for her. 2. On 7/5/19 at 11:01am, V10 and V11 CNA's entered R4's room to transfer her with the sit to stand mechanical lift. After locking the wheelchair wheels, the CNA's instructed R4 to place her feet on the platform and lean forward so they could apply the lift sling about her waist. The sling was positioned about her waist and was not cinched snuggly as instructed in the handbook but hung loosely about R4's waist/lower chest area. As the CNA's lifted R4 off her wheelchair, they did not check the hooks, cinch the sling tighter or instruct her to lean back into the sling. The sling slid up under her armpits as they lifted R4 off her wheelchair and moved her to the bed. R4's care plan dated 6/4/19 identifies her to have impaired balance and require a sit to stand machine transfer with two assists. A note dated 6/25/19 documents staff was educated on safe usage of the lift chair. 3. On 7/5/19 at 1:30pm, V12 and V13 CNA's entered R5's room to transfer her with a sit to stand mechanical lift. R5 was instructed to place her feet on the lift platform as the CNA's locked the wheels of her wheelchair. The CNA's then had R5 lean forward as they slid the sling down applying it over her breasts as they latched it. The sling was not located at the base of her spine. As the CNA's lifted R5 to a standing position, the sling slid further up under her arm pits. No instructions to lean back into the sling was given nor was any attempt made to ensure proper positioning of the sling prior to the lift. The Care plan dated 5/23/19 document R5 to have impaired mobility and a congenital deformity of the feet. Interventions include a sit to stand transfer with the assist of two.

Based on observation, record review, and interview, the facility failed to provide professional standards of care to prevent injury from a fall for 1 of 7 residents (R2), reviewed for accidents, in a sample of 16. This failure resulted in R2 sustaining a distal femoral shaft fracture and subarachnoid hemorrhage to her left parietal lobe. Findings Include: On 9/13/18 at 10:45AM, R2 was lying in bed with a floor mat next to her bed. R2 was asleep with a leg brace on her left lower extremity. A laminated star was affixed to the outside of R2's door. R2's Minimum Data Sets (MDS), dated [DATE] and 9/5/18, both document R2 being extensive assistance with transfers and bed mobility. R2's Care Plan revised on 9/11/18, documents in part, R2 having Activities of Daily Living (ADL) self-care deficits related to impaired mobility/balance, and having a left femur fracture on 9/5/18 with no surgical intervention, but does not list R2 having a subarachnoid hemorrhage. The Care Plan also documents R2 needing assistance with ADLs, requiring a knee extension brace on at all times, and non-weight bearing to her left lower extremity. The Care Plan further documents R2 is at risk for falls related to having history of falls. R2's Care Plan dated 10/13/17 documents R2 being a partial mechanical lift. R2's Care Plan revised on 9/11/18 documents R2 being a full mechanical lift for transfers. Fall Risk Evaluation dated 9/4/18 documents R2 scoring 16, indicating high risk for falls, legally blind, and intermittent confusion. Nursing Note dated 9/5/18 at 2:00 PM, documents in part, Staff member entered room approximately 5:15AM noted resident lying on the ground next to bed with a large amount of water on the floor. Per staff member, resident stated I fell out of bed. Resident was assisted up x (times) 1 to bed to get ready for the day. Facility Incident/Accident Report dated 9/12/18 at 12:30PM, documents in part, R2 having sustained a fall on 9/5/18 at 5:15AM. The report also documents in part, that V21, Certified Nursing Assistant (C.N.A.), entered R2's room and noted R2 lying on the ground next to her bed, and V21 assisted (R2) to bed to get ready for the day. After a while, (R2) began complaining of a headache and left leg pain. The report also documents R2 was sent to the emergency room (ER), and while there, received a Computed Tomography (CT) scan and X-Rays that revealed a distal femoral shaft fracture and Intraparenchymal hemorrhage or tiny subarachnoid hemorrhage in the left parietal lobe. The Report further documents R2 returned to the facility on [DATE] with a knee brace on her left leg, with no surgical intervention planned. Nursing Note dated 9/7/18 at 6:40PM, documents in part, (R2) arrived on a stretcher. Transferred to her bed with three assist and did cry out with pain in her leg. physician's orders [REDACTED]. Use oxygen, suction and manual treatment of [REDACTED]. Patient prefers no transfer to hospital for life-sustaining treatments. Transfer if comfort needs cannot be met in current location. treatment plan: [REDACTED] physician's orders [REDACTED]. Skilled Nursing Note dated 9/14/18, documents, R2 recently returned from being hospitalized due to a fall resulting in a left femur fracture with conservative management and non-weight bearing status, and being a full mechanical lift for all transfers, with an assist of two. R2's Electronic Health Record (EHR) dated 9/7/18, documents in part, R2 having a left femur fracture and [MEDICAL CONDITION], and a date of birth of 2/3/1914. The EHR fails to documents R2 having a subarachnoid hemorrhage upon return from the hospital on [DATE]. Facility Separation Report for V21, CNA, dated 9/7/18, documents in part, Violation of Company Policy. Facts of Incident: Failure to report a fall that resulted in serious injury to resident. Training Sign in Sheet dated 8/13/18, documents V21, CNA, was provided training on New Hire partial mechanical and full mechanical lifts and their uses. V21, CNA's statement dated 9/5/18, documents in part, (R2) fell out of bed I then put a gait belt around her and lifted her back on the bed I then got her up and put her in the chair she (R2) told me she was having pain in her leg I told the nurse she was having pain and that she may be hurt. (sic) V12, Licensed Practical Nurse (LPN), statement dated 9/5/18, documents in part, Around 5 or 5:30 I was called to (R2's) room by her CNA (V21) to investigate c/o(complaints of) LLE(left lower extremity) pain. (R2) was sitting in her wheelchair inside the doorway. (V12) noted [MEDICAL CONDITION], redness & (and) warmth to (R2) L(left) thigh down through her knee with c/o(complaints of) extreme pain. V12's statement further documents that because R2 was having difficulty with pain control, she was sent to the ER. On 9/17/18, at 10:30AM, V2, Director of Nursing (DON), stated in part, (V21, CNA) knew she shouldn't have picked up (R2), and she didn't tell the nurse until after (R2) complained of pain. V2, DON, further stated, V21, CNA, not only put R2 in bed after sustaining a fall, V21 moved R2 again by transferring her from the bed to the chair after getting her dressed for the day. V2 further stated she would've expected staff to get the nurse to assess any resident with any fall, before moving a resident. On 9/18/18 at 9:00AM, V1, Administrator, stated she had a meeting with the family of R2 recently and came to the conclusion that R2 most likely didn't roll out of bed. On 9/13/18 at 10:51AM, V4, Registered Nurse Manager (RN), stated in part, that R2 doesn't move, so not a 100% sure, but (R2) was placed back into bed by the CNA (V21), and didn't notify the nurse (V12) of the fall and only notified the nurse (V12) of R2's leg pain, and that's when the nurse went to assess the resident. The nurse wasn't told of the fall until the resident was back in bed and fully dressed. V4, RN further stated R2 was a partial mechanical lift prior to the fall and is now a full mechanical lift. On 9/18/18 at 1:35PM, V25, family member, stated when she was at the hospital on [DATE] with R2, the ER staff stated that R2 fell when going from the bed to the wheelchair, and the resident is not ambulatory. V25 also stated R2 was not noted prior to the 9/5/18 fall to have moved independently in bed. V25 further stated V26, transportation coordinator, called her on 9/5/18 at approximately 7:00AM, to inform her that R2 was being sent to the hospital and when V25 asked what happened, V26 stated R2 fell or could have been dropped by the CNA. Facility Policy entitled Fall Prevention, dated 2/2/2010, and revised on 10/18/2013, documents in part, Falling Start Protocol. The Falling Star Protocol is a facility-based portion of the Fall Management Program. A resident qualified for the Falling Star Program if Experience a change in condition or decline in ADLs. Facility Policy entitled Mechanical Lift Transfers, revised on (MONTH) 8, (YEAR), documents in part, Policy. To identify and designate residents who require assistance to transfer by a mechanical lift for the safety of both residents and staff member. The Policy further documents in part, Procedure. 2. Use two staff members when transferring a resident on sling mechanical lift. Facility Occurrence and Event Policy revised on (MONTH) 14, 2013, documents in part, Procedures. Care of the Resident. 1. Assess the resident for any injury. 2. If assistance is needed, summon help.

Based on observation, interview and record review the facility failed to supervise, follow, implement new and effective interventions, follow standard care of practice for transfers, and use proper equipment for 6 of 9 residents (R41, R58, R60, R129, and R206) reviewed for falls in the sample of 43. This failure resulted in R41 falling and lacerating her head and requiring staples to close the wound on 08/12/17. Then, R41 falling and fracturing her Left femur on 05/14/18 requiring hospitalization and surgical intervention for hip replacement. Findings include: 1. R41's Clinical Record documents that R41 has had 16 documented falls, with the first fall being on 06/19/17 and the last fall being on 05/14/18 with this fall resulting in, R41 falling at the facility and fracturing femur, requiring Left total hip replacement. The fall on 07/25/17, documented on post fall management QA form, documents staff education was done for proper transfer status. Following by proper gait belt use at all times. R41's Progress Notes dated 06/19/17, at 6:48PM documents that R41, was found lying on the floor, in her room beside her bed in front of the wheelchair. R41's Progress Notes, document no injuries. The facility QA form documents the facility's Post Fall Management QA form, dated 06/19/17, documents root cause determination as fixing pillows and lost balance. The QA for documents the following new interventions and recommendations need to be implemented; evaluate for restorative programs, anti-rollback. R41's Progress Notes dated 06/24/17, at 3:30 PM, documents that overhead page for assistance in the dining room. R41 was observed sitting on her buttocks, on the floor with her back against another resident's wheelchair. R41's Progress Notes document no injuries. The facility's Post Fall Management QA form, dated 06/29/17, documents root cause determination felt as if she could walk attempted to self-transfer. The QA form documents the following, new interventions and recommendations need to be implemented; falling star program, chair and bed alarm. R41's Progress notes dated 06/26/17 at 3:57 PM, documents that staff reported to the nurse, R41 was on the floor in her room. R41's Progress Notes document that R41 was trying to get out of her bed. R41 stated, she fell out of bed and hit her head hard. R41's Progress Notes document no injuries. The facility Post Fall Management QA form, dated 06/26/17, documents the facility's Post Fall Management, documents root cause determination as attempting to get out of bed. The QA form documents the following new interventions and recommendations need to be implemented; falling star program, encourage staff to lie down after meals. R41's Progress notes dated 07/25/17, 6:05 PM, documents R41 was observed sitting on the floor in front of her bed. R41's Progress Notes, document that V27 Certified Nursing Assistant, (CNA), stated that she lowered, R41 to the floor during transfer. R41 stated that she lost her balance when she was being transferred from her wheelchair to the bed. The facility Post Fall Management QA form dated 07/25/17, documents root cause determination as lowered to the ground, weakness. The QA form documents the following new interventions and recommendations need to be implemented; falling star program, therapy to screen for strengthening. The QA form also, documents staff education attached. The attached Facility Training Sign in Sheet, dated 07/26/17, documents V27, CNA received training for following proper transfer status, wearing gait belt at all times. R41's Progress notes dated 07/28/17, 7:05 AM, documents R41 was found on the floor in her room. R41's Progress Notes document, that R41 stated, she was trying to go to the bathroom and clean up, before going to the dining room. R41's Progress Notes document no injuries. The facility Post Fall Management QA form dated 07/28/17; documents root cause determination self-transfer attempting to go to the bathroom. The QA form documents the following new interventions and recommendations need to be implemented; falling star program, encourage to get up early morning (get up list). R41's Progress notes dated 08/12/17, 3:48 PM, documents R41 was found on the floor in her room with her back leaning against the air conditioning unit, with blood noted on the floor and back of her head. Progress Notes document ambulance called and R41 was sent to the hospital for evaluation and treatment. Injury documented as a laceration to the back of R41's head. R41's emergency room discharge instructions, dated 08/12/17, documents that R41 received staples to her head to close laceration. The QA form documents the following new interventions and recommendations need to be implemented; falling star program, and glow tape to the call light. R41's Progress Notes, dated 09/15/17, 7:21 AM, documents R41 found sitting on floor in her room. R41 stated that she was trying to get up to get a pair of socks. R41's Progress notes document no injuries. The facility Post Fall Management QA form, dated 09/15/17, documents root cause determination as ambulating without assistance to get socks. The QA form documents the following, new interventions and recommendations need to be implemented, offer to get up earlier, non-skid shoes at bedtime offered. R41's Progress Notes 09/29/17, 3:47 PM, documents R41 found sitting on floor in her room. R41 stated that she was trying to get into bed and fell . R41's Progress Notes document no injuries. The facility, Post Fall Management QA form dated, 09/29/17, documents root cause determination as, non-compliance, self-transferring. The QA form documents the following, new interventions and recommendations need, to be implemented assess for restorative transfer program. R41's Progress Notes 10/19/17, at 10:16 PM, documents R41 in her bathroom sitting on floor. R41 stated that she was trying to get to the toilet from her wheelchair, but had incorrect shoes on. R41's Progress notes document no injuries. The facility Post Fall Management QA form, dated10/19/17, documents root cause determination as self-transfer to bathroom. The QA form documents the following new interventions and recommendations, falling star program, 3 day voiding diary. R41's Progress Notes 11/01/17, at 2:52 PM, documents R41 found lying on her left side on the floor in her room. R41 stated that she bent over with reachers, trying to get her wig and fell out of the wheelchair. R41's Progress Notes, document no injuries. The Facility Post Fall Management QA form, dated 11/01/17, documents root cause determination as slid out of wheelchair. The QA form documents the following, new interventions and recommendations need to be implemented to apply anti-skid pad in wheelchair. R41's Progress Notes, 11/17/17, at 9:00 PM, documents R41 resident fell attempting to self-ambulate in her room. R41's Progress notes document no injuries, The Facility Post Fall Management QA Form documents root cause determination as self-transfer to bed. The QA form documents, the following new interventions and recommendations, falling star program, non- skid strips in front of the bed, re-educate on the importance of waiting for assistance. R41's Progress notes dated, 12/16/17, at 5:18 PM, documents R41 was found on the floor in her room. R41 stated that she had spilled her soda and was trying to clean it up, when she fell forward on the floor from her chair. R41's Progress notes, document no injuries. The Facility Post Fall Management QA Form dated, 12/16/17, documents root cause determination as leaning over to clean up spilled soda. The QA form documents the following new interventions and recommendations therapy to screen for balance and trunk control. R41's Progress Notes dated, 02/25/18 at3:38 PM, documents R41 found on the floor in her room. R41 stated, slid out of chair when getting something out of her drawer. R41's progress notes document no injuries. The Facility Post Fall Management QA Form, dated 02/25/18, documents root cause determination as cushion slide out of wheelchair. The QA form documents the following new interventions and recommendations assess resident wheelchair cushion and apply non-stick material if needed. R41's Progress noted 02/26/18, at 8:43 PM, documents R41 found on floor in her room. R41's progress notes document no injuries. The Facility's Post Fall Management QA Form dated 02/26/18, documents no root cause determination. The QA form documents the following new interventions and recommendations, PT screen, Make sure items that R41 uses frequently are in reach, anti-roll backs if she doesn't already have them. R41's Progress note dated 04/14/18, at 9:32 PM, documents staff witnessed R41 falling, but could not reach her in time. R41's progress notes document no injuries. The Facility Post Fall Management QA Form dated 04/04/18, documents root cause determination as attempting to self-transfer to the bathroom. The QA form documents the following new interventions and recommendations need to be implemented; call physician and request urinalysis (UA) related to increased confusion. R41's Progress note dated 05/14/18, at 11:54 AM, documents R41 was walking, pushing another resident in her wheelchair when she lost her balance and fell . House X-ray done because R41 later complained of left leg pain. X-ray results showed a femoral neck fracture. The facility Post Fall Management QA form dated 05/14/18, documents root cause determination as self-transferring while helping another resident. The QA form documents the following new interventions and recommendations to be implemented: falling star program, re-educate importance of assistance and not assisting others. The Incident/Accident Report or Unusual Occurrence for R41 for incident on 5/14/18 documents after initially having no pain, (R41) then complained of left leg pain. An x-ray was then ordered and performed in house. reports showed a femoral neck fracture. (R41) was then sent to the ER (emergency room ). (R41) was admitted to (local hospital). A time line entitled, (R41) - Falls, provided by V2, Director of Nursing on 6/27/18, documents [DIAGNOSES REDACTED]. R41's Minimum Data Set ((MDS) dated [DATE], documents that R41 requires extensive assistance and 2 plus person physical assistance for transfers and extensive assistance. R41's MDS documents that R41 has a Brief Interview of Mental Status (BIMS) of 12 with a score of 8-12 being cognitively impaired. R41's Minimum Data Set ((MDS) dated [DATE], documents that R41, requires extensive assistance and 2 plus person physical assistance for transfers and extensive assistance. R41's MDS documents that R41 has a BIMS of 13, with a score of 13-15 being cognitively intact. R41's Fall Risk evaluation dated 06/15/17, documents a score of 16 which indicates high risk for falls. R41's Fall Risk evaluation dated 06/26/17, documents a score of 12 which indicates high risk for falls. R41's Fall Risk evaluation dated 02/25/18, documents a score of 20 which indicates high risk for falls. R41's Fall Risk evaluation dated 04/04/18, documents a score of 17 which indicates a high risk for falls. R41's Care Plan dated 05/17, documents in part that R41 has a [DIAGNOSES REDACTED]. R41's Care Plan Dated 05/04/17, documents R41 is High risk for falls r/t (related to), impaired mobility, MS, weakness, Dementia and receives medication that could have adverse reaction and Stroke Hx, (history). On 06/27/18, at 1:20 PM, V2, Director of Nursing (DON), stated things can be prevented when discussing concerns of falls. On 06/28/18, at 2:30PM, V30, primary Physician, stated that he would expect staff to try to use a gait belt during transfers. V30 agreed, if the same interventions are used and R41 continues to fall, the interventions are ineffective. V30 stated R41 has a [DIAGNOSES REDACTED]. The Facility Policy Fall Prevention dated (MONTH) 2, 2010 documents it is the policy of the facility to provide each resident with an appropriate assessment and interventions to prevent falls. The policy documents all resident falls in the facility are analyzed and trended through the QA process to maintain a safe environment 2. R206's Care Plan dated 06/19/18, documents in part R206 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Focus: Resident is at risk of falls related to: Impaired mobility. Resident has attempted to transfer herself and ambulate without assistance. Goal: Resident will have no more than minor injury if a fall occurs, through the review date. Interventions/Tasks 06/21/18, Anti-roll backs to be placed on wheelchair. 06/25/18, Falling Star Program. 06/26/18, Fall mats placed on floor next to bed. *Be sure call light is within reach and encourage to use it for assistance as needed. Needs prompt, response to all requests for assistance. *Ensure wearing appropriate footwear when ambulating, transferring or mobilizing in wheelchair. *Ensure resident is wearing corrective lenses, if applicable. *Keep furniture in locked position. *Keep needed items, water, etc, in reach. *Maintain a clear pathway in room, free of obstacles. *Monitor for decline in ADLS. R206's Progress notes dated 06/20/18, documents, Resident was noted walking up hallway from her room and was assisted to her wheelchair and placed at nurse's station for observation. While there, she got up and before staff could reach her, she fell to floor. Upon skin check, a skin tear was noted to resident's right elbow. Treatment to skin tear given and steri-strips applied and a foam adhesive. Vital signs obtained and PROM (Passive Range of Motion) without c/o, back up to wheelchair and sitting with staff on duty, Post fall huddle. On 06/25/18 at 10:00 AM, R206 is sitting near the nurse's desk in her wheelchair and was getting up V20, Licensed Practical Nurse, (LPN), is asking her several times to sit back down. At 10:43, R206 is getting up, out of her wheelchair and V20 is asking her to sit back down. 06/25/18, 12:28 PM, R206 is in the large dining room, stood up from wheelchair, trying to step over the wheelchair foot pedals, no staff was around, surveyor told V29 Dietary Aide, who was behind the food counter, that someone needs to get her before she falls. V29 went to 300 Hall and got V20, who came to the dining room and took R206 back to 300 Hall. On 06/26/18 at 9:41 AM, when asked why R206 would be left in the dining room, without staff around since she is a high fall risk. V20 states, She is on the Falling Star Program, we can't do 1 on 1 with everyone. 3. On 06/27/18 at 9:10 AM, V11 and V17, CNA's transferred R60 from her bed to her wheelchair using a partial mechanical lift. (Used machine model, with weight (wt.) capacity of 350 pounds, with a sling underweight rated. Used wrong machine for her wt. Sling does not belong to this lift machine; it belongs to another lift machine. R60's Electronic Medical Record (EMR) dated 06/04/18, documents R60's weight to be 364.6 pounds. On 06/27/18 at 9:35 AM, V6 LPN stated, That is the only machine the resident will use, she says the other one is not comfortable for her. We always interchange the slings with the machines; I didn't know we had to use the sling that goes to the machine. On 06/27/18 at 2:00 PM, V1 stated, That is the only machine she will use. The Operation Manual for Products dated 2011, documents in part, Sling and Belt safety Instructions Important Notice, This sling or belt has been specifically designed and tested for use with lifts or stands manufactured 4. On 06/25/18, at 10:18 AM, V16, Certified Nurse Assistant, (CNA) entered R129's room with the partial mechanical lift products, Care Stand Plus Total Support. V16 applied the care belt, for the partial mechanical lift around R129. V16 raised R129 up from the wheelchair, with the use of the partial mechanical lift and transferred R129 from her room into the bathroom and lowered her onto the toilet. After R129 was finished, V16 raised R129 off the toilet, with the partial mechanical lift and pushed R129 into her room. V16 left R129 in her room up in the lift unattended for 3 minutes, while V16 was observed in the bathroom, flushing the toilet and getting toilet paper. V16 transferred R129, into the wheelchair when care was completed. V16 then removed the belt from R129. V16 did not apply the shin support strap, located on the partial mechanical lift, to V129. 5. On 06/26/18 at 10:29 AM, V25 and V26, CNA's, entered R58's room with the partial mechanical lift products, Care Stand Plus Total Support, V25 and V26 applied the care belt for the partial mechanical lift around R58. V25 raised R58 up from the wheelchair with the use of the partial mechanical lift and transferred R58 from her room into the bathroom and was lowered onto the toilet. After R58 was finished, V25 raised R58 off the toilet with the partial mechanical lift and transferred R58 into the wheelchair when care was completed. V26 then removed the belt from R58. V25 and V26 did not apply the shin support strap, located on the partial mechanical lift. The Partial Mechanical Lift Products Operation Manual, (dated 2011) documents, Care Stands Model, Care Stand Operations Care Belt 2. Have the patient place their feet on the support plate, with their shins against the shin support pad. For added stability, fasten strap around calves.

