Every finding on record at Arcadia Care Morris

Based on observation, interview, and record review, the facility failed to complete wound care and treatments per the physician's orders.This applies to 4 of 4 (R2, R6, R7, R8) residents reviewed for wound care in the sample of 17. 1.R2's face sheet showed R2 was admitted to the facility on [DATE], and discharged on March 31, 2026. R2 had multiple diagnoses that included respiratory failure, pneumonia, cirrhosis of the liver, diabetes, abnormal gait and mobility, hypertension, falls, and atrial fibrillation On August 15, 2026, at 12:00 PM, R2 said that he had an open sore on his buttocks that V2 (Director of Nursing) was aware of. R2 said that V2 took photos of the wound, however the facility hardly treated it. R2 said that when he asked the nurses to change the dressing on his wound, he was told by the nurse that it was not their responsibility. R2 said that his wound did not get better the entire time he was there. R2 said that he was taken off of some of his blood pressure medications while in the hospital and the skilled facility had a hard time adjusting his blood pressure. R2's previous TAR (Treatment Administration Record) showed that R2 had a treatment order for a wound to the left buttock. Staff were to cleanse the area with wound cleanser, pat dry, apply alginate calcium and a bordered gauze daily for wound healing. There were no signatures to show completion of this order on March 01, 2026, and March 04, 2026. A new order for R2's left buttock was entered for March 11, 2026, to March 23, 2026, that showed staff should cleanse the area with wound cleanser, pat dry, and apply zinc and a border gauze for wound healing daily. There was no signage to show that this order was completed on March 15, 2026, or March 16, 2026. R2's TAR also showed a treatment order for the right abdomen. Staff were to cleanse the area with wound cleanser and apply mupirocin ointment daily for wound healing. There was no signage to show that this order was completed on March 06, 2026. R2 had an abdominal incision with sutures that was to be monitored every shift. There was no signage to show that this was completed on March 01, 2026, on the day, evening or night shift, March 03, 2026, on the evening shift, and March 04, 2026, on the day shift. 2. R6's face sheet showed R6 was admitted to the facility on [DATE]. R6 had multiple diagnoses that included cellulitis, mycosis, candidiasis, lymphedema, open wound to right lower leg, severe obesity, diabetes, sleep apnea, open wound to left lower leg, falls, and psychophysiologic insomnia. On August 15, 2026, at 11:20 AM, R6 said that he had dressing changes for wounds on both of his legs that were to be changed two to three times daily. R6 said that when it comes to providing wound care the staff was very lackadaisical on when the care was provided and said his dressings did not get changed according to the physician's order. R6's current TAR showed an order for treatment to R6's left and right shins, right plantar foot, and right toes. Staff were to cleanse with wound cleanser, pat dry, apply xeroform, alginate calcium with silver, a superabsorbent pad, and secure with rolled gauze and compression wrap twice daily for lymphedema wound. There was no signage to show completion of the task on August 01, 2026, August 02, 2026, and August 10, 2026. R6 did not receive the second dressing change on August 4, 2026, August 5, 2026, August 7,2026, August 10, 2026 and August 12, 2026. R6 did not receive the initial dressing on August 11, 2026, or August 13, 2026. 3.R7's face sheet showed R7 was admitted to the facility on [DATE]. R7 had multiple diagnoses that included edema, peripheral vascular disease, chronic kidney disease, diabetes, unspecified open wound, stage 4 pressure ulcer, and stage 3 pressure ulcer of the sacral region. R7's current TAR showed R7 had a treatment order for the left lower ischium and sacrum. Staff were to cleanse the area with wound cleanser, pat dry, apply calcium alginate dressing and cover with bordered foam dressing every night. There was no signage to show completion of this task on August 03, 2026, August 04, 2026, and August 07, 2026. R7's TAR showed an order for R7's right lateral shin. Staff were to cleanse with wound cleanser, pat dry, apply iodosorb and cover with a gauze dressing once daily. There was no signage to show that this was completed on August 01, 2026, August 02, 2026, and August 07, 2026. 4. R8's face sheet showed R8 was admitted to the facility on [DATE]. R8 had multiple diagnoses that included heart failure, convulsions, hypotension, hydronephrosis, multiple sclerosis, quadriplegia, and neuromuscular dysfunction of the bladder. R8's current TAR showed an order to treat R8's left buttock with wound cleanser, pat dry, apply a thin layer of Triamcinolone cream, apply a collagen sheet, and cover with a bordered gauze twice daily. There was no signage to show that this was completed on August 01, 2026, August 02, 2026, August 07, 2026, and August 10, 2026. A second treatment was not signed out as completed on August 04, 2026, August 11, 2026, August 12, 2026, and August 13, 2026. R8's treatment was similar for the right buttock and there was no signage for completion on August 07 2026, and August 10, 2026. There was only one treatment signed as completed on August 11, 2026, August 12, 2026, and August 13, 2026. R8's TAR showed an order to treat the left ischium. Staff were to cleanse with wound cleanser, pat dry, pack with iodoform packing, and cover with foam dressing twice daily. There was no signage to show completion of the task