During record review, interview and observation, the facility neglected to follow their policy and procedure to identify, assess, and treat multiple pressure ulcers for 2 of 5 residents (R1 and R2) reviewed for pressure ulcer treatment in the sample of 5. This failure resulted in R1 and R2 developing pressure ulcers ranging from Stage IV's to necrotic areas. Findings include: 1. Facility Policy #CN-1801 (undated) documented, Skin/Pressure Ulcer Risk Evaluation 6. The licensed nurse will remove, inspect, and provide skin care to the skin of the resident with braces, splints and associated wrappings, or other devices every shift and prn (as needed), unless contraindicated by the physician. The findings of the skin inspection will be documented on the Treatment Administration Record (TAR). 2. R2's Hospital Discharge Plan, dated 8/2/2015, documents R2 was discharged from the Hospital Emergency Department with a left leg fracture. The Hospital Patient Instructions and Activity Restrictions or Additional Instructions, dated 8/2/2015 documents The nursing staff may remove the boot for skin care, neuro, and skin checks per their protocols. R2's physician's orders [REDACTED]. On the Treatment Administration Record, (TAR) Z1, Orthopedic Physician documented, 8/3/15-8/12/15 Patient's Diagnosis, (DX), distal fibial fracture, (FX). Patient is to be strictly non weight bearing, including no use of foot to scoot around in wheelchair. Continue boot with instructions provided. On 8/12/15, Z1 documented on the TAR, Patient ' s DX distal fibial spiral FX. May return to use of assisted transfers with partial wt (weight) bearing with boot on if pain free; Continue boot but may remove several times a day for ankle Range of Motion in all planes as tolerated. R2's Nurse's Note, dated 8/2/15 7:24 PM, written by E9, Licensed Practical Nurse, (LPN) documented, Boot to L (left) foot intact, pedal pulse present. R2's Nurse's Note, dated 8/4/15 at 9:33 AM, written by E13, LPN, documented, Pedal pulse present to LLE (left lower extremity). R2's Nurse's Note, dated 8/4/15 7:19 PM, E13 documented, Ortho boot remains in place with no redness to skin. R2's Nurse's Note, dated 8/11/15 at 10:18 PM, E14 documented , LPN, documented, Boot in place to left lower extremity, swelling has decreased a lot, no [MEDICAL CONDITION] noted at this time. R2's Nurse's Note, dated 8/12/15 at 9:21 PM, written E14, Boot in place to left lower extremity. Circulation and range of motion is good at this time. 8/15/15 9:23 PM, E14 Boot in place to left lower extremity. No problems observed related to circulation to the left foot and leg. Minimum Data Set ((MDS) dated [DATE] documents R2 ' s Brief Interview for Mental Status (BMI)score as 15, cognitively intact and is totally dependent for transfers with assist of 2 staff. On 9/29/15 at 12:00 PM, R2 stated, Nobody ever took the boot off to check my leg. The only reason they took the boot off is because it was time for it to come off, I was supposed to wear the boot for 6 weeks. On 9/29/15 at 12:40 PM, E4, stated, I removed the boot on 8/19/15 because (R2) was complaining of pain. When I took the boot off is when the wounds were first found. On 9/30/15 E6 - E20, LPN's and E21 and E22, RN's confirmed through interview that they did not remove R2's boot from her left leg between 8/2/15 through 8/20/15: On 10/1/15 at 11:50 AM, Z2, RN for Z1 stated, (R2) should have skin checks per facility protocol and physician's order [REDACTED]. R2's Nurse's Notes dated 8/19/15, at 5:37 PM, and Weekly Wound Flow Sheet dated 8/19/15, E21, LPN, documents, Resident has two left lower leg skin tears, first one measuring 5cm(length)x0.1cm(depth)x2.5cm(width) and second one measuring 1cm(length)x0.1cm(depth)x0.5(wide). Also has 3 pressure spots on left great, left second and third toe, as well as wound on top of foot. There were no measurements of the 3 pressure ulcers on R2's left great, left second and third toes. Weekly Wound Flow Sheet, dated 8/19/15, documents, Onset Date 8/19/15: Left Lower Leg Skin Tear 5cmx0.1cm, Left lower leg Skin Tear 1cmx0.5cmx0.2cm, Pressure Left great toe 0.5x0.25cmxUTD (Unable To Determine), Pressure Left second toe 2cmx1.5cmxUTD, Pressure 0.5x0.5xUTD. 8/20/15 at 1:28 PM, E7, LPN, documents, Call out to Z3, Physician, (Primary Care Physician) for skin check orders under brace q (every) shift, waiting on return call. Z1 wrote the following orders on the TAR, dated 8/20/2015, Skin checks to LLE under brace q (every) shift every shift for wound Wound Prevention Check skin under brace q shift. Z4, Wound Physician's Wound Care Specialist Initial Evaluation form, dated 8/25/15, documents the following regarding R2's pressure ulcers: Site 1, Unstageable (Due to Necrosis) Of The Left Lateral Calf, wound size (LxWxD) 3.5x3.0x Not Measureable cm (centimeter); Site 2, Stage 3 Pressure Wound Of The Left, Dorsal Foot 2.0x2.0x0.4 cm; Site 3, Unstageable (Due to Necrosis) Of The Left, Dorsal, Second Toe 0.3x0.5xNot Measurable cm; Site 4 Unstageable (Due to Necrosis) Of The Left, Dorsal, Third Toe 0.2x0.2x5xNot Measurable cm; Site 5 Unstageable (Due to Necrosis) Of The Left, Distal, Medial Foot 0.3x0.3xNot Measurable cm. R2 's dressing change was observed on 9/29/15 at 12:40 PM. E4, (LPN), removed the dressings from R2's pressure ulcers. R2 had the following pressure ulcers: The Left Lateral Calf, Stage 4 Pressure Wound, (LxWxD) 10.4x4.4x Not Measureable cm, muscle exposed, moderate serous sanguineous exudate slough, eschar, granulation. Left Dorsal Foot, Stage 4 Pressure Wound, 3.0x3xNotMeasureable cm, tendon exposed, Moderate serous exudates, slough, granulation. Left Dorsal, Second Toe, Unstageable (Due to Necrosis), 1.0x0.9xNot Measurable cm, Moderate serous exudates, slough, eschar. Facility Policy #CN-1801 (undated) documented, Skin/Pressure Ulcer Risk Evaluation 6. The licensed nurse will remove, inspect, and provide skin care to the skin of the resident with braces, splints and associated wrappings, or other devices every shift and prn (as needed), unless contraindicated by the physician. The findings of the skin inspection will be documented on the Treatment Administration Record (TAR). 2. R1's Hospital discharge summary dated 8/17/15 documented, Wear TLSO (Thorsacolumbar Sacral, Orthosis Brace) at all times. Nurse Notes dated 8/21/15 at 12:00 PM, E5 documents, Message left with Z5, Physician, office regarding resident TLSO brace. Brace rides up really bad on resident when she sits down and resident is complaining of pain in underarms. This writer afraid if this isn't adjusted then it may cause sores or bruising. Requesting information on who adjusts braces or who to call. Awaiting return call. 8/26/15 at 12:33 PM, E5 documents, Explanation of skin concerns and treatments: redness and discoloration under arms r/t (related to) brace applying pressure to area, dry foam applied to prevent further skin issues. 9/10/15 at 12:47 PM, E5 documents, Z5 ordered, R1 has to have TLSO brace on. Okay to take off at night when lying in bed. Pressure Ulcer log documents R1's pressure areas as: 8/26/15, Left axillary arm Pressure 2.4x5.0xUTD, Right axillary arm Pressure 0.7x6.0xUTD. 9/15/15, Midline upper back Pressure 2.2x0.8xUTD. Nurses Note by E5, dated 8/26/15 12:48 PM, Resident c/o (complained) pain under arms where TLSO brace presses. Observed area and noted redness and discoloration where brace lays. Areas blanchable although new order obtained to apply dry foam dressing on area to reduce pressure and prevent further skin issues. Resident has appt (appointment) with (Clinic) tomorrow 8-27-15 to refit brace. Clinic report dated 8/27/15, Follow up visit today to adjust the TLSO fit at hospital on [DATE]. Today the patient arrived with the orthosis in place. The patient complains that it is not fitting well. The patient complains that the TLSO is riding up and choking her. The patient also states that it is digging into her abdomen. I removed the orthosis and trimmed the anterior and posterior shells. I also replaced all six anterior shell straps as they were heavily soiled. I reapplied the orthosis and marked new straps for proper fit. The patient is pleased with the results. The patient will follow up with our office with ant other problems or concerns. Wound Care Specialist (Z4) Evaluation dated 9/1/15, Site 3 Unstageable (Due to Necrosis) Of the Left, Axillary Area Arm Pressure 2.0x8.5xNot Measureable cm. Site 4 Unstageable (Due to Necrosis) Of the Right, Axillary Area Arm Pressure 1.0x5.0xNot Measureable cm. On 9/29/15 at 11:05 AM, E5, LPN, stated, I called the doctor ' s office on 8/21/15 and left a message about getting (R1's) brace needing to be trimmed because it was making under her arms red, I ' m not sure when they called back. I did not follow up with another phone call. Minimum Data Set ((MDS) dated [DATE] documents R1 ' s Brief Interview for Mental Status (BMI) score as 15, cognitively intact and is extensive assist for transfers with assist of 2 staff. On 9/30/15 observed R1 at 11:00 AM sitting in wheelchair wearing her TLSO brace. On 9/30/15 at 1:30 PM R1 was laying in bed with her brace off. R1 had dressings on her left and right axilla, mid back, and right buttocks. Wound Care Specialist Initial Evaluation, dated 9/29/15, Z4, Wound Physician (MD) documents, Stage 3 Pressure Wound Of The Left, Axillary Area Arm Pressure 1.0x0.3x0.3 cm. Unstageable (Due to Necrosis) Of the Right, Axillary Area Arm Pressure 0.50x0.5xNot Measureable cm. Unstageable (Due to Necrosis) Of the Midline Back, 1.6x0.5x5xNot Measureable cm. Interview on 9/30/15 at 1:30 PM, R1 refused dressing change. R1 stated, I have areas under her armpits that bleed and my back and butt have wounds on them. That brace is killing me.

Based on observation, interview and record review, the facility failed to assess, monitor, treat per physician's orders and provide adequate pressure relief to prevent the development of pressure ulcers for one of two residents (R2 and R1) reviewed with pressure ulcers. This resulted in R2 developing one Stage 3 and 4 Unstageable pressure ulcers to her left leg and foot/toes. Findings include: 1. R2's Hospital Discharge Plan, dated 8/2/2015, documents R2 was discharged from the Hospital Emergency Department with a left leg fracture. The Hospital Patient Instructions and Activity Restrictions or Additional Instructions, dated 8/2/2015 documents The nursing staff may remove the boot for skin care, neuro, and skin checks per their protocols. R2's Physician's Order Sheet (POS) had orders from Z1, Orthopedic Physician, dated 8/3/15 to continue in boot with instructions provided. On the Treatment Administration Record, (TAR) Z1, Orthopedic Physician documented, 8/3/15-8/12/15 Patient's Diagnosis, (DX), distal fibial fracture, (FX). Patient is to be strictly non weight bearing, including no use of foot to scoot around in wheelchair. Continue boot with instructions provided. On 8/12/15, Z1 documented on the TAR, Patient ' s DX distal fibial spiral FX. May return to use of assisted transfers with partial wt (weight) bearing with boot on if pain free; Continue boot but may remove several times a day for ankle Range of Motion in all planes as tolerated. R2's Nurse's Note, dated 8/2/15 7:24 PM, written by E9, (Licensed Practical Nurse) LPN documented, Boot to L (left) foot intact, pedal pulse present. R2's Nurse's Note, dated 8/4/15 at 9:33 AM, written by E13, LPN, documented, Pedal pulse present to LLE (left lower extremity). R2's Nurse's Note, dated 8/4/15 7:19 PM, E13 documented, Ortho boot remains in place with no redness to skin. R2's Nurse's Note, dated 8/11/15 at 10:18 PM, E14 documented , LPN, documented, Boot in place to left lower extremity, swelling has decreased a lot, no [MEDICAL CONDITION] noted at this time. R2's Nurse's Note, dated 8/12/15 at 9:21 PM, written E14, Boot in place to left lower extremity. Circulation and range of motion is good at this time. 8/15/15 9:23 PM, E14 Boot in place to left lower extremity. No problems observed related to circulation to the left foot and leg. Minimum Data Set ((MDS) dated [DATE] documents R2 ' s Brief Interview for Mental Status (BMI)score as 15, cognitively intact and is totally dependent for transfers with assist of 2 staff. On 9/29/15 at 12:00 PM, R2 stated, Nobody ever took the boot off to check my leg. The only reason they took the boot off is because it was time for it to come off, I was supposed to wear the boot for 6 weeks. On 9/29/15 at 12:40 PM, E4, stated, I removed the boot on 8/19/15 because (R2) was complaining of pain. When I took the boot off is when the wounds were first found. The following nurse's were interviewed on 9/30/15 regarding if they ever removed R2 's boot from her left leg between 8/2/15 through 8/20/15: E6, LPN, stated at 5:40 PM, Took it off to change dressing 1 time. E7 LPN, stated at 4:34 PM, I only took boot off after she had wounds. E8, LPN, stated at 4:50 PM, I only remember taking a boot off for a dressing change. E9, LPN, stated at 6:11 PM, No, I never took the boot off. E10, LPN, stated at 4:53 PM, No, I didn't take the boot off. E11, LPN, stated at 4:55 PM, I can't remember taking the boot off. E12, LPN, stated at 5:35 PM, I removed it to do a dressing change only. E13, LPN, stated at 10:14 PM, I don't even remember a boot; I don ' t remember ever removing a boot. E14, LPN, stated at 5:17 PM, I checked under the boot 4 days after she had it on to see if the swelling had gone down, but that was the only time. E15, LPN stated at 9:19 PM, No, I didn't ever remove the boot before there was an order. E16, LPN, stated at 5:25 PM, Didn't ever remove the boot. E17, LPN, stated at 5:27 PM, No. E18, LPN, stated at 6:04 PM, No, I never took it off at that time. E19, LPN, stated at 6:50 PM, I only remember her having a dressing on her leg and never took the boot off otherwise. E20, LPN, stated at 5:39 PM, I don't remember ever removing the boot before the 20th, only removed the boot to do a dressing change. E21, Registered Nurse (RN), stated at 6:40 PM, No, I didn't. E22, RN, stated at 6:06 PM stated, No. On 10/1/15 at 11:50 AM, Z2, RN for Z1 stated, (R2) should have skin checks per facility protocol and physician ' s order. This was a significant error on the facility's part. R2's Nurse's Notes dated 8/19/15, at 5:37 PM, and Weekly Wound Flow Sheet dated 8/19/15, E21, LPN, documents, Resident has two left lower leg skin tears, first one measuring 5cm(length)x0.1cm(depth)x2.5cm(width) and second one measuring 1cm(length)x0.1cm(depth)x0.5(wide). Also has 3 pressure spots on left great, left second and third toe, as well as wound on top of foot. There were no measurements of the 3 pressure ulcers on R2's left great, left second and third toes. Weekly Wound Flow Sheet, dated 8/19/15, documents, Onset Date 8/19/15: Left Lower Leg Skin Tear 5cmx0.1cm, Left lower leg Skin Tear 1cmx0.5cmx0.2cm, Pressure Left great toe 0.5x0.25cmxUTD (Unable To Determine), Pressure Left second toe 2cmx1.5cmxUTD, Pressure 0.5x0.5xUTD. 8/20/15 at 1:28 PM, E7, LPN, documents, Call out to Z3, Physician, (Primary Care Physician) for skin check orders under brace q (every) shift, waiting on return call. Z1 wrote the following orders on the TAR, dated 8/20/2015, Skin checks to LLE under brace q (every) shift every shift for wound Wound Prevention Check skin under brace q shift. Z4, Wound Physician's Wound Care Specialist Initial Evaluation form, dated 8/25/15, documents the following regarding R2's pressure ulcers: Site 1, Unstageable (Due to Necrosis) Of The Left Lateral Calf, wound size (LxWxD) 3.5x3.0x Not Measureable cm (centimeter); Site 2, Stage 3 Pressure Wound Of The Left, Dorsal Foot 2.0x2.0x0.4 cm; Site 3, Unstageable (Due to Necrosis) Of The Left, Dorsal, Second Toe 0.3x0.5xNot Measurable cm; Site 4 Unstageable (Due to Necrosis) Of The Left, Dorsal, Third Toe 0.2x0.2x5xNot Measurable cm; Site 5 Unstageable (Due to Necrosis) Of The Left, Distal, Medial Foot 0.3x0.3xNot Measurable cm. R2 's dressing change was observed on 9/29/15 at 12:40 PM. E4, (LPN), removed the dressings from R2's pressure ulcers. R2 had the following pressure ulcers: The Left Lateral Calf, Stage 4 Pressure Wound, (LxWxD) 10.4x4.4x Not Measureable cm, muscle exposed, moderate serous sanguineous exudate slough, eschar, granulation. Left Dorsal Foot, Stage 4 Pressure Wound, 3.0x3xNotMeasureable cm, tendon exposed, Moderate serous exudates, slough, granulation. Left Dorsal, Second Toe, Unstageable (Due to Necrosis), 1.0x0.9xNot Measurable cm, Moderate serous exudates, slough, eschar. Left Distal, Medial Foot, Unstageable (Due to Necrosis) Of 0.4x0.4xNot Measurable cm, no exudate. Facility Policy #CN-1801 (undated) documented, Skin/Pressure Ulcer Risk Evaluation 6. The licensed nurse will remove, inspect, and provide skin care to the skin of the resident with braces, splints and associated wrappings, or other devices every shift and prn (as needed), unless contraindicated by the physician. The findings of the skin inspection will be documented on the Treatment Administration Record (TAR). 2. R1's Hospital discharge summary dated 8/17/15 documented, Wear TLSO (Thorsacolumbar Sacral, Orthosis Brace) at all times. Nurse Notes dated 8/21/15 at 12:00 PM, E5 documents, Message left with Z5, Physician, office regarding resident TLSO brace. Brace rides up really bad on resident when she sits down and resident is complaining of pain in underarms. This writer afraid if this isn't adjusted then it may cause sores or bruising. Requesting information on who adjusts braces or who to call. Awaiting return call. 8/26/15 at 12:33 PM, E5 documents, Explanation of skin concerns and treatments: redness and discoloration under arms r/t (related to) brace applying pressure to area, dry foam applied to prevent further skin issues. 9/10/15 at 12:47 PM, E5 documents, Z5 ordered, R1 has to have TLSO brace on. Okay to take off at night when lying in bed. Pressure Ulcer log documents R1's pressure areas as: 8/26/15, Left axillary arm Pressure 2.4x5.0xUTD, Right axillary arm Pressure 0.7x6.0xUTD. 9/15/15, Midline upper back Pressure 2.2x0.8xUTD. Nurses Note by E5, dated 8/26/15 12:48 PM, Resident c/o (complained) pain under arms where TLSO brace presses. Observed area and noted redness and discoloration where brace lays. Areas blanchable although new order obtained to apply dry foam dressing on area to reduce pressure and prevent further skin issues. Resident has appt (appointment) with (Clinic) tomorrow 8-27-15 to refit brace. Clinic report dated 8/27/15, Follow up visit today to adjust the TLSO fit at hospital on [DATE]. Today the patient arrived with the orthosis in place. The patient complains that it is not fitting well. The patient complains that the TLSO is riding up and choking her. The patient also states that it is digging into her abdomen. I removed the orthosis and trimmed the anterior and posterior shells. I also replaced all six anterior shell straps as they were heavily soiled. I reapplied the orthosis and marked new straps for proper fit. The patient is pleased with the results. The patient will follow up with our office with ant other problems or concerns. Wound Care Specialist (Z4) Evaluation dated 9/1/15, Site 3 Unstageable (Due to Necrosis) Of the Left, Axillary Area Arm Pressure 2.0x8.5xNot Measureable cm. Site 4 Unstageable (Due to Necrosis) Of the Right, Axillary Area Arm Pressure 1.0x5.0xNot Measureable cm. On 9/29/15 at 11:05 AM, E5, LPN, stated, I called the doctor ' s office on 8/21/15 and left a message about getting (R1's) brace needing to be trimmed because it was making under her arms red, I ' m not sure when they called back. I did not follow up with another phone call. Minimum Data Set ((MDS) dated [DATE] documents R1 ' s Brief Interview for Mental Status (BMI) score as 15, cognitively intact and is extensive assist for transfers with assist of 2 staff. On 9/30/15 observed R1 at 11:00 AM sitting in wheelchair wearing her TLSO brace. On 9/30/15 at 1:30 PM R1 was laying in bed with her brace off. R1 had dressings on her left and right axilla, mid back, and right buttocks. Wound Care Specialist Initial Evaluation, dated 9/29/15, Z4, Wound Physician (MD) documents, Stage 3 Pressure Wound Of The Left, Axillary Area Arm Pressure 1.0x0.3x0.3 cm. Unstageable (Due to Necrosis) Of the Right, Axillary Area Arm Pressure 0.50x0.5xNot Measureable cm. Unstageable (Due to Necrosis) Of the Midline Back, 1.6x0.5x5xNot Measureable cm. Interview on 9/30/15 at 1:30 PM, R1 refused dressing changes. R1 stated, I have areas under her armpits that bleed and my back and butt have wounds on them. That brace is killing me.

Based on observation, interview and record review, the facility failed to timely identify, assess, provide adequate treatment, and implement interventions for healing pressure ulcers and preventing the development of new pressure ulcers for 1 of 4 residents (R3) reviewed for pressure ulcers in the sample of 8. This failure resulted in R3 developing avoidable stage 3 pressure sores while in the facility. Findings include: 1. R3's Minimum Data Set (MDS) of 1/19/15 documents R3 has no cognitive impairment and requires extensive assistance of 2 or more staff for transfer, bed mobility and toileting and is frequently incontinent of urine. MDS documents R3 is at risk for development of pressure sores. R3's Braden Scale for Predicting Pressure Sore Risk of 1/13/15, 3/17/15 and 3/24/15 document R3 is at moderate risk for the development of pressure ulcers/sores. All 3 assessments document R3's nutrition is adequate and eats four servings of protein a day. R3's Nutritional Assessment of 3/17/15 documents R3 weighs 179.4 pounds (lbs) with usual weight 175 -180 lbs and weight has been stable in the past 12 months. R3's Care Plan of 6/29/14 documents R3 has a history of pressure ulcers and gout area on right foot. Care Plan Note of 3/12/15 documents noted left great toe red/swollen. Right lower extremity increased [MEDICAL CONDITION], back of calf red. Care Plan Note of 3/22/15 documents bilateral buttocks noted with stage 3 pressure ulcers one on each side noted on 3/8/15. Care Plan Note on 3/24/15, documents R3 is declining to lay down between meals and is requesting to get up early in the mornings. Care Plan interventions document the following, in part: revision on 8/4/14 - "Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. Pressure reducing device on her bed/chair. Requires assistance to turn/reposition at least every 2 hours, more often as needed or requested. 3/22/15 Treatment as ordered to buttocks and left lower extremity as ordered on [DATE]. Encourage R3 to lay down between meals and/or to get into her recliner chair. 3/24/15 follow facility policies/protocols for the prevention/treatment of [REDACTED]. Facility Pressure Ulcer Log of 3/8/15 - 3/14/15 documents R3 has facility acquired stage 3 pressure ulcer on left buttock measuring 2.5 centimeters (CM) length, 1.5 cm width and .5 cm depth. Treatment is Cleanse, apply collagen, then apply foam dressing, change daily. The Pressure Ulcer Log documents a facility acquired stage 3 pressure ulcer on the right buttock measuring 1.0 cm length x 2.0 cm width and .5 cm depth. Treatment is to cleanse, apply collage, then apply foam dressing, change daily. The log documents that the pressure ulcers were identified on 3/8/15 and were a stage 3 when the facility found the pressure ulcers. R3's Physician order [REDACTED]. R3's Laboratory tests of 3/12/15 document a normal [MEDICATION NAME] at 3.4 g/dl (grams/deciliter) with normal (3.4 -4.8) and a normal total protein at 5.9 g/dl with normal (5.7 -8.2 g/dl). Laboratory test of 3/16/15 document a normal [MEDICATION NAME] at 26.4 mg/dl (milligram/deciliter) with normal (20 - 40). On 3/20/2015, R3 was sitting in her wheelchair. R3 ate 100% of her french toast and syrup, fruit loops, whole mile and orange juice at the breakfast meal. R3 was observed at 7:55 AM to be up in her wheel chair by the Nurses Station drinking Prostat and took 100%. On 3/20/15 at 9:30 AM, R3 was ambulated 6 feet from her wheel chair to the toilet by E8 and E9, Certified Nurse's Aides (CNAs). R3's disposable incontinent had a dried brownish/greenish drainage and smears of red. E8 stated she thought it was from her wound (pressure ulcer) on her buttocks. R3 had a boarder foam dressing on her buttocks dated 3/20/15. E8 and E9 placed R3 on the toilet seat. The back of R3's back thighs and buttocks were deep creased and red. E9 stated he had not given any care to R3 that morning. E8 stated she was the CNA assigned to R3 that shift and had not had R3 out of her wheel chair. E8 stated she came to work at 6:00 AM and R3 was already up in her wheel chair and hadn't been out of the wheel chair since now. On 3/20/15 at 9:33 AM, E10, CNA, stated she had not worked or given care to R3 today. At 9:35 AM, E11, CNA stated she was not assigned to R3 but had pushed R3 to the dining room. E11 stated she had not gotten R3 out of her wheel chair or gave any care. At 9:37 AM, E12 stated she was not assigned to R3 and had not given her any care or had her out of wheel chair. On 3/20/15 at 9:45 AM, E4, Licensed Practical Nurse (LPN), came down R3's hall with a boarder foam package in her hand. E4 was almost to R3 room and stated that she needed to get something. E4 came back with wound spray and a handful of bulk 2 x 2 gauze. E4 removed R3's pressure ulcer dressing as R3 stood over the toilet holding onto a walker and E8 holding R3 up with a gait belt. There was a packing in the border foam dressing and brownish/green drainage. E4 stated the packing was collagen. The toilet was in a cubical area approximately 4 feet by 4 feet. E4 washed the pressure ulcer while standing in front of R3 and reaching around R3 to cleanse buttocks. E4 wiped with the gauze that had been sprayed with the wound cleanser. The gauze was bright blood tinged. R3 was hunched over her walker standing in front of the toilet. E8 stated she didn't know how much longer R3 could stand. R3 was groaning and appeared to be anxious while being stood over the toilet for the dressing change. E4 suggest Surveyor could now do a skin check and Surveyor declined as R3 was very unsteady on her feet. E4 put a boarder form on R3's buttocks but did not apply the collagen as per R3's physician's orders [REDACTED]. On 3/24/15, at 1:25 PM, E13, CNA, stated R3 does not refuse care and isn't resistive. E13 stated R3 does not refuse to lay down. E13 stated R3 will tell you when she wants to lay down, "She's a sweet heart." At 1:35 PM, E14, LPN, stated R3 was a real pleasant lady, liked to socialize and needed encouragement to get out of her wheel chair. E14 stated R3 will get into her recliner for short periods. E14 stated R3 told her they may have to put R3's recliner in the area by Nurses Station because R3 likes to know what's happening. R3 likes to socialize and be out of her room. This was no addressed on R3's Care Plan. On 3/26/15 at 9:20 AM, Z1, R3's Wound Doctor, stated, "Of course" when asked if she would have expected the facility to find R3's pressure sore on the buttocks before it was a stage 3. Z1 stated R3's Pressure Ulcers developed from laying too long in bed without being repositioned. Z1 stated not repositioning R3 in the wheel chair increases the risk of developing pressure sores on the ischium. Z1 stated comorbidities, poor appetite and depleted/low [MEDICATION NAME] and [MEDICATION NAME] lead to unavoidable pressure sore. Z1 stated it would be very difficult to see R3's pressure ulcer if R3 was standing over the toilet during the dressing change. Z1 stated it would be preferred to lay R3 down to do the dressing change unless she refused. Z1 stated she would have expected E4 to to put collagen on R3's pressure ulcer. Z1 stated "That's why I ordered it." Facility Policy and Procedure for Skin/Pressure Ulcer Risk Evaluation of 1/16/14 documents Residents with a score of 13 -14 are considered "At Moderate Risk" for skin breakdown. Facility Policy and Procedure for Wound Management of 1/14/14 documents "It is the policy of the facility to facilitate resident independence, promote resident comfort, and preserve resident dignity through an effective wound management program." The Procedure documents under Pressure Ulcers,"A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue (s). Pressure ulcers are staged to determine the extent of tissue damage. treatment of [REDACTED]."

A. Based on interview and record review, the facility staff neglected to develop and implement a policy to address what procedures should be taken if a resident has potential head or spinal cord injury and failed to adequately assess/ monitor and call 911 for 1 of 3 residents (R2) reviewed for nursing care provided immediately following an injury. This failure resulted in R2 being moved and a delay in transport during change in mental status due to being thrown off of a mechanical wheelchair lift on a van. R2 sustained C6-C7 cervical fractures and subsequently died . This resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the facility policies and procedures and their system of communication. Findings Include: 1. The Facility's Policy "Occurrence and Event Policy", revision date [DATE], was reviewed. This policy did not address what procedures should be taken if a resident has a potential head or spinal cord injury. 2. R2's Minimum Data Set (MDS) , dated [DATE], documents that R2 requires extensive physical assistance of one person for transfers and has severe cognitive impairment. R2's Care Plan, initiated [DATE], documents that R2 is at a risk for falls related to frequent fall history and recent fracture related to a fall at home. R2's Progress Notes by E6, Licensed Practical Nurse (LPN), dated [DATE], documents, "Transport manager called this writer at (11:00 AM) stating resident (R2) had tipped off of transport lift onto ground outside in the parking lot. Resident (R2) was lifted approx. (approximately) 6 inches off of ground on lift and equipment malfunctioned. Upon arriving to parking lot resident was sitting in w/c (wheelchair) with his head down, chin toward chest. Resident (R2) talking to staff but speech was slurred. Alert and oriented x3. This writer brought resident back inside and obtained vitals, WNL (within normal limits). Resident (R2) speech remained slurred and pupils fixed, nonresponsive to light. Hand grasps equal but weak. Resident c/o (complaint of) pain in left shoulder and pain in neck. (Physician) called at (11:20 AM) and gave order to send to (local emergency department) for eval (evaluation) and treat. (Local) Ambulance called and arrived at (11:45 AM), resident (R2) left facility at (11:50 AM) via ambulance to (local emergency department)." R2's Hospital Discharge Summary dated [DATE], documents " He (R2) sustained injuries including a fracture of C7 and C6." The Summary documents "He failed his speech swallow study and was given a Keofeed and provided with nutrition by tube feeds. Ortho spine discussed the patient's situation with the family and the patient, and they opted for nonoperative course." The Summary documented the family chose not place a feeding tube and opted for comfort care and Hospice. R2's Death Certificate, dated [DATE], documents his cause of death as [MEDICAL CONDITION] and Cervical Spine Fracture. Risk Management Witness Interview Form, dated [DATE], written by E9, LPN/Admission Coordinator, documented "Myself, CNA and other nurse assessed him (R2). Assisted him up to w/c. Staff talking to resident speech became garbled, looking (down) and not able to hold head up. Brought back into facility. Floor nurse came out to assess and speak to driver. Resident (alert and oriented x 2), pupils nonreactive, unable to hold head up, c/o (complains of) neck pain, S/T (Skin Tear) noted to L (Left) elbow , vitals obtained, resident fireman lifted to bed neck supported by ADON. Wife c (with) resident and aware. Hand grasps weak." On [DATE], at 12:15 PM, an interview was conducted with E6. E6 stated when she arrived at the incident site she was told R2 had fallen off the van lift. E6 stated R2's pupils were fixed and his chin was to his chest. E6 stated she had to take R2 back inside because she had no equipment to take vitals. E6 stated she noticed R2 wasn't himself so she asked another nurse to call the ambulance. When questioned why she didn't call 911, E6 responded " I had to get him in and assess him." E6 stated the staff told her when they got him up he was alert and oriented. E6 stated when she assessed him inside the facility he was alert but confused . E6 stated she told staff to put him to bed so the ambulance staff could transfer him to a board upon arrival. E6 stated "He did seem to be having pain in his neck." On [DATE] at 8:45 AM E8, LPN/ Restorative Nurse was interviewed in regards to the incident on [DATE]. E8 states that she was working on the 300 hall when staff called and said that R2 had fell off the lift. E8 stated that when she looked out the window he was in the wheelchair. E8 stated that by the time she got down there, they were bringing him down the hallway in the wheelchair. E8 stated the minute she saw him she knew there was something wrong. E8 stated that every time R2 would see her he would smile and say 'Hi' and give her a hug. E8 stated that she said 'Hi' to R2 and that he looked at her, but there was nothing there. E8 stated he was moaning in pain when laid in the bed. E8 stated R2 had a "goose egg" on the back of his head. On [DATE], at 1:24 PM, an interview was conducted with E9, LPN/Admission Coordinator. E9 confirmed she was the first nurse on the scene of this incident. E9 stated she was made aware by the van driver and Z1, R2's wife, R2 had been thrown off the lift. E9 stated that R2 was alert and able to answer questions when she arrived to assess his condition. E9 stated "I noticed he had pitechia on his head." When questioned what that may have indicated, E9 responded "Possibly he hit his head." E9 stated she assisted R2 into a wheelchair. E9 stated R2's speech became garbled. E9 stated that is why the staff moved him inside of the facility so they could get a better assessment. E9 stated R2 stated his neck hurt. E9 stated the they transferred R2 into bed. When asked when staff would call 911, she sated "We call 911 if there was a true emergency." On [DATE], at 12:13 PM, an interview was conducted with E2, Director of Nurse's (DON). E2 confirmed through the conversations she had with those who witnessed R2's incident, R2 was thrown from the lift. When questioned why R2 was transferred twice, E2 responded R2 was alert and talking after the incident. When questioned what would be done if a resident could have sustained a head injury from an incident, E2 responded "I think assessment would be first." E2 stated the facility had no "911 Policy". E2 stated she always tells her staff if there is a question to call 911. The website www.merckmanual.com on the topic "Spinal Trauma: Merck Manual Professional", printed on [DATE], documents "Overall, nearly 48% occur in motor vehicle crashes, and 23% results from falls; however, falls are the most common causes in the elderly." The website documents "An important goal is to prevent secondary injury to the spine or spinalcord. In unstable injuries, flexion or extension of the spine can contuse or transect the cord. Thus, when injured people are moved, inappropriate handling can precipitate [MEDICAL CONDITIONS], or even death from spinal injury. Patients who may have a spinal injury should have the spine immobilized immediately; the neck is held straight manually (in line stabilization) during endotracheal intubation. As soon as possible, the spine is fully immobilized on a firm, flat, padded backboard or similar surface to stabilize the position without excessive pressure. A rigid collar should be used to immobilize the cervical spine." The website documents "Suspect spinal cord injuries in patients who have a high-risk injury mechanism (including minor fall in the elderly), an altered sensorium, neurologic deficits suggesting cord injury, or localized spinal tenderness." The Immediate Jeopardy situation was identified to have begun on [DATE] when the facility van lift malfunctioned, catapulted R2 from the lift, and staff transferred R2 twice prior to calling 911. E1 and E2, Director of Nursing (DON), were notified of the Immediate Jeopardy on [DATE] at 2:45 PM. On [DATE], based on interviews, observation, and record review, the facility took the following actions to remove the Immediacy: 1. [DATE]- Immediately after the incident, the resident was assessed by licensed facility staff. 2. [DATE]- The facility reviewed the Occurence and Event Policy for accuracy. All facility staff were inserviced on the facility's Occurrence and Event Policy with an emphasis on prohibiting the movement of any persons with the potential for injury prior to an assessment by licensed personnel. This inservice commenced on [DATE] and has been repeated multiple times in order to ensure that all staff are reeducated with regard to the Occurrence and Event Policy prior to reporting for duty. Last inservice was completed on [DATE]. PRN (as needed) or FMLA (family medical leave act) staff will be inserviced prior to reporting for duty. Inservice being conducted under the direction of DON, Executive Director and/or their designee. DON will report compliance to the Quality Assurance (QA) Committee. 3. [DATE]- The facility DON will monitor ongoing compliance through direct observation of staff response to incidents and accidents as well as a formal review of the responses to all incidents and accidents for the next 4 weeks. The review of the responses to all accidents and incidents will be conducted at daily clinical meeting at the facility starting [DATE]. DON will report compliance to the QA Committee. B. Based on interview and record review, the facility neglected to develop and implement policy/procedures and provide routine maintenance of the mechanical lifts on the vans to prevent potential malfunction for 75 of 75 residents (R1, R2, R7, R11-R21, R23-R83) that potentially use the van lift in the sample of 83. This failure resulted in R2 being catapulted from the van lift, sustaining cervical spine fractures, and subsequently dying. This failure resulted in Immediate Jeopardy. While the immediacy was removed on [DATE], the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the facility policies and procedures and their system of communication. Findings Include: 1. The Facility had no documented policy regarding van lift routine maintenance. 2. R2's Progress Notes by E6, Licensed Practical Nurse (LPN) , dated [DATE], documents, "Transport manager called this writer at (11:00 AM) stating resident (R2) had tipped off of transport lift onto ground outside in the parking lot. Resident (R2) was lifted approx. (approximately) 6 inches off of ground on lift and equipment malfunctioned. Upon arriving to parking lot resident was sitting in w/c (wheelchair) with his head down, chin toward chest. Resident (R2) talking to staff but speech was slurred. Alert and oriented x 3. This writer brought resident back inside and obtained vitals, WNL (within normal limits). Resident (R2) speech remained slurred and pupils fixed, nonresponsive to light. Hand grasps equal but weak. Resident c/o (complaint of) pain in left shoulder and pain in neck. (Physician) called at (11:20 AM) and gave order to send to (local emergency department) for eval (evaluation) and treat. (Local) Ambulance called and arrived at (11:45 AM), resident (R2) left facility at (11:50 AM) via ambulance to (local emergency department.)" The Facility Incident/Accident Report, dated [DATE], documents, (in part) "Per ER (emergency room ) report, (R2) sustained a fracture to C6-C7 (cervical spine) and they were going to admit him overnight. There is no surgery planned at this time and it is anticipated that he will return to the facility." R2's Certificate of Death Worksheet, certified [DATE] for date of death [DATE], documents, "Cause of death- a. [MEDICAL CONDITION] due to (or as a consequence of): b. cervical spine fracture." On [DATE] at 10:00 AM, E3, Driver, was interviewed in regards to the incident involving R2 on [DATE]. E3 stated R2 was on the lift, and the lift went up approximately ,[DATE] inches, and the lift would not go up anymore. E3 stated he was beside the lift, not more the 2 feet away. E3 stated he called his boss from his cell phone, as phone was ringing, E3 stated he heard a spring effect sound, and R2 was catapulted from the lift. E3 stated the noise alone was what made him aware. E3 stated he was in shock. E3 stated R2 was thrown from the lift, out of his wheelchair, and onto the pavement on his left side. E3 stated that after R2 was thrown off the lift, then the lift did raise. E3 stated that the local handicap vehicle and mobility lift dealer said it was a bearing problem in the left arm of the lift. E3 stated he had problems with the lift before, as it would not go down. E3 stated that before the incident on [DATE], (the local city) Mass Transit District (MTD) did the work on the vans. E3 stated he did not think MTD worked on the lift, because it didn't get fixed. E3 stated the lift still would not lower. E3 stated after the incident with R2, the van was sent to (the local handicap vehicle and mobility lift dealer.) The Service Manual for the (lift dealer) Century Series Public Use Wheelchair Lifts, dated [DATE], documents a maintenance and lubrication schedule. The Maintenance and Lubrication Schedule documents proper maintenance is necessary to ensure safe trouble free operation. The manual documents inspecting the lift for any wear, damage or other abnormal conditions should be part of all transit agency's daily service program. The manual documents the maintenance and lubrication procedures specified in this schedule must be performed by a (lift dealer) authorized service representative at the scheduled intervals according to the number of cycles (movement of the lift up and down one time) The manual documents that all listed inspection, lubrication and maintenance procedures should be repeated at "750 cycle" intervals following the scheduled "4500 Cycles" maintenance. The manual documents these intervals are a general guideline for scheduling maintenance procedures and will vary according to lift use and conditions. Lifts exposed to severe conditions (weather, environment, heavy usage, etc) may require inspections and maintenance procedures performed more often than specified. The manual documents to discontinue lift use immediately if maintenance and lubrication procedures are not properly performed, or if there is any sign of wear, damage or improper operation. The manual documents a black box warning that maintenance and lubrication procedures must be performed as specified by an authorized service technician. Failure to do so may result in serious bodily injury and/or property damage. On [DATE] at 12:40 PM, Z5, (lift dealer) Service Representative was interviewed by telephone. Z5 stated that the maintenance described in the manual for lubricating and checking based on how many cycles is as important as getting the oil changed in your car. Z5 stated that if you don't take care of it, it will eventually bind up. On [DATE] at 11:09 AM, E4, Transportation Supervisor, was interviewed. E4 stated the facility takes the vans with the mechanical lifts out for maintenance when necessary, and every six months for certification by Illinois Department of Transportation. E4 stated that the certification involves the vehicle and the lift. E4 stated that MTD does maintenance on the vans and lifts. E4 stated that is done on a schedule basis by MTD. On [DATE], E4 was interviewed at 2:29 PM. E4 stated that he was not aware of any problems with the mechanical lift prior to the incident on [DATE]. E4 stated that he had no idea what a cycle was, and they normally do not take the vans with mechanical lifts in for maintenance unless there is a problem. E4 stated that is why the vehicles have a six month inspection by the Illinois Department of Transportation. When E4 was asked about the Illinois Department of Transportation Vehicle Inspection Forms not documenting any inspection of the mechanical lifts, E4 stated that he did not know how they do their inspections or what their inspection involves. On [DATE] at 8:45 AM E8, LPN/ Restorative Nurse was interviewed in regards to the incident on [DATE]. E8 stated a few days or a week before the incident involving R2, she had heard it discussed in morning meeting that they were going to get the van with the lift serviced. On [DATE] at 11:48 AM, Z3, (the local handicap vehicle and mobility lift dealer) Service Personnel was interviewed by telephone. Z3 stated they always type what the customer says on the work order. Z3 stated in the notes that is why "jerky" is in quotations. Z3 stated they do not automatically schedule for routine maintenance. Z3 stated they offer an equipment mobility inspection that includes greasing, checking fluid levels, checking for loose screws and bolts. Z3 stated they only do the equipment inspections if the customer requests the service. Z3 stated when they repaired the facility mechanical lift , they did not do a complete inspection. The facility's (local handicap vehicle and mobility lift dealer) invoice, dated [DATE], documents that the customer noted that lift is "jerky" and stalls. The invoice documents that on [DATE] trouble shooting lift problem, checked electronics and all lift functions for possible failures. Nothing found. Loaded lift and found lift arms binding. The invoice states they notified (the lift dealer) technicians and ordered new lift arms. On [DATE] new lift arms were installed and they discovered a wrong part had been ordered, so correct part was ordered and finished installing the correct part on. The invoice documents that on [DATE] installed new lift arm, checked all levels and adjusted accordingly, loaded lift, cycled lift multiple times, all operations checked good. On [DATE] at 3:13 PM, E1, Administrator, stated, "There is a bit of a mix up in regards to we don't take the van in for general maintenance and it is taken every 6 months for the safety inspection, and of course if something needs fixed, it goes into (MTD), or (the local handicap vehicle and mobility lift dealer,) whoever is available." The Cooperation Agreement between the MTD and the facility for Vehicle Repair and Maintenance Services (Regional Maintenance Program) dated [DATE] documents that MTD is a regional maintenance center designated by the Illinois Department of Transportation for the maintenance and repair of, among others, specialized equipment use on paratransit vehicles. The agreement documents scope of services under the agreement is to provide non-routine maintenance and repair services not generally available in the private sector for paratransit vehicles due to their specialized characteristics. However, the MTD will provide routine maintenance and repair services for items identified during the courtesy inspection, if desired by the agency. The agreement, under Courtesy inspection, documents when the agency vehicle is brought in, the MTD will perform a check-in courtesy inspection of the vehicle to assess its overall condition with particular attention to any problems identified by the agency. However, the MTD shall not be responsible for detecting any problems not identified by the agency. Z4, Superintendent of Maintenance Mass Transit District, was interviewed on [DATE] at 10:25 AM. Z4 stated that MTD is a Regional Maintenance Center. Z4 stated they do not automatically schedule routine maintenance. Z4 stated they offer a preventative maintenance program and they suggest that customers schedule every 3,000 miles instead of going by cycles. Z4 stated that the facility does not take advantage of that program. Z4 stated that every customer is provided a copy of work that was done. Z4 stated that the Illinois Department of Transportation Vehicle Inspection does not include inspection of any equipment added to the vehicle. Z4 states that the inspection only includes the chassis. On [DATE] at 10:51 AM, R1, a discharged resident that used the lift, was interviewed by telephone. R1 stated that while at the facility, he was going to an appointment on [DATE] and there was a problem with the lift. R1 stated the lift was going up, the lift stopped moving and would not go up. R1 stated the driver kept shaking the lift and pushing on it, and pushing the button. R1 stated the lift did finally go up. On [DATE], E1 provided a list of current residents (R7, R11-R21, R23-R83) that "have the potential to use the van." In an interview on [DATE] at 2:56 PM, E1 agreed that these are the residents that use the lift on the vans. The Immediate Jeopardy situation was identified to have begun on [DATE] when the facility van lift malfunctioned, catapulted R2 from the lift, and R2 sustained cervical spine fractures and subsequently died . The facility had yet to implement routine van lift maintenance per the lift manual. E1 and E2 were notified of the Immediate Jeopardy on [DATE] at 2:45 PM. On [DATE], based on interviews, observation, and record review, the facility took the following actions to remove the Immediacy: 1. [DATE]- Immediately after the incident, the resident was assessed by licensed facility staff. 2. [DATE]- The facility took the van and lift that was involved in the incident out of commission until the lift could be fully inspected to determine the nature of the malfunction. 3. [DATE]- The facility interviewed the driver to review the procedure that was utilized with R2 to determine if the proper procedure was filed. 4. [DATE]- The facility make all drivers aware of the lift issue and instructed not to use the van and lift to ensure that proper transfer procedures were utilized. 5. [DATE]- The facility van and lift were not returned to service until after the mechanism was repaired. 6. [DATE]- The facility removed the van and lift again from service and will be inspected and reviewed for maintenance. Any necessary or regularly scheduled maintenance in accordance with the manufacturer's recommendations will be completed on [DATE] at the local handicap vehicle and mobility lift dealer. Both vans and the respective lifts will be subject to routine maintenance beginning [DATE] and will be ongoing. 7. [DATE]- The facility Director of Transportation will monitor the maintenance schedule of the van and lift to ensure that it is being properly followed. A review and revision of the maintenance was completed and system was put into place to ensure ongoing compliance including daily, weekly and monthly checks starting [DATE]. The Director of Transportation provided disservice education to the transport drivers with regard to this revision and review on [DATE]. Administrator to monitor and report compliance to the QA Committee. 8. [DATE]- The facility reviewed the maintenance schedule for the van and lift to confirm that it had been properly followed.

Based on interview and record review, the facility failed to provide routine maintenance of the mechanical lifts on the vans to prevent potential malfunction for 75 of 75 residents (R1, R2,R7, R11-R21, R23-R83) that potentially use the van lift in the sample of 83. This failure resulted in R2 being catapulted from the van lift, sustaining cervical spine fractures, and subsequently dying. This failure resulted in Immediate Jeopardy. While the immediacy was removed on [DATE], the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the facility policies and procedures and their system of communication. Findings Include: R2's Progress Notes by E6, Licensed Practical Nurse (LPN) , dated [DATE], documents, "Transport manager called this writer at (11:00 AM) stating resident (R2) had tipped off of transport lift onto ground outside in the parking lot. Resident (R2) was lifted approx. (approximately) 6 inches off of ground on lift and equipment malfunctioned. Upon arriving to parking lot resident was sitting in w/c (wheelchair) with his head down, chin toward chest. Resident (R2) talking to staff but speech was slurred. Alert and oriented x 3. This writer brought resident back inside and obtained vitals, WNL (within normal limits). Resident (R2) speech remained slurred and pupils fixed, nonresponsive to light. Hand grasps equal but weak. Resident c/o (complaint of) pain in left shoulder and pain in neck. (Physician) called at (11:20 AM) and gave order to send to (local emergency department) for eval (evaluation) and treat. (Local) Ambulance called and arrived at (11:45 AM), resident (R2) left facility at (11:50 AM) via ambulance to (local emergency department.)" The Facility Incident/Accident Report, dated [DATE], documents, (in part) "Per ER (emergency room ) report, (R2) sustained a fracture to C6-C7 (cervical spine) and they were going to admit him overnight. There is no surgery planned at this time and it is anticipated that he will return to the facility." R2's Certificate of Death Worksheet, certified [DATE] for date of death [DATE], documents, "Cause of death- a. respiratory failure due to (or as a consequence of): b. cervical spine fracture." On [DATE] at 10:00 AM, E3, Driver, was interviewed in regards to the incident involving R2 on [DATE]. E3 stated R2 was on the lift, and the lift went up approximately ,[DATE] inches, and the lift would not go up anymore. E3 stated he was beside the lift, not more the 2 feet away. E3 stated he called his boss from his cell phone, as phone was ringing, E3 stated he heard a spring effect sound, and R2 was catapulted from the lift. E3 stated the noise alone was what made him aware. E3 stated he was in shock. E3 stated R2 was thrown from the lift, out of the wheelchair, and onto the pavement on his left side. E3 stated that after R2 was thrown off the lift, then the lift did raise. E3 stated that the local handicap vehicle and mobility lift dealer said it was a bearing problem in the left arm of the lift. E3 stated he had problems with the lift before, as it would not go down. E3 stated that before the incident on [DATE], (the local city) Mass Transit District (MTD) did the work on the vans. E3 stated he did not think MTD worked on the lift, because it didn't get fixed. E3 stated the lift still would not lower. E3 stated after the incident with R2, the van was sent to (the local handicap vehicle and mobility lift dealer.) The Service Manual for the (lift dealer) Century Series Public Use Wheelchair Lifts, dated [DATE], documents a maintenance and lubrication schedule. The Maintenance and Lubrication Schedule documents proper maintenance is necessary to ensure safe trouble free operation. The manual documents inspecting the lift for any wear, damage or other abnormal conditions should be part of all transit agency's daily service program. The manual documents the maintenance and lubrication procedures specified in this schedule must be performed by a (lift dealer) authorized service representative at the scheduled intervals according to the number of cycles (movement of the lift up and down one time) The manual documents that all listed inspection, lubrication and maintenance procedures should be repeated at "750 cycle" intervals following the scheduled "4500 Cycles" maintenance. The manual documents these intervals are a general guideline for scheduling maintenance procedures and will vary according to lift use and conditions. Lifts exposed to severe conditions (weather, environment, heavy usage, etc) may require inspections and maintenance procedures performed more often than specified. The manual documents to discontinue lift use immediately if maintenance and lubrication procedures are not properly performed, or if there is any sign of wear, damage or improper operation. The manual documents a black box warning that maintenance and lubrication procedures must be performed as specified by an authorized service technician. Failure to do so may result in serious bodily injury and/or property damage. On [DATE] at 12:40 PM, Z5, (lift dealer) Service Representative was interviewed by telephone. Z5 stated that the maintenance described in the manual for lubricating and checking based on how many cycles is as important as getting the oil changed in your car. Z5 stated that if you don't take care of it, it will eventually bind up. On [DATE] at 11:09 AM, E4, Transportation Supervisor, was interviewed. E4 stated the facility takes the vans with the mechanical lifts out for maintenance when necessary, and every six months for certification by Illinois Department of Transportation. E4 stated that the certification involves the vehicle and the lift. E4 stated that MTD does maintenance on the vans and lifts. E4 stated that is done on a schedule basis by MTD. On [DATE], E4 was interviewed at 2:29 PM. E4 stated that he was not aware of any problems with the mechanical lift prior to the incident on [DATE]. E4 stated that he had no idea what a cycle was, and they normally do not take the vans with mechanical lifts in for maintenance unless there is a problem. E4 stated that is why the vehicles have a six month inspection by the Illinois Department of Transportation. When E4 was asked about the Illinois Department of Transportation Vehicle Inspection Forms not documenting any inspection of the mechanical lifts, E4 stated that he did not know how they do their inspections or what their inspection involves. On [DATE] at 8:45 AM E8, LPN/ Restorative Nurse was interviewed in regards to the incident on [DATE]. E8 stated a few days or a week before the incident involving R2, she had heard it discussed in morning meeting that they were going to get the van with the lift serviced. On [DATE] at 11:48 AM, Z3, (the local handicap vehicle and mobility lift dealer) Service Personnel was interviewed by telephone. Z3 stated they always type what the customer says on the work order. Z3 stated in the notes that is why "jerky" is in quotations. Z3 stated they do not automatically schedule for routine maintenance. Z3 stated they offer an equipment mobility inspection that includes greasing, checking fluid levels, checking for loose screws and bolts. Z3 stated they only do the equipment inspections if the customer requests the service. Z3 stated when they repaired the facility mechanical lift , they did not do a complete inspection. The facility's (local handicap vehicle and mobility lift dealer) invoice, dated [DATE], documents that the customer noted that lift is "jerky" and stalls. The invoice documents that on [DATE] trouble shooting lift problem, checked electronics and all lift functions for possible failures. Nothing found. Loaded lift and found lift arms binding. The invoice states they notified (the lift dealer) technicians and ordered new lift arms. On [DATE] new lift arms were installed and they discovered a wrong part had been ordered, so correct part was ordered and finished installing the correct part on. The invoice documents that on [DATE] installed new lift arm, checked all levels and adjusted accordingly, loaded lift, cycled lift multiple times, all operations checked good. On [DATE] at 3:13 PM, E1, Administrator, stated, "There is a bit of a mix up in regards to we don't take the van in for general maintenance and it is taken every 6 months for the safety inspection, and of course if something needs fixed, it goes into (MTD), or (the local handicap vehicle and mobility lift dealer,) whoever is available." The Cooperation Agreement between the MTD and the facility for Vehicle Repair and Maintenance Services (Regional Maintenance Program) dated [DATE] documents that MTD is a regional maintenance center designated by the Illinois Department of Transportation for the maintenance and repair of, among others, specialized equipment use on paratransit vehicles. The agreement documents scope of services under the agreement is to provide non-routine maintenance and repair services not generally available in the private sector for paratransit vehicles due to their specialized characteristics. However, the MTD will provide routine maintenance and repair services for items identified during the courtesy inspection, if desired by the agency. The agreement, under Courtesy inspection, documents when the agency vehicle is brought in, the MTD will perform a check-in courtesy inspection of the vehicle to assess its overall condition with particular attention to any problems identified by the agency. However, the MTD shall not be responsible for detecting any problems not identified by the agency. Z4, Superintendent of Maintenance Mass Transit District, was interviewed on [DATE] at 10:25 AM. Z4 stated that MTD is a Regional Maintenance Center. Z4 stated they do not automatically schedule routine maintenance. Z4 stated they offer a preventative maintenance program and they suggest that customers schedule every 3,000 miles instead of going by cycles. Z4 stated that the facility does not take advantage of that program. Z4 stated that every customer is provided a copy of work that was done. Z4 stated that the Illinois Department of Transportation Vehicle Inspection does not include inspection of any equipment added to the vehicle. Z4 states that the inspection only includes the chassis. On [DATE] at 10:51 AM, R1, a discharged resident that used the lift, was interviewed by telephone. R1 stated that while at the facility, he was going to an appointment on [DATE] and there was a problem with the lift. R1 stated the lift was going up, the lift stopped moving and would not go up. R1 stated the driver kept shaking the lift and pushing on it, and pushing the button. R1 stated the lift did finally go up. On [DATE], E1 provided a list of current residents (R7, R11-R21, R23-R83) that "have the potential to use the van." In an interview on [DATE] at 2:56 PM, E1 agreed that these are the residents that use the lift on the vans. The Immediate Jeopardy situation was identified to have begun on [DATE] when the facility van lift malfunctioned, catapulted R2 from the lift, and R2 sustained cervical spine fractures and subsequently died . The facility had yet to implement routine van lift maintenance per the lift manual. E1 and E2, Director of Nursing (DON), were notified of the Immediate Jeopardy on [DATE] at 2:45 PM. On [DATE] based on interviews, observation, and record review, the facility took the following actions to remove the Immediacy: 1. [DATE]- Immediately after the incident, the resident was assessed by licensed facility staff. 2. [DATE]- The facility took the van and lift that was involved in the incident out of commission until the lift could be fully inspected to determine the nature of the malfunction. 3. [DATE]- The facility interviewed the driver to review the procedure that was utilized with R2 to determine if the proper procedure was filed. 4. [DATE]- The facility make all drivers aware of the lift issue and instructed not to use the van and lift to ensure that proper transfer procedures were utilized. 5. [DATE]- The facility van and lift were not returned to service until after the mechanism was repaired. 6. [DATE]- The facility removed the van and lift again from service and will be inspected and reviewed for maintenance. Any necessary or regularly scheduled maintenance in accordance with the manufacturer's recommendations will be completed on [DATE] at the local handicap vehicle and mobility lift dealer. Both vans and the respective lifts will be subject to routine maintenance beginning [DATE] and will be ongoing. 7. [DATE]- The facility Director of Transportation will monitor the maintenance schedule of the van and lift to ensure that it is being properly followed. A review and revision of the maintenance was completed and system was put into place to ensure ongoing compliance including daily, weekly and monthly checks starting [DATE]. The Director of Transportation provided disservice education to the transport drivers with regard to this revision and review on [DATE]. Administrator to monitor and report compliance to the QA Committee. 8. [DATE]- The facility reviewed the maintenance schedule for the van and lift to confirm that it had been properly followed.

Based on interview and record review, the facility failed to adequately assess/ monitor and call 911 for 1 of 3 residents (R2) reviewed for nursing care provided immediately following an injury. This failure resulted in R2 being moved and a delay in transport during change in mental status due to being thrown off of a mechanical wheelchair lift on a van. R2 sustained C6-C7 cervical fractures and subsequently died . This resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the facility policies and procedures and their system of communication. Findings Include: R2's Minimum Data Set (MDS) , dated [DATE], documents that R2 requires extensive physical assistance of one person for transfers and has severe cognitive impairment. R2's Care Plan, initiated [DATE], documents that R2 is at a risk for falls related to frequent fall history and recent fracture related to a fall at home. R2's Progress Notes by E6, Licensed Practical Nurse (LPN), dated [DATE], documents, "Transport manager called this writer at (11:00 AM) stating resident (R2) had tipped off of transport lift onto ground outside in the parking lot. Resident (R2) was lifted approx. (approximately) 6 inches off of ground on lift and equipment malfunctioned. Upon arriving to parking lot resident was sitting in w/c (wheelchair) with his head down, chin toward chest. Resident (R2) talking to staff but speech was slurred. Alert and oriented x 3. This writer brought resident back inside and obtained vitals, WNL (within normal limits). Resident (R2) speech remained slurred and pupils fixed, nonresponsive to light. Hand grasps equal but weak. Resident c/o (complaint of) pain in left shoulder and pain in neck. (Physician) called at (11:20 AM) and gave order to send to (local emergency department) for eval (evaluation) and treat. (Local) Ambulance called and arrived at (11:45 AM), resident (R2) left facility at (11:50 AM) via ambulance to (local emergency department.)" R2's Hospital Discharge Summary dated [DATE], documents " He (R2) sustained injuries including a fracture of C7 and C6." The Summary documents "He failed his speech swallow study and was given a Keofeed and provided with nutrition by tube feeds. Ortho spine discussed the patient's situation with the family and the patient, and they opted for nonoperative course." The Summary documented the family chose not place a feeding tube and opted for comfort care and Hospice. R2's Death Certificate, dated [DATE], documents his cause of death as [MEDICAL CONDITION] and Cervical Spine Fracture. Risk Management Witness Interview Form, dated [DATE], written by E9, LPN/Admission Coordinator, documented "Myself, CNA and other nurse assessed him (R2). Assisted him up to w/c. Staff talking to resident speech became garbled, looking (down) and not able to hold head up. Brought back into facility. Floor nurse came out to assess and speak to driver. Resident (alert and oriented x 2), pupils nonreactive, unable to hold head up, c/o (complains of) neck pain, S/T (Skin Tear) noted to L (Left) elbow , vitals obtained, resident fireman lifted to bed neck supported by ADON. Wife c (with) resident and aware. Hand grasps weak." On [DATE], at 12:15 PM, an interview was conducted with E6. E6 stated when she arrived at the incident site she was told R2 had fallen off the van lift. E6 stated R2's pupils were fixed and his chin was to his chest. E6 stated she had to take R2 back inside because she had no equipment to take vitals. E6 stated she noticed R2 wasn't himself so she asked another nurse to call the ambulance. When questioned why she didn't call 911, E6 responded " I had to get him in and assess him." E6 stated the staff told her when they got him up he was alert and oriented. E6 stated when she assessed him inside the facility he was alert but confused . E6 stated she told staff to put him to bed so the ambulance staff could transfer him to a board upon arrival. E6 stated "He did seem to be having pain in his neck." On [DATE] at 8:45 AM E8, LPN/ Restorative Nurse was interviewed in regards to the incident on [DATE]. E8 states that she was working on the 300 hall when staff called and said that R2 had fell off the lift. E8 stated that when she looked out the window he was in the wheelchair. E8 stated that by the time she got down there, they were bringing him down the hallway in the wheelchair. E8 stated the minute she saw him she knew there was something wrong. E8 stated that every time R2 would see her he would smile and say 'Hi' and give her a hug. E8 stated that she said 'Hi' to R2 and that he looked at her, but there was nothing there. E8 stated he was moaning in pain when laid in the bed. E8 stated R2 had a "goose egg" on the back of his head. On [DATE], at 1:24 PM, an interview was conducted with E9, LPN/Admission Coordinator. E9 confirmed she was the first nurse on the scene of this incident. E9 stated she was made aware by the van driver and Z1, R2's wife, R2 had been thrown off the lift. E9 stated that R2 was alert and able to answer questions when she arrived to assess his condition. E9 stated "I noticed he had pitechia on his head." When questioned what that may have indicated, E9 responded "Possibly he hit his head." E9 stated she assisted R2 into a wheelchair. E9 stated R2's speech became garbled. E9 stated that is why the staff moved him inside of the facility so they could get a better assessment. E9 stated R2 stated his neck hurt. E9 stated the they transferred R2 into bed. When asked when staff would call 911, she sated "We call 911 if there was a true emergency." On [DATE], at 12:13 PM, an interview was conducted with E2, Director of Nurse's (DON). E2 confirmed through the conversations she had with those who witnessed R2's incident, R2 was thrown from the lift. When questioned why R2 was transferred twice, E2 responded R2 was alert and talking after the incident. When questioned what would be done if a resident could have sustained a head injury from an incident, E2 responded "I think assessment would be first." E2 stated the facility had no "911 Policy". E2 stated she always tells her staff if there is a question to call 911. The website www.merckmanual.com on the topic "Spinal Trauma: Merck Manual Professional", printed on [DATE], documents "Overall, nearly 48% occur in motor vehicle crashes, and 23% results from falls; however, falls are the most common causes in the elderly." The website documents "An important goal is to prevent secondary injury to the spine or spinalcord. In unstable injuries, flexion or extension of the spine can contuse or transect the cord. Thus, when injured people are moved, inappropriate handling can precipitate [MEDICAL CONDITIONS], or even death from spinal injury. Patients who may have a spinal injury should have the spine immobilized immediately; the neck is held straight manually (in line stabilization) during endotracheal intubation. As soon as possible, the spine is fully immobilized on a firm, flat, padded backboard or similar surface to stabilize the position without excessive pressure. A rigid collar should be used to immobilize the cervical spine." The website documents "Suspect spinal cord injuries in patients who have a high-risk injury mechanism (including minor fall in the elderly), an altered sensorium, neurologic deficits suggesting cord injury, or localized spinal tenderness." The Facility's Policy "Occurrence and Event Policy", revision date [DATE], was reviewed. This policy did not address what procedures should be taken if a resident has a potential head or spinal cord injury. The Immediate Jeopardy situation was identified to have begun on [DATE] when the facility van lift malfunctioned, catapulted R2 from the lift, and staff transferred R2 twice prior to calling 911. E1 and E2, Director of Nursing (DON), were notified of the Immediate Jeopardy on [DATE] at 2:45 PM. On [DATE] based on interviews, observation, and record review, the facility took the following actions to remove the Immediacy: 1. [DATE]- Immediately after the incident, the resident was assessed by licensed facility staff. 2. [DATE]- The facility reviewed the Occurrence and Event Policy for accuracy. All facility staff were inserviced on the facility's Occurrence and Event Policy with an emphasis on prohibiting the movement of any persons with the potential for injury prior to an assessment by licensed personnel. This inservice commenced on [DATE] and has been repeated multiple times in order to ensure that all staff are reeducated with regard to the Occurrence and Event Policy prior to reporting for duty. Last inservice was completed on [DATE]. PRN (as needed) or FMLA (family medical leave act) staff will be inserviced prior to reporting for duty. Inservice being conducted under the direction of DON, Executive Director and/or their designee. DON will report compliance to the Quality Assurance (QA) Committee. 3. [DATE]- The facility DON will monitor ongoing compliance through direct observation of staff response to incidents and accidents as well as a formal review of the responses to all incidents and accidents for the next 4 weeks, The review of the responses to all accidents and incidents will be conducted at daily clinical meeting at the facility starting [DATE]. DON will report compliance to the QA Committee.

Based on observation, interview and record review the facility failed to identify hazards and risks and provide supervision to prevent avoidable accidents for one of four residents (R4)with a history of falls in a total sample of six. This failure resulted in R4 sustaining a right temporal acute subdural hematoma, small intraparenchymal hemorrhage to the right front lobe and large right scalp hematoma. Findings include: R4's Physicians Order Sheet (POS) dated 11/1/2014 to 11/30/2014, documented R4's [DIAGNOSES REDACTED]. R4's Minimum Data Set ((MDS) dated [DATE], documented R4's Brief Interview for Mental Status (BIMS) as 11 (Score 8-12: moderately impaired cognition). R4's MDS documented R4's needs extensive assistance with one person physical assist for transfers. The MDS documents R4 needs extensive assistance of two person physical assist for toileting. R4's Care Plan, date initiated 5/15/13, Revision date 6/3/13, documented, follow facility fall protocol/falling star program. The facility's Falling Star Protocol, not dated, documented, "The falling star protocol is a center based portion of the Fall Management Program. Purpose: To identify residents who are at risk for falling. To ensure residents benefit from participation. To distinguish residents with a visual identifier 'Falling Star' To include staff and families in fall prevention strategies. Protocol: A resident qualifies for the Falling Star Program if: They have fallen within 30 days prior to admission. Experience a change in condition or decline in Activities of Daily Living. Fallen in the facility. The resident is identified by a star on their name plate outside their door and on their wheelchair/walker." The facility's Incident Log for September documented R4 had fallen on 9/9/14 and 9/11/14. The Incident Log documented R4 did not fall in October. In November R4 fell on [DATE] which resulted in a hematoma to R4's forehead. On 11/16/14 R4 fell which resulted in a hematoma to R4's forehead and subdural hematoma. Nurse's Notes dated 11/16/14 at 2:45 PM, documented, "Writer heard slapping noise in the hallway and went down to residents room. Observed resident lying on the floor on right side with right arm under body and visible blood under her face. Co-nurse was present and immediately placed pillow under head. Co-nurse began first aide and cleansed area and applied cool compress to slow bleeding. Hematoma visible at left upper corner of forehead (3.5 centimeters (cm) x 4 cm), raised by 2 cm with laceration in center of hematoma. New orders were received from Personal Care Physician (PCP) to send (R4) to the emergency room for evaluation." The hospitalization Summary dated 11/19/14, documented, included, R4 was admitted to the hospital on [DATE] and discharge back to the facility on [DATE]. Cat scan of head documented "1. Small right temporal acute subdural hematoma. 2. There is a tiny, 5 millimeter intraparenchymal hemorrhage in the right frontal lobe without significant associated edema/mass effect. 3. Large right scalp hematoma. 4. Volume loss and chronic ischemic microangiopathy." On 11/25/14 at 10:50 AM, R4 was observed sitting in her wheelchair in the middle of 200 hallway. R4 was asking "Where am I?" R4 had a large amount of purple bruising on the top of her nose, on both right and left cheeks and under her chin. Yellowish brown bruising noted to her forehead. R4 was asked what had happened to her and replied "I fell down." On 11/25/14 at 10:50 AM and 3:07 PM, No falling star was observed on R4's door or R4's wheelchair. On 11/25/14 at 3:07 PM, E8, Licensed Practical Nurse (LPN) was asked what does it mean when a star is on one side of the door. E8 said the side of the door where the star is, means that resident is on the falling star program. E8 was asked why there was no star on R4's door or wheelchair. E8 said "There should be a star on R4's door and wheelchair, it must have fallen off." On 11/25/14 at 8:57 AM, Z1, R4's daughter/ Power of Attorney, was asked about R4's fall on 11/16/14. Z1 said, R4 was assisted to the bathroom and on the toilet riser. The staff then gave R4 the call light and left her in the bathroom alone. Z1 said the staff found R4 beside her bed on the floor with her head facing toward the foot of the bed and her pants were half way down. Z1 said she did not know how R4 managed to get from the bathroom to the bed with her pants half way down. Z1 said R4 cannot manage sitting on the toilet by herself. Z1 stated R4 needs someone to stay with her because she will just get up when she is finished and not wait for help. On 11/26/14 at 11:21 AM, E8 was asked if on 11/16/14 prior to R4's fall if R4 had been in the bathroom and walking back to her bed without assistance. E8 said she could have been. E8 was asked if any staff would take R4 to the bathroom and give her the call light and tell her to call for help when she was finished. E8 said, "No one was to leave her alone on the toilet because (R4) was on the falling star program and could not be left alone in the bathroom." E8 said R4 was noncompliant about turning on her call light and asking for help. Nurse's notes dated 9/6/14 at 1:40 PM, documented, "Resident non compliant with transfer and putting herself to bed. Nurse's Noted dated 9/6/14 at 9:29 AM, documents "Resident is non compliant with asking and waiting for help with going to the restroom or getting into bed." R4's Nurse's Note, on 10/26/14 at 11:02 AM, documents "Resident attempting to self transfer from her bed to the bathroom. Resident reminded that she needed assistance with ambulation and transfers." R4's Nurse's Note on 10/27/14 at 1:01 PM, documents "Resident noted to be self ambulating in her room without her walker. Resident states that she was going to the bathroom. Staff assisted resident to the bathroom. Afterwards resident was placed by the nurses station for observation." On 11/16/14 at 9:14 AM, Nurse's Notes documented "Resident non-compliant with waiting for help. Resident will turn her call light on but not wait for someone to help her. Resident has been explained that she really needs to wait for help so she doesn't fall again and get hurt." The facility's Fall Incident/Occurrence witness statement dated 11/16/14 at 2:45 PM, written by E9, Certified Nurse's Assistant (CNA) , documented, R4 was found in her restroom at 2:43 PM. E9 statement documented E9 left R4 in the restroom to see why the resident across the hall was hollering and heard the nurse running down the hall to R4's room. The Fall Incident/Occurrence, witness statement dated 11/16/14 at 2:45 PM, written by, E10, Registered Nurse (RN) documented "Walking by residents room as I was coming into work today and saw staff running to (R4's) room. (R4) was lying on her right side on the floor beside her bed. Her pants were half way up. Resident fell yesterday as well. Direct pressure applied to bleeding hematoma on right forehead. Bleeding stopped. Ice then applied to hematoma. Appears the resident also broke nose as septum deviated, swollen and bleeding. (E9) said she put R4 in her bathroom, call bell given. Resident instructed to stay there and use call bell when finished. had shoes and socks on, pants halfway up."

Based on record review and interview, the Facility failed to provide adequate supervision for 2 of 2 resident's (R2, R4) reviewed for falls in the sample of 5. This failure resulted in both R2 and R4 experiencing falls while being toileted. R2 sustained an impacted subcapital fracture of her right hip. R4 sustained a fracture of her left femur. Findings include: 1. The Facility "Accident/Incident Report" for R4, dated [DATE], documents that at 7:40 AM "while transferring off toilet, resident became combative with Certified Nurses Aide (CNA) hitting and scratching, trying to sit mid-transfer. Staff lowered resident to the floor with residents left leg bent behind resident. Resident is alert with confusion. While being toileted with staff, CNA stood resident up off of the toilet. According to the CNA, the resident then became agitated and started hitting and scratching staff. Resident then started to lose balance and staff lowered resident to the floor with the gait belt. Resident was noted with her left leg bent behind her and right leg straight out in front of her. Resident admitted to the hospital with [REDACTED]. The "Accident/Incident Reports" for R4 documents that she experienced previous falls while walking in the Facility on [DATE], [DATE], [DATE] and [DATE]. These reports document the following: "[DATE], 1:00 PM, Resident was walking with staff and was lowered to the floor with the gait belt. No injuries". The investigation does not document potential causative factors or corrective actions based on the causative factors. "[DATE], 12:45 PM, No injuries noted. Resident was lowered to floor by staff utilizing a gait belt. Resident was being walked by a CNA with gait belt when resident started to sit down and was lowered to floor". The investigation does not document potential causative factors or corrective actions based on the causative factors. "[DATE], 10:00 AM, CNA was assisting the resident to the bathroom with the gait belt when resident took about 4 steps and her legs gave out. Second CNA lowered her to the floor. No apparent injuries". The investigation does not document potential causative factors or corrective actions based on the causative factors. "[DATE], 10:00 AM, Resident was being transferred from her wheelchair to her recliner when her legs buckled and she was lowered to the floor by the CNA. There are no potential causative factors documented on the investigation. The "Plan of Action to Prevent Reoccurrence" documents "therapy to screen for transfers, possible two staff transfers". During an interview with E3, Restorative Nurse, on [DATE], at 2:05 PM, it was confirmed that the investigations into R4's falls were not complete. E3 said that she does remember actions which were taken for most of R4's falls. These actions are as follows: E3 stated that for the fall on [DATE], the Facility decided to institute rest breaks while they were walking with R4. E3 said that R4's family did not want R4 to use a wheelchair, as was suggested by the Facility. E3 said that R4 has a lot of behaviors - "if she wanted to sit, she would just sit right down". E3 confirmed that the Facility did not document potential causative factors for the fall. After R4 fell on [DATE], E3 said that she asked R4's family if the Facility could utilize a wheelchair for transporting R4. E3 said that R4's family refused however, they suggested that staff follow R4 with a wheelchair when staff are ambulating R4. E3 said that therapy evaluated R4 at that time. Therapy told E3 that R4 had reached her maximum potential and was not a candidate for additional therapy. E3 said that R4 had no signs of weakness - she would just sit down. E3 confirmed that the Facility did not document potential causative factors for this fall. E3 said that she spoke to R4's family about making an appointment for R4 with the psychiatrist as she felt that R4's falls were due to behaviors. E3 said that soonest that the psychiatrist could see R4 was in February 2012. E3 said that she contacted R4's physician, and they changed the times of R4's Seroquel. E3 confirmed that the Facility did not assess for any other causative factors besides behaviors. E3 said that she remembers asking therapy to screen R4 for utilizing two staff members while transferring R4 after her fall on [DATE]. E3 said that therapy did not assess R4 until [DATE] and when they did assess her, it was for wheelchair positioning - not for her falls. E3 confirmed that the Facility did not institute two person transfers for R4. During an interview with E2, Director of Nursing, on [DATE], at 2:30 PM, E2 stated that the Facility felt that R4's falls were caused due to her behaviors. E2 confirmed that the Facility's investigations into R4's falls did not document potential causative factors with subsequent corrective action based on those factors. R4's Minimum Data Set (MDS), dated [DATE], documents: behaviors of inattention, disorganized thinking; requires extensive physical assistance of one person for transfers, bed mobility and ambulation; unsteadiness in transfers, walking and moving on and off the toilet; and, no impairments in range of motion. R4's Care Plan, with a start date of [DATE] documents the following: "Problem in moderate cognitive impairment, anxiety/anxiousness, agitation, tearfulness/crying episodes. Has [DIAGNOSES REDACTED]. Will frequently attempt to self transfer or ambulate. Not always compliant with safety measures. Vision poor in right eye. Currently taking an anti-depressant, anti-anxiety and anti-psychotic". Approaches for this problem includes: "Remind R4 about the personal alarm system and what it means to her. Monitor Frequently. Walk as needed with appropriate discipline. Verbal reminders not to rise without assist". R4's plan of care also documents a "Problem" of "has impaired safety with risk for falls related to impaired mobility, impaired cognition, poor balance and poor safety awareness. She fell at home in [DATE] and fractured her left wrist. She attempts to self transfer frequently and a personal alarm is in place at all times to remind her to sit back down". Approaches for this problem document the following: "E4 is to rest in recliner after dinner. Offer rest periods when ambulating. Verbal reminders not to ambulate or transfer without assist". R4's plan of care does not address how the number of staff members that should be present when transferring R4. R4's plan of care does not address her legs bucking while she is walking. R4's hospital "history and physical examination the patient had a fall and sustained a left femur fracture. She was admitted to the hospital and had surgical repair on [DATE]. The patient was fairly lethargic and more confused than usual. Once the patient was stable from a medical/orthopedic standpoint, there was initial discussion about extended-care facility transfer. However, given her history of recurrent delirium and postoperative status, it was recommended to stabilize her mental status and nutrition while providing physical therapy. Family is aware that the patient's prognosis is guarded at this time related to her age, dementia and postoperative status. She has a component of failure to thrive at this time". R4 was readmitted to the facility on [DATE]. R4's Physician order [REDACTED]. 2. The Facility "Incident/Accident Report" for R2 documents that on [DATE], at 1:45 PM, "Resident was observed on the floor with her back against the wall and both lower extremities extended toward the toilet. This [AGE] year old female was admitted to the facility on [DATE], and is currently on hospice care with the following [DIAGNOSES REDACTED]. Prior to the fall, resident is alert with confusion, able to make needs and wants known at times. Prior to fall, resident's transfer and ambulation status is assist of one staff with gait belt, moderate to maximum assist with wheeled walker. On [DATE], staff observed resident in upright sitting position, back against wall with legs extended forward, in bathroom. Upon nurse's exam, resident was complaining of pain to right hip, pain medication given and pain was monitored. Physician notified and new orders received to send to emergency room (E.R.) to evaluate and treat. At 6:45 PM, on [DATE], resident returned to the Facility via stretcher with a [DIAGNOSES REDACTED]. The "Investigation Conclusion" for this incident documents "Resident was toileted in the shower room. As staff turned away to grab wipes, resident attempted to get up or may have leaned forward too far. Shower room toilet does not have a toilet riser and handle bars like R2 has in her bathroom in bedroom does, so resident did not have the arm bar support. R2 also had regular socks on which can cause a slick surface". On [DATE], at 2:10 PM, E2 stated that the CNA involved in R2's fall was fired as she left the resident while R2 was sitting on the toilet and did not stand by her side. E2 said that the CNA went to get something out of the cupboard. The "Final Report" from R2's visit to the E.R. on [DATE] documents "Patient brought in by Emergency Management Services. Patient fell on to right side at nursing home. Fall was witnessed by staff. No loss of consciousness and patient did not hit head. Patient complains of pain to right hip/leg. Patient has dementia and combative. Long discussion with Power of Attorney. R2 is a hospice patient. Family not wanting further treatment - wanting comfort. Will adjust pain management and discharge". R2's radiology report from the hospital E.R, dated [DATE], documents that "There is an impacted subcapital fracture of the right femur. Generalized osteopenia". Facility nurses notes document that R2 was transported by ambulance to the hospital on [DATE] at 2:20 PM, and returned to the Facility at 6:45 PM. The following is documented in R2's nurses notes: "[DATE], 7:30 PM, R2 attempted to use bedpan but pain was too severe. Indwelling catheter inserted. Tolerated well. Morphine and Ativan given. [DATE], 1:50 PM, Has been sleepy most of the day. Hospice has been called related to R2's lethargy. [DATE], 1:30 PM, Resident very lethargic today. Continues on bedrest. Resident did not eat or drink today. [DATE], 7:00 AM, Resident continues to be lethargic, not easily aroused. Resident not alert enough to suck on straw for drinks. 12:00 PM, R2 continues to be lethargic. Yells out when turned and repositioned. 6:40 PM, Daughter came running from the resident's room saying "Mom said that she can't breathe". Resident not in respiratory distress but coughing. Tried to place resident on oxygen but resident refused. [DATE], 12:20 AM, Resident expired." R2's "Fall Risk Assessment", dated [DATE], documents that R2 was at "High Risk" for falls. R2's MDS, dated [DATE], documents that R2 sometimes understood verbal content-responded adequately to simple, direct communication only; had short and long term memory problems; had moderate impairment in cognitive skills for daily decision making; behaviors of inattention and disorganized thinking; did not ambulate; required the extensive assistance of one staff member for transfers and toilet use; and had unsteady balance in moving on and off the toilet.

Based on record review and interview, the Facility failed to correctly administer medications to the resident it was prescribed for 1 of 5 residents (R1) reviewed for medications in the sample of 5. This failure resulted in R1 being hospitalized for [REDACTED]. Findings include: The "Medication Incident Report", dated 12/30/11, 8:45 AM, documents that "R1 was given the wrong medications. The nurse was told his room number was 408. The nurse called him by another patients name and this patient never corrected the nurse. There was no picture in resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]". R1's nurses notes document that he was admitted to the Facility from the hospital on [DATE], following surgery for [REDACTED]. a history of [MEDICAL CONDITION] and [MEDICAL CONDITION]. R1's "Physician's Progress Notes", written and signed by E6, Nurse Practitioner, document "12/30/11, 11:30 AM, Patient is [AGE] year old man who was recently admitted to Facility from hospital for additional therapy. This morning, he received another patients medications in error, including [MEDICATION NAME], [MEDICATION NAME] and [MEDICATION NAME]. R1 states that at the present time, he does not feel very well and is very nauseous. He has not actually vomited at this point but, feels he could at any time. His appetite has been poor thus far and he is unsure if he can eat the soup that was just brought to him. He does take [MEDICATION NAME] on a daily basis due to a history of [MEDICAL CONDITIONS] but the dose today was double his usual dose. Will continue with 30 minute vital sign checks and begin Accuchecks every hour. Should patient become un-stable at any time, including drop in blood pressure below parameters, loss of consciousness or if we feel patient needs to be monitored more closely for any reason, we will immediately transfer him to the hospital. Will consider adding intravenous fluid to help flush medication from patient's system, however given his history of [MEDICAL CONDITION] we will need to proceed carefully. Explained to patient the importance of eating and drinking at this time and frequency throughout the afternoon to avoid hypoglycemic episode." R1's physician's orders [REDACTED].(cc) per hour for [DIAGNOSES REDACTED]. Call for BP less than 85 mmHg. Accucheck's every hour until blood sugar remains above 80 for 3 consecutive readings and patient is eating, then in the morning and at bedtime. May give Glucose 1 tube as needed for blood sugar less than 70 or 1 [MEDICATION NAME] of [MEDICATION NAME] SQ as needed if blood sugar less than 70. 3:00 PM, Give 1 tube of Glucose orally now for blood sugar of 66 and recheck blood sugar in 15 minutes. Increase D5 1/2 Normal Saline to 100 cc's per hour. 4:30 PM, Certified Nurses Aide (CNA) reported blood pressure (BP) low, 76/44 mmHg. [MEDICAL CONDITION] - believe acute drop in BP due to medication peaking, which could lead to acute [MEDICAL CONDITION], secondary to lack of perfusion. For this reason, believe it would be best for a patient to be transferred to the emergency room for additional support and monitoring. Intravenous fluid continued for transport". R1's emergency room notes documents that "patient is sent from nursing home after he's had persistent [MEDICAL CONDITION] after he was given the wrong medications earlier today. He became hypotensive and despite IV hydration at the nursing home, remained hypotensive. When he arrives at the emergency room he remained asymptomatic other than his blood pressure is low with a systolic blood pressure in the 70's. Electrocardiogram (EKG) shows sinus [MEDICAL CONDITION] with a ventricular rate of 59. Nothing acute. Patient was stable on arrival. Patient was given 2 [MEDICATION NAME] of 0.9 normal saline 250 milliliters each [MEDICATION NAME] with improvement of his blood pressure to a systolic pressure in the 90's". R1's nurses notes document "12/31/11, 2:00 AM, Spoke with hospital. Resident admitted with [DIAGNOSES REDACTED]. The Hospital "Clinical Resume" for R1, dated 1/5/12, documents that he was discharged from the hospital on [DATE] and sent to another facility. This "Clinical Resume" documents that R1 was hospitalized due to "Accidental overdose at the nursing home. This [AGE] year old gentleman had been discharged following surgical procedure with a small bowel resection and lysis of adhesions, and status [REDACTED]. He had gone to the nursing home for therapy. There, he received medications that were not his including [MEDICATION NAME], aspirin, [MEDICATION NAME] and [MEDICATION NAME]. He developed significant [DIAGNOSES REDACTED] and [MEDICAL CONDITION] and was brought to the E.R. He was admitted and resuscitated from these matters and the rest of his course was relatively unremarkable, although he did have difficulty with [MEDICAL CONDITION]". During an interview with E5, Licensed Practical Nurse, on 1/10/12 at 3:00 PM, E5 stated that R1 was sitting in the hallway and someone told her the wrong room number for R1. R1 was a new admit and she could not recall what he looked like. E5 said that she called R1 by the wrong name twice and he never said anything. E5 said that R1 told her that there were more medications than he was used to but, E5 said new resident's often say that. E5 said that she was working down the hall when she overheard one of the therapists asking R1 if he went by R5's first name. R1 said "No, I'm (R1)". E5 said that's when she knew she had made an error. E5 said that she immediately reported her error to R1's physician and E2, the Director of Nursing. E5 said that R1 had been complaining of nausea before he got the wrong pills and also stated that his blood pressure runs low. R1's physician's orders [REDACTED]. R5's physician's orders [REDACTED]. The 2012 Nursing Drug Handbook documents the corresponding indications for usage and adverse reactions for the following medications which R1 received in error: [MEDICATION NAME] - used for chronic stable [MEDICAL CONDITION]. Adverse reactions include: fatigue, dizziness, light headedness. Because drug is metabolized by the liver, use cautiously in patient's with severe hepatic disease. [MEDICATION NAME] - used for hypertension. Adverse reactions include: [MEDICAL CONDITION], stroke, [MEDICAL CONDITION], fatigue, dizziness. [MEDICATION NAME] - used for adjunct to diet to lower glucose level in patients with Type 2 diabetes. Adverse reactions include: Anorexia, headache, nausea, vomiting and weakness. [DIAGNOSES REDACTED] may follow excessive dosage. [MEDICATION NAME] - used for Acute [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. Adverse reactions include: [MEDICAL CONDITION], headache, dizziness, orthostatic [MEDICAL CONDITION], pancreatitis and hepatic dysfunction. [MEDICATION NAME] - used for hypertension. Adverse reactions include: orthostatic [MEDICAL CONDITIONS], dizziness, headache, fatigue and [MEDICAL CONDITION]. [MEDICATION NAME] - is an antiprotozoal drug used for bacterial infections, [MEDICAL CONDITION], etc. Adverse reactions include: headache, [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. [MEDICATION NAME] - used for Benign Prostatic Hypertension. Adverse reactions include: orthostatic [MEDICAL CONDITION], dizziness and headache. [MEDICATION NAME] - is an antibiotic indicated to treat sinusitis, skin infections, [MEDICAL CONDITION], etc. Adverse reactions include: [MEDICAL CONDITIONS] and [DIAGNOSES REDACTED].

Based on observation, record review, and interview, the facility failed to have a system in place to accurately access and measure pressure ulcers; change treatments; provide nutritional support; turn and reposition timely; ensure residents were clean and dry; monitor for drainage and intact dressings; follow Care Plans; and follow their own Policy and Procedures for Wound/Pressure Sore Management for 9 of 11 residents (R2, R22, R4, R8, R11, R5, R7, R9 R6) in a sample of 24, who have existing pressure sores or are at risk of developing pressure sores. These failures resulted in R6 was admitted to the facility with a stage 4 pressure ulcer which failed to progress towards healing; R9 and R11 developed facility-acquired avoidable pressures ulcers; R11's pressure sore had shown a decline; and R5 had a deterioration of a sacral pressure ulcer. Findings include: The facility's Resident Census and Conditions of Residents completed on 6/21/11 documented the facility had 8 residents with pressure ulcers, 5 of the 8 were admitted with pressure ulcers. The facility's Weekly Pressure Ulcer Log dated 6/19/11 - 6/25/11 documented 11 residents with pressure ulcers, with 7 residents "facility-acquired" pressure ulcers 1. On 6/2/10 R6's ADMISSION NURSING EVALUATION documented under SKIN CONDITION, "slow healing coccyx wound - 1.5 x 1.0 x 1.7 cm with 2.2 cm tunneling at 2 o'clock." Facility Weekly Wound Documentation report of 6 -2-10 identifies R6's pressure ulcer as being a stage 3 pressure sore. R6 has a Wound Consultant report from an outside wound consulting company dated 6-2-10 that documents R6 has a healing Stage 4 pressure sore on the coccyx with the same measurements. On 3/9/11, it is documented on R6's Wound Consultant Report that R6 was admitted with a chronic coccyx wound measuring .5 cm long x .5 cm width with less that 0.2 cm depth and 1.0 cm tunneling at 3 o'clock. Healing Stage 4. On 4/6/11 the Wound Consultant Report shows minimal serosanguineous drainage. Wound size is documented as being .5 cm long x .5 cm width x 1.7 cm depth with 1.0 cm tunneling at 3 o'clock. On 5/9/11 the Wound Consultant Report of documents a stage 4 pressure sore measuring .5 cm long x .5 cm width 1.8 cm depth with 1.0 cm tunnel extends to right at 3 o'clock, is the only wound bed remaining open. Tissue is not visible but Q tip inserted has serosanguineous drainage on it. The Facility WEEKLY PRESSURE ULCER LOG of 5/8/11 - 5/14/11 documents R6's Pressure Sore on her coccyx is a stage 3 with length .5 x .5 cm width with 0.1 cm depth and 1.8 cm tunnel to the right at 3 o'clock. On 6/1/11 the Wound Consultant Report documents a healing stage 4 pressure sore measuring 0.4 cm length x 0.4 cm width with 1.8 cm depth with 1.8 cm tunnel extends to the right at 3 O'clock,is the only wound bed remaining open. The Facility WEEKLY PRESSURE ULCER LOG of 5/29/11-06/4/11 documents Stage 3 pressure sore 0.5 length x 0.5 cm width with depth of 0.1 cm with minimal serosanguinous drainage, "Wound bed is 100% intact, maturing scar tissue at base of deep indentation over coccyx; 1.7 cm tunnel extends to right @ 3:00, tissue not visible but Q tip inserted has serosanguineous drainage on it..." The Facility WEEKLY PRESSURE ULCER LOG of 6/12/11 - 6/18/11 documents a stage 3 on coccyx measuring 0.6 cm x 0.6 cm with depth of 1.5 cm and 1.8 cm tunneling. On 6-28-11 the facility provided another WEEKLY PRESSURE ULCER LOG dated 6/19/11-6/25/11 which identified R6's Pressure Sore on her coccyx to now be a stage 4 measuring .5 x .5 with 1.7 depth moderate serosanguineous drainage and 1.7 cm tunnel to the right at 3:00. On 6-22-11 at 8:07AM, R6 was observed to be in the Dining Room, sitting in a geriatric chair with a tray. R6 remained in the Dining Room until 8:52AM when she was taken to her room and remained in the geriatric chair throughout the morning. R6 remained up in her geriatric chair in her room until 11:06AM when E20 Certified Nurse Aid (CNA) took her out of her room and E21, CNA, took R6 to the Dining Room for lunch. R6 remained in the Dining Room in her geriatric chair until 12:30PM. At 12:30PM R6 was taken to her room and remained up in the geriatric chair until 12:55PM when E18 and E29, Restorative Aides (RA), went into her room to transferred her by a mechanical sling lift to bed. R6 told the E18 and E29 that she was tired and ready to lay down. R6 did not have a pressure relieving cushion on her geriatric chair. She had a bed pad on the seat of the chair, the mechanical sling lift and a folded sheet that were all soaked with urine and urine was puddled on the seat of the geriatric chair. R6's incontinent brief was saturated with urine and she had had a bowel movement. R6 had a strong foul odor of urine. At 1:15PM, E20 came into the room and told R6 she was going to clean her up. R6 stated OK and that she wanted to take a nap. R6 asked E20, "When you're done with me, can I take a nap. I'm very tired." E20 started to clean R6 and R6 kept apologizing stating "I'm sorry" for needing to be cleaned up. R6's buttocks and back of thighs were deep creased and red. She had a pressure sore bandage on her coccyx that was dated 6-22-11, tinged pink, was saturated and unattached on 3 sides. E24, Licensed Practical Nurse (LPN), was present and told E20 to remove the bandage. R6 became incontinent of urine again and the draw sheet on her bed was soaked with urine. E20 removed the bandage and packing. At 1:40PM, E24 did the dressing change to R6's coccyx. E24 sprayed wound cleanser into the pressure sore and wiped with a 4 x 4 gauze. There was blood on the gauze after cleansing. The pressure sore was a stage 4 with a deep dimpled wound with a white moist base and had rolled edges and tunneling off to the side. E24 completed the dressing as ordered by the Physician. E24 stated she does not do staging or measurements, it's done by E6 the facility Wound Nurse . On 6-22-11 at 11:10AM, E9 and E22, CNA's, were interviewed and both stated they had not given any care to R6 that morning. They stated E20 is her CNA today. At 11:35PM, E23, CNA, was interviewed and stated she had not given any care to R6 that morning. At 12:32PM, E28, CNA, stated he had not given R6 any care that day. At 12:55PM, E18 and E19, also confirmed they had not given any care to R6 that day and that they were there to transfer R6 from her geriatric chair to bed. R6's June 2011 Physician order [REDACTED].@ 3:00 with silver hydrogel filler, pack callasorb loosely into upper section of tunnel, cover with border foam dressing daily. R6's Care Plan of 6-1-11 identifies R6 as having potential for further skin breakdown, admitted with with stage 3 coccyx pressure wound, [MEDICAL CONDITION], aspirin use, limited mobility. Requires assist with all ADL's (Activities of Daily Living) and mobility and [MEDICAL CONDITION]. Goal: R6 will not experience any skin breakdown through next review. Present wound will show signs of healing as evidenced by decreased length, width, depth & absence of signs and symptoms of infection by next review. The Care Plan approach, in part, is to treat as ordered; [MEDICATION NAME] as ordered; Notify physician/family of any change in status; Appropriate support surface in bed/chair. Air loss mattress with overlay and pressure relieving cushion of wheel chair, bilateral heel float devices; Turn and reposition every 2 hours; Teach to shift weight in chair every 30 minutes (R6 is unable to reposition self and this conflicts with MDS that documents R6 requires extensive assistance of 2 for bed mobility); and Prompt incontinent care. On 6-23-11, R6's Care Plan showed new documentation dated 6-22-11 identifying a problem that R6 refuses to get out of bed at times and refuses to be repositioned at times. States that she knows her right and doesn't have to. The Care Plan approach documented, "Reluctant to get up, out of bed at times and chooses to eat meals in bed. Encourage to get up for meals. Provide reminder of need for activity to promote good skin care." On 6-29-11 at 11:05AM, E27, Social Service Director, stated she had written the new documentation on R6's Care Plan on 6-22-11 stating she was refusing to get out of bed and repositioned based on what the 6-2 shift Nurse had told her on 6-22-11 that R6 did not want to get out of bed for supper. E27 stated she was unaware that R6 had been up for over 5 hours that morning without being turned, repositioned and given incontinent care and was telling staff she was tired and wanted to nap when she documented that R6 was refusing care. R27 was informed that staff interview reflected R6 is not resistive to care and R27 stated maybe its only the evening shift. There is no assessment to determine why R6 appears to not want to get only on 3-11 shift. On 6-23-11 at 9:30AM, the facility provided a copy of PATIENT WOUND CARE ORDER SHEET dated 6-1-11 that documents R6 has a healing stage 4 pressure sore measuring .4 x .4 cm with depth of 1.8 cm and no tunneling or undermining. There is a hand written note dated 6-23-11 by Z1, R6's Physician, documenting, "This is a chronic wound that may never heal but has had long term management and close care." On 6-23-11 at 10:55AM, during telephone conversion, Z1 stated R6's pressure sore has been chronic. It gets better then it gets worse. Z1 stated R6 sees Z2, Wound Nurse Consultant, and he depends on her for treatment since he can't be there all the time. Z1 stated the facility should stay aggressive with providing turning and repositioning; it's only logical that R6 should be repositioned more often than 5 hours and given incontinent care; R6 is coherent and can refuse to be repositioned if she wants; Z1 agreed that the facility needs to be more aggressive with positioning and kept clean and that would help heal the pressure sore. "It's only logical to think if aggressive with repositioning and keeping clean the wound (pressure sore) may heal. She 's had other wounds (pressure sores) that have healed. Can't say with proper care/treatment the wound (pressure sore) would never heal. " Z1 stated he was not informed of rolled edges of the pressure sore. Z1 stated the pressure sore is clean and has little serosanguineous drainage. Z1 stated R6's labs are good and there is no nutritional problem that would interfere with the pressure sore healing, other than she should lose weight. (R6's laboratory tests of 6-3-11 shows total protein and [MEDICATION NAME] and hemoglobin and hematocrit are within normal limits.) On 6-23-11 at 9:00AM, E6 stated she reassessed R6's pressure sore on 6-22-11 and gave documentation the the pressure sore measured .5 x .5 x .1 cm. At 11:15AM, E6, Facility Treatment Nurse, E30, Director of Nursing for Long Term Care, and E16 did a skin check on R6. R6 had a bandage on her coccyx that was dated 6-22-11 which was soaked with drainage and 3 sides of the bandage were loose. E6 stated she was going to measure the pressure sore. E6 confirmed the following: the estimated opening measured .5 x .5.; when she assesses R6's pressure sore she does not measure the pressure sore at the opening she just estimates the size; she does not measure the depth of the pressure sore because there is scar tissue at the depth and she doesn't want to damage the tissue; she uses a (cotton swab) to measure the tunneling at 3:00. E6 inserted a (cotton swab) into the tunneling and stated the pressure sore had 2.5 cm tunneling. E6 staged the pressure sore as a stage 3 because there is no bone or tissue showing. She stated there is moderate to heavy serosanguineous drainage;she treated the pressure sore 2 times on 6-22-11. There is no documentation regarding the dressing being soaked with drainage and the bandage was coming off. The order is for daily. There is nothing in R6's Nurses or Treatment Administration Record (TAR) that describes the pressure sore that Nurses could use on a day to day basis, while doing treatments, to show if pressure sore is improving or declining. On 6-23-11 at 3:40PM, Z2, Wound Consultant Nurse, gave a written statement indicating, "R6 - Only remedy for epibole is surgical incision to remove rolled edges. Depth of tunnel varies with position and has since treatment began." Z2 stated she did not know if pressure sore had epibole or not. She stated she doesn't know if the pressure is a stage 3, stage 4 or unstageable. "You would have to ask the doctor." When asked if lack of repositioning, lack of a pressure relieving device in the geriatric chair and resident being incontinent for 5 hours could contribute to pressure sore decline. Z2 stated she did not want to say if lack of repositioning and incontinent care could contribute to lack of healing. Z2 stated she was not an employee of the facility and was not comfortable giving an opinion on turning and positioning and keeping clean. Z2 stated the last time she assessed R6's pressure sore was 6-1-11. Z2 stated she doesn't measure depth. There is skin and scar tissue making it difficult to measure. On 6-28-11, during a meeting with the facility at 9:45AM, E2, stated E6 has resigned as the facility Wound Treatment Nurse. The Wound Consultant Nurse was fired. E2 stated that Z2 never did treatments and did not measure pressure sores. "She was completely hands off." R6 now has a catheter due to the stage 4 pressure sore and treatment is now twice a day. On 6-29-11, at 1:00PM, Z1, R6's attending physician, stated he had depended on Z2 for the assessment and care for R6's pressure sore. Z1 stated the pressure sore improves and then deteriorates. Z1 appeared surprised to learn that Z2 did not touch the residents, was hands off and did no measurements or treatments. He stated he thought he was doing every thing he could by having a consultant wound nurse see R6. Z1 stated he would have recommended R1 go to a wound clinic at the hospital if he had known. He stated he was unaware of drainage on 6-22-11 and would expect to be notified when facility first noticed increase in drainage so there could be a change in treatment. The facility Wound Assessment Policy and Procedure dated 4-21-09 documents, "To promote a systemic, comprehensive approach to the assessment of wounds. To document an accurate, ongoing assessment of wounds in the medical record." This wound assessment includes measurement of wounds and pressure ulcers. The facility Policy and Procedure on WOUND MANAGEMENT PROGRAM dated 4-21-09. "Policy: It is the policy of the Nursing Home to facilitate resident independence, promote resident comfort, and preserve resident dignity through an effective wound management program." Approaches include, in part: Assessing the local wound condition; Managing tissue loads: Promoting the healing of pressure ulcers that are present. The Procedure includes, in part: Daily Skin Assessment/Wound Status Documentation on TAR; Managing Tissue Load through the use of appropriate positioning practices, positioning devices, and support surfaces. This Policy relates to all wounds including pressure sores. 2. R9's June 2011 POS documents on 6-16-11 to discontinue Silver hydrogel. Start Santyl with Calcium Alginate - covered with boarder foam bandage daily to right and left thighs. R9's MDS of 4-7-11 shows she requires assistance of 1 with transfer and bed mobility and is frequently incontinent of urine. R9's Braden Scale for Predicting Pressure Sore Risk of 6-8-11 documents R9 as having a score of 14 which is moderate risk. Laboratory tests of 6-6-11 show hemoglobin and hematocrit within normal limits. Laboratory test of 5-13-11 document Total Protein and [MEDICATION NAME] to be within normal limits. R9's Care Plan of 4-12-11 identifies R9 to be at risk for skin breakdown related to impaired mobility, frequent bowel/bladder incontinence. On 6-14-11 the Care Plan was revised with, Open areas to right and left posterior thighs. Care plan goal is she will not experience any further skin breakdown through next review. Care Plan approach, includes, in part: Skin checks per protocol and monitor for signs and symptoms of breakdown during care; Appropriate support surface in bed/chair pressure relieving mattress on bed; turn/reposition at least every 2 hours; Encourage/assist to float heels when in bed; Monitor skin during ADL's, report any new findings to the nurse. R9's laboratory tests of 5-13-11 shows [MEDICATION NAME], total protein and hemoglobin and hematocrit are within normal limits. The facility Weekly Wound Documentation of 6-7-11 identifies a pressure sore from "friction versus shearing" on R9's right posterior thigh measuring 6.0cm x 4.0cm with no depth. The Note documents the skin is intact and this area is not open but fragile and may open up. Weekly Wound documentation dated 6-7-11 shows stage 2 pressure sore from friction measuring 4.0 x 3.0 cm with no depth. A written note states, "this area is not open but fragile et may open up." The facility Pressure Ulcer Staging and Recommended Products form that E6 stated she uses for staging pressure sores reflects a stage 1 pressure ulcer shows partial thickness loss of dermis presenting as a shallow open ulcer or an intact or open/ruptured serum- filled blister. The facility WEEKLY PRESSURE ULCER LOG OF 6/12/11- 6/18/11 documents R9's pressure sore on right posterior thigh as being a stage 2 measuring 6.0cm x 4.0 cm with 0.2 cm depth. The left posterior thigh is addressed as a stage 2 pressure sore measuring 4.0 cm x 3.0 cm with depth of .2 cm. On 6-21-11 at 12:40PM R9 was toileted after lunch by E20, CNA, and E35, LPN. R9 was transferred from her wheel chair to the toilet using a mechanical sit to stand lift. R9 had been sitting on a bunched up bed pillow with a white pillow case. R9 was toileted and then transferred to bed. During skin check, R9 was observed to have two bandages on bilateral posterior thighs and a stage 2 pressure sore on her coccyx the size of a dime that the facility was unaware of. On 6-22-11, R9 was up in her wheel chair in an activity from 10AM to 11:40PM. R9 was taken directly from the activity to the Dining Room for lunch. At 12:07PM, R9 was served her lunch. At 12:50PM, R9 was taken from the Dining Room to the area by the 200 Hall Nurses Station. During interview with E20, CNA, E20 stated she had last toileted or repositioned R9 before going to activity at 10AM. E20 confirmed she was the CNA caring for R9 that day and that R9 had not been repositioned since before activity. On the afternoon of 6-22-11, E2 and E16 were informed of concerns of R9 not being repositioned and checked for incontinency timely, and having a new avoidable stage 2 pressure sore on her coccyx found on 6-21-11. On 6-23-11 at 9:00AM, E6 provided new measurement for R9's pressure sores that she documented as being done at 7PM on 6-22-11. R9's right thigh was documented at 3.5 cm x 2.0 cm with no depth recorded and no staging. R9's left thigh was documented as measuring 1.0 cm x 0.5 cm with no depth or staging. On 6-23-11 at 11:30AM, E6 observed R9's pressure sores. R9's back of her right thigh was identified by E6 as being a stage 2 with bridging present within the wound bed. The pressure sore had minimal drainage and was very moist with a yellow bed that showed full thickness tissue loss. E6 measured the pressure sore as being 3.5 cm x 5 cm. The pressure sore on the back of the left thigh was circular with a white wound base between 11PM to 1AM. There was a dark area from 6PM to 8PM. E9 did not measure the pressure sore on the left thigh or the coccyx. R9 was in bed with socks on but nothing to float her heels off the bed. On 6-23-11 at 3:40PM, Z2, Wound Consultant, provided a written document that reflects R9 has "partial thickness (stage 2) with [MEDICATION NAME]. R (right) has [MEDICATION NAME] buds showing through which are not present with full thickness tissue loss.) Z2 stated she had not seen R9's pressure sores before today. She stated she the pressure sores were from abrasion/friction from the mechanical sling lift. 3. R5's Care Plan, dated 02/25/11, identifies that R5 is at risk skin breakdown related to decreased mobility and incontinence of both bowel and bladder. A revision to the Care Plan, dated 05/31/11, identifies loose stools related to [MEDICAL CONDITIONS], and the Care Plan interventions include daily wound checks, turned and repositioned every 2 hours, keep bony prominences from direct contact, avoid direct side lying positions on the trochanter and elevate head of bed as little as possible. The Minimum Data Set (MDS) for 03/04/11 and 05/22/11, assesses R5 as cognitively impaired, requires extensive assistance with bed mobility, transferring, dressing and personal hygiene. R5 currently does not ambulate. R5 is incontinent of bowel and bladder. The Braden Scale, dated 03/04/11, assesses R5 as a high risk for skin breakdown. On 05/26/11, documentation indicated on R5's Care Plan that pressure areas on spine, buttocks and ischial crest with goals of decrease in measurements each time they are done through next review. A review of the most recent lab values provided did not include protein or [MEDICATION NAME]. On 06/21/11, documentation indicated that information was added to the Care Plan that included, R5 does scoot about when in bed and reposition self after positioned. On 06/21/11 from 11:30 am to 4:10 pm, R5 was either sitting up at a 40 degree angle in bed or in a wheelchair. On 06/21/11, documentation on the Rounds Tool showed that from 10:00 am to 14:45 pm, R5 was either sitting/laying in bed or sitting in a wheelchair. On 06/22/11 from 8:17 am to 10:45 am, R5 was sitting up at a 40 degree angle in bed. At 10:55 am, R5 was transferred to a wheelchair. At 1:00 pm, R5 was transferred back to bed and placed in an upright position at a 40 degree angle. There is no documentation indicating that R5 was repositioned so that pressure was completely taken off coccyx/ischial area, keeping direct pressure off bony prominences and avoiding elevating head of bed as little as possible according to her care plan. On 06/23/11 at 10:55 am, R5 was sitting up with the head of bed at a 40 degree angle. At 10:57 am, E6 was observed to demonstrate wound care for R5 on the left ischial area of the buttocks. E6 measured the wound to be 1.8 cm L X 2.0 cm W and Unable To Determine (UTD) depth. The dressing that was removed had a quarter sized area of serosanguineous drainage. E6 also described the wound to have yellow slough that was flesh colored and stringy with pink partial tissue, and no bone or muscle affected. E6 reported the wound to be stage III although the depth was undetermined. The wound bed was a yellow/tan circular area with a waxy looking appearance with the upper right quadrant to be dark brown to black like necrotic tissue. When interviewed about the area being necrotic, E6 responded with "It's not black. Necrotic tissue is black." E30 was present and agreed with E6. physician's orders [REDACTED]. E6 and E2 reported that the facility uses a Pressure Ulcer Staging and Recommended Products for staging pressure ulcers. According to this document, if the depth cannot be determined, the stage cannot be determined. Unstageable is described as, full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Based on weekly skin reports, R5 had a total of 5 pressure ulcers on readmission, dated 05/26/11, 4 have since healed, leaving the left ischial wound that has had a decline since readmission. Documentation dated 05/26/11 indicates the wound was a stage II measuring 2.5 cm X 2.0 cm. On the weekly Pressure Ulcer Log, R5's left ischial crest wound measurements and stagings are as follows: 05/22/11 to 05/28/11, 1.5 X 3.0 cm, UTD, Stage III; 05/29/11 to 06/04/11, 1.3 x 2.8 cm, UTD, Stage III; 06/05/11 to 06/11/11, 2.5 x 2.5 cm, UTD, Stage III; 06/12/11 to 06/18/11, 1.5 x 1.5 cm, UTD, Stage III; 06/19/11 to 06/25/11, 2.0 x 1.5 cm, UTD, Stage III. According to the pressure ulcer staging recommendations that the facility follows, the wound deteriorated from a stage II on readmission to an unstageable on 6/24/11. On 6/29/11 at 2:20pm, E17, Licensed Practical Nurse (LPN) stated she believed the wound is smaller in diameter but has become deeper since readmission stating "it's going to get worse before it gets better." She also indicated that she was aware that the surveyor spent most of the day observing in the hallway near R5's room. 4. R11 was admitted to the facility on [DATE]. R11's initial Nursing assessment dated [DATE] documented R11's skin on buttocks was excoriated. There were no other open areas noted. On 5/18/11, R11's Braden Score to determine risk for pressure ulcers was assessed at 17, which placed him at mild risk for pressure sores. R11's Minimum Data Set ((MDS) dated [DATE] assessed him as needing extensive assistance of staff for bed mobility, transfers, locomotion on the unit, dressing, toilet use. There are no recent laboratory results on R11's chart. Hospital lab results dated 4/24/11 documented normal levels for total protein - 6.9 (normal 6.4 - 8.3). His [MEDICATION NAME] level was slightly low at 3.4 (normal 3.5 - 5.0). R11's Nursing Notes dated 5/12/11 at 13:00 documented (in part), "....N.O. (new order) to d/c (discontinue) [MEDICATION NAME] brace. Res has open area on mid-spine. Area of redness 4 x 6 cm with open center 2 x 1.5 cm.....". At 17:00, Nursing Notes documented "New tx. order to mid-spine open area - santyl to wound bed, cover with calcium alginate and bordered foam dressing daily. Suspect open area is r/t strap on back brace rubbing et res has Kyphosis of spine....." The facility's Pressure Ulcer Weekly Log for 5/15/11 - 5/22/11 documented the wound as Mid-Spine, Stage III. Measurements 1.0 x 1.7 cm, depth UTD (unable to determine), Wound bed 100% slough. The treatment ordered is Santyl to wound bed, Calcium alginate and bordered foam dressing. The weekly report for 5/22 - 5/28 and 5/29 - 6/1 documented some improvement in the size of the wound - 0.5 x 1.0, depth UTD. Treatment remained unchanged. On the 6/5/11 - 6/11/11Weekly Report, the pressure ulcer showed deterioration as it is documented to have increased in size to 2.0 x 1.0, Depth - UTD. Treatment remained unchanged. The the weekly report dated 6/12/11 - 6/18/11, the mid-back wound again increased in size to 2.2 x 1.2 cm, Depth - UTD. Treatment was unchanged although the wound deteriorated. On 6/21/11 the Nurses Notes documented a new open sore on R11's sacrum. The facility provided no justification for the development of this pressure sore. The physician's orders [REDACTED]." On 6/22/11, the facility also showed by measurements that the mid-spine wound had again increased in size to 2.4 x 1.4 - with 100% yellow [MEDICATION NAME]. The wound was not staged. R11's sacral wound measured 1.5 x 1.0 x 0.2 cm - Stage II. Measurements provided by the facility on 6/27/11 documented the mid-spine wound increased in size to 2.5 x 1.5 cm, Depth - UTD. There was no changed to R11's treatment when the wound began to increase in size. R11's admission weight recorded on 4/27/11 was 134.9 pounds. Weekly weights showed a rapid weight loss: 5/5 - 125.8 pounds; 5/10 - 125.1; 5/19 - 118.1; 6/7 - 113; 6/15 - 111.4 pounds. R11's Nutritional Progress Record on 5/19/11 documented the wound, "Stage III mid-spine, protein needs increased to 79 grams every day. Fair appetite noted....no recent protein stores to review. Rec milk.....". R11's diet orders were for Mechanical Soft, with Med Pass 60 ml. tid between meals, milk with each meal, Vit C juice with each meal, sandwiches. R11 was observed for three meals during the survey, lunch on 6/21 and 6/22, breakfast on 6/22. R11 did not receive mechanical soft meat for lunch on 6/21. R11 did not receive milk on lunch of 6/21 and breakfast on6/22 or Vitamin C juice. R11 was not prompted or cued to eat during the observed meals. R11's Meal Intake Record for June was reviewed. The documentation is incomplete, with no records of intake for breakfast and lunch on 6/3, 6/4, 6/9, 6/10, 6/14, 6/19. On 6/22/11 at 11:00 AM, R11 was placed onto the toilet in his room by E18, Restorative Aide, and E12, Certified Nursing Assistant. R11 had pronounced kyphosis (curvature) of his spine. There was a dressing on his mid-spine and coccyx. E18 and E12 placed R11 back into his wheelchair and pushed the wheelchair into the Dining Room. R11 remained in the Dining Room, observed at 11:30 AM, 11:45 AM, 12:05 PM, 12:25 PM. At 12:40 PM, R11 was seated in his wheelchair, at his bedside. R11 remained seated in the same position in his wheelchair, observed at 12:50 PM, 1:15 PM, 1:35 PM, and 2:10 PM. There was no turning and repositioning observed from 11 AM until after 2:10 PM, three hours and ten minutes. On 6/23/11 at 12:40 PM, R11's dressings were changed. The wound to his mid-spine had a moderate amount of yellowish drainage. The wound bed was covered with yellow slough. There was a dark red periwound around the open area. The wound was cleaned with wound cleanser, santyl ointment applied to the wound bed, covered with calcium alginate and bordered foam dressing. The dressing to R11's coccyx was removed. R11 complained of pain as the dressing was removed. The wound was an open, Stage II on his right coccyx. The wound was cleaned with wound cleanser, silver hydrogel was applied, covered with bordered foam. R11's Care Plan dated 5/15/11 documented a problem - Potential for skin breakdown related to limited mobility, anticoagulant therapy, admitted with left hip surgical incision. Update on 5/13/11 - Stage 3 open area to mid spine. Update on 6/21/11 - stage 2 open area sacrum. Approaches included Turn/reposition at least every 2 hours; encourage food intake and monitor which the facility failed to implement. 5. R8 was admitted to the facility on [DATE]. The hospital's History and Physical dated 11/3/10 documented admission to the hospital for debridement of wounds to sacrum and right foot. On admission to the facility, R8 had a sacral pressure ulcer on admission assessed by E6, LPN, Treatment Nurse. The wound was assessed as Stage III, 5.0 cm (centimeter) by 2.0 cm - Depth - UTD (unable to determine). R8 also had a pressure ulcer on her right medial heel on admission. The facility's wound care report dated 4/6/11 described the wound as a "Pressure - Healing Stage III, 2.5 cm by 0.80 cm, Depth - 0.4 cm. Treatment was (in part), "Clean BID (twice daily) with NS (normal saline) or wound cleanser. Cover with silver calcium alginate. Cover with a bordered foam dressing." The facility's wound care report dated 5/9/11 described the wound as "healing - Stage III, 1.5 x 0.5 x 0.2." The treatment did not change. The facility's wound care report dated 6/1/11 described the wound as "Pressure - Healing Stage III, 0.7 x 0.3 x 0.2. Comments documented (in part), "wound is at risk for contamination D/T fecal/urine incontinence and location....Dressing develops strike-through within 12 hours and compromises dressing integrity (heavy to copious exudate level)". There was no documentation of treatment change or culture and sensitivity of drainage. On 6/9/11, R8 was admitted to the hospital for "altered mental status". The 6/9/11 History and Physical described symptoms of increased weakness, chills, fever, and decreased appetite. The plan was to admit for IV hydration, antibiotics, possible decubitus ulcer debridement, wound cultures, urine cultures and blood cultures.

Based on interviews, observations and record review, the facility failed to ensure that 4 of 10 residents (R3, R6, R7, R11) reviewed for weight and nutritional concerns in a sample of 24, assessed residents for weight loss; provided assistance with meals; initiated interventions for wight loss and failed to monitor those interventions. This failure resulted in R3, R7 and R11 having a significant unplanned weight loss. Findings include: 1. According to the Admission Sheet, R3 was originally admitted to the facility on [DATE] and readmitted following a brief hospitalization on [DATE]. The Minimum Data Set ((MDS) dated [DATE] identifies R3 as having memory deficits with moderate cognitive and requires extensive assist for most activities of daily living (ADL's). The MDS for eating indicates R3 requires set/supervision with meals. According to the care plan dated 5/9/11, R3 has a potential for skin breakdown and has had some gradual weight loss with some fluctuation, receiving encouragement and cueing at meals identified as a "problem." The care plan does not include a goal toward weight maintenance and/or weight gain. Interventions for the skin potential addressing weight include "encourage and assist during meal time as needed, monitor intake and record, offer substitutes as needed. Encourage fluids during meals and throughout the day with care. Monitor weights per protocol. RD (registered dietician) to evaluate as needed." On 6/21/11 at 11:40am, R3 was sitting in his wheelchair at the dining room table. He had only a bone-in pork chop and lima beans on his plate and had a 1/2 piece of pie sitting off to the side of his plate. R3's only fluid was water. R3 was observed to sit with no assistance/cueing and not eating. He fidgeted with his food and at one point, took the basket of bread from the center of the table handling each of the individually wrapped pieces of bread eventually setting the entire basket down on top of his plate and pie. He ate nothing. No staff intervened during the mealtime. At 12:36pm, he had drank 100% of his water and continued to tip the glass trying to drink more. Again, no staff intervened. At 12:31pm, a CNA (certified nurses aide) asked R3 if he was done, he shook his head yes and she propelled him back to his room. No substitutes were offered and no encouragement/cueing occurred to eat more. Dietary staff were observed clearing tables quickly after residents left the table with no intakes recorded as they did so. According to the weight change records, R3's admission weight was recorded as 295.3 pounds. On 5/19/11, his weight was recorded as 256 pounds, 5/24/11 - 254.4 pounds, 5/31/11 - 256.7 and on 6/10/11 - 245 pounds. According to the E2, Director of Nursing (DON) on 6/22/11, R3's weight of 295 on admission was taken off hospital records and not an actual weight taken by the facility. It was not rechecked until 10 days later. The RD's assessment dated [DATE] reflects the 295.3 weight along with the 256 pounds but doesn't recommend reweigh. The assessment indicates R3 feeds self with set up. The recommendations document "diet meets her needs." admission orders [REDACTED]. On 5/17/11, R3 had skilled speech therapy ordered 5 times a week for diet change/assessment, and cognitive retraining. Meal intake records for May 2011 document 100% for most meals. The nurses notes document that R3 was admitted to the hospital on [DATE] for Pneumonia and returned on 6/10/11 on a cardiac diet which was heart healthy, no added salt. On 6/13/11, speech therapy resumed according to the physician's orders [REDACTED]. On 6/10/11, R3 weighed 245 pounds and the dietician's assessment 6/14/11 on readmission identifies no risk factors for dietary. It does document that he has his own teeth/good condition when the prior one identified few/poor condition of teeth/mouth. The RESIDENT MEAL INTAKE RECORD for June was provided on 6/29/11 at 9:15am by E2, Director of Nursing who stated that the resident's CNA's are responsible to document meal intakes. The record was blank from 6/1/11 through 6/24/11 and then only had 2 of 4 dinner intakes documented. E2 stated they realized an intake record wasn't initiated following his readmission until 6/25/11. Therefore, the care plan for monitoring intakes was not followed. Review of the DYSPHAGIA PROGRESS WEEKLY notes dated 6/13/11 and 6/20/11 identify R3's treatment goals as "cues/setup with attn (attention) to task for feeding.:" and verbal cues to completed directives... such as self feeding." 2. R7's MDS of 5-4-11 documents R7 as being admitted to the facility on [DATE] and having moderately impaired cognition and requiring extensive assistance of 1 staff for eating. R7's Care Plan of 4-20-11 identifies a problem that R7 refuses to eat. A written note undated states at times he is resistive to allow being fed. Will spit out meds and food. Care Plan approach is :Fluids and liquid nourishment, and snacks will be offered every shift to resident. Hand written note of 4-21-11 documents Med Pass as ordered and sandwich between meals. Iron as ordered with juice Recheck CBC(complete blood count) as ordered. There are no other interventions or approaches listed. R7's April Physician order [REDACTED]. Order 4-10-11 states to hold [MEDICATION NAME] due to lethargy. R7 has an order on 4-15-11 to discontinue the [MEDICATION NAME] and start [MEDICATION NAME] 2.5 mg at HS. On 4-19-11 [MEDICATION NAME] was increased to 5 mg HS. POS shows an order of 5-2-11 to add 2.5 mg [MEDICATION NAME] in the AM. R7's June 2011 POS shows an order for [REDACTED]. Facility weight records show R7 weighed 173.3 lbs when admitted on [DATE]. Weight records show a significant unplanned 29.8% weight loss from 4-4-11 to 6-15-11. Weight records show the following weight loss: 4-21-11 -146.10 lbs 4-27-11 -121.3 lbs. 5-5-11 - 125.1 lbs 6-8-11 - 122 lbs. 6-15-11 121.6 lbs. Facility Informed Consent Sheet of 4-11-11 for [MEDICATION NAME] show potential side effects of sedation and nausea, among others. On 6-28-11 at 9:45AM, Z3, R7's Physician, stated he had to change the [MEDICATION NAME] due to R7 being sedated from the [MEDICATION NAME]. The Informed Consent for [MEDICATION NAME] that is not dated identifies potential side effects of change in taste, decrease in appetite or weight loss, , nausea, tiredness, trouble sleeping, drowsiness and agitation and restlessness. There is no assessment of the potential side effects and possibility of medications contributing to R7's significant weight loss. R7's DIETARY DATA HISTORY AND INITIAL SCREENING of 4-12-11 documents R7 as weighing 173.3 lbs there is no height recorded. Nutritional needs of 2212 calories, 79 gram protein, and 2370 cc's of fluids a day. A Registered Dietitian (RD) note of 4-21-11 states weight meeting - weight on 4-21 was 146.1 lbs and shows loss of 27.2 lbs weight loss (15%). Family stated usual weight is 130 lbs. Meals skipped due to behavior/alertness...Weight loss is expected due to missing meals...Add sandwich between meals to supplement oral intake. Note of 4-28-11 state weight on 4-22 was 121.3 lbs. This weight shows loss of 24.8 lbs/16.9 % in one week. PO (intake) review with behavior. Med pass 60 cc qid (4 x's a day) and sandwich /cookies served between meals tid (three x's a day). R7 is confused with meals refused at times. "When awake with meals good, he eats well. RD note of 6-9-11 review of weights show loss of 7.9 /6% in 1 month. Eats at restorative table. Supplements between meals. Recommend to increase med pass to 120 cc qid to provide 960 calories, 40 gm protein in addition to po intake. Weekly weight to continue. At noon meal on 6-21-11 R7 started meal feeding himself and finished meal being fed by E18, Restorative Aide (RA). R7 was observed to drink 1/2 of an orange drink, 1/2 of his water and less than 25% of food served. R7 had liquid supplement which he did not touch consuming 0%. R7 was not offered substitutions for foods not eaten. R7 was observed at breakfast meal on 6-22-11. R7 was in a wheel chair and bent over and appeared to be sleeping when brought into the Dining Room at 8:20AM. E29, RA was observed to pat R7 and cue him to wake up so he could eat breakfast. R7 had scrambled eggs, toast /butter, bacon, and orange juice. At 8:30AM, E29 Got R7 a bowel of cream of wheat. E24, LPN, came to the table and tried to wake R7 to eat. Both E29 and E24 stated sometimes R7 will not wake up to eat and other times he eats good. On 6-29-11 at 9AM, E24, LPN, stated R7 will take his Med pass if it has ice in it and is real cold. E24 stated Med Pass is documented on the MAR (Medication Administration Record). Review of the MAR shows initials that R7 was given the Med Pass but there is no documentation that shows how much was consumed. E25 stated R7 gets a sandwich between meals and confirmed Nurses and CNA's do not document amount consumed of the sandwich or Med Pass. Interview with E7, Food Service Director, on 6-29-11 reflected Dietary staff also do not document R7's Med Pass intake or snacks between meals. The facility Policy and Procedure for Nutrition and Weight Loss of 4-14-09 reflects The the facility will offer substitutions for foods not eaten and will have individualized interventions addressed on their care plan. 3. R6's June 2011 POS documents an order for [REDACTED]. POS shows an order for [REDACTED]. R6 was observed at noon meal on 6-21-11 to receive pureed meat, pureed meat and pureed potatoes and a piece of cream pie. R6 ate less than 25% of her pureed food and did eat the pie. (She did not receive 2 soft food items as ordered.) On 6-21-11, at breakfast meal, R6 ate 100% of scrambled eggs with ground sausage. She did not eat any hot cereal. At noon meal, she received pureed fish, pureed vegetables, mashed potatoes and gravy, chili and a cherry dessert. R6 did not touch her pureed meat or vegetables. Ate a few bites of mashed potatoes and gravy. She ate her chili and dessert. R6's Resident Meal Intake Record for June 21, 2011 at lunch documents R6 ate 100% of food served, yet observation showed she consumed less than 25%. Breakfast on 6-22-11 shows documentation she ate 100% yet she did not touch her hot cereal. Lunch is recorded that she ate 100% but she did not touch her pureed fish, pureed vegetable and ate only a few bites of mashed potatoes and gravy. R6 stated she does not like pureed food. R6's DIETARY DATA HISTORY AND INITIAL SCREENING (annual) of 5-17-11 documents R6 as requiring 110 grams of protein a day. Assessment states Protein needs are met with intake and interventions in place. RD note of 6-13-11 documents R6 has a stage 3 pressure sore on her coccyx. Facility Wound Consultant report documents a stage 4. Protein needs are 120 grams are met with diet and interventions. (This conflicts with observations.) On 6-29-11, E7, Dietary Manager, stated she has instructed staff to ask R6 before each meal what 2 mechanical soft food items she would like. 4. R11's admission weight recorded on 4/27/11 was 134.9 pounds. Weekly weights showed a rapid weight loss: 5/5 - 125.8 pounds; 5/10 - 125.1; 5/19 - 118.1; 6/7 - 113; 6/15 - 111.4 pounds. R11's Nutritional Progress Record on 5/19/11 documented the wound, "Stage III mid-spine, protein needs increased to 79 grams every day. Fair appetite noted....no recent protein stores to review. Rec milk.....". R11's diet orders were for Mechanical Soft, with Med Pass 60 ml. tid between meals, milk with each meal, Vit C juice with each meal, sandwiches. R11 was observed for three meals during the survey, lunch on 6/21 and 6/22, breakfast on 6/22. R11 did not receive mechanical soft meat for lunch on 6/21. R11 did not receive milk on lunch of 6/21 or Vitamin C juice. R11 was not prompted or cued to eat during the observed meals. R11's Nursing Notes dated 5/12/11 at 13:00 documented (in part), "....N.O. (new order) to d/c (discontinue) [MEDICATION NAME] brace. Res has open area on mid-spine. Area of redness 4 x 6 cm with open center 2 x 1.5 cm.....". At 17:00, Nursing Notes documented "New TX. order to mid-spine open area - santyl to wound bed, cover with calcium alginate and ordered foam dressing daily. Suspect open area is R/T strap on back brace rubbing et res has Kyphosis of spine.....". Weekly Pressure Ulcer Log for 6/12/11 - 6/18/11, documented the mid-back wound size increased to 2.2 x 1.2 cm, Depth - UTD. On 6/21/11 the Nurses Notes documented a new open area on R11's sacrum. The physician's orders [REDACTED]." On 6/22/11, the measurements documented by the facility show the mid-spine wound had increased in size to 2.4 x 1.4 - with 100% yellow [MEDICATION NAME]. The wound was not staged. R11's sacral wound measured 1.5 x 1.0 x 0.2 cm - Stage II. Measurements provided by the facility on 6/27/11 documented the mid-spine wound increased in size to 2.5 x 1.5 cm, Depth - UTD. R11's Meal Intake Record for June was reviewed. The documentation is incomplete, with no records of intake for breakfast and lunch on 6/3, 6/4, 6/9, 6/10, 6/14, 6/19. On 6/24/11 at 11:20 AM, E25, Dietician, verified R11's weight loss of 23.5 pounds. E25 stated, "He is seeing Speech Therapy, is on weekly weights, and started Restorative program for nutrition." E25 was unaware that R11 did not receive milk or ground meat on 6/21/11. There are no recent laboratory results on R11's chart. Hospital lab results dated 4/24/11 documented normal levels for total protein - 6.9 (normal 6.4 - 8.3). His [MEDICATION NAME] level was slightly low at 3.4 (normal 3.5 - 5.0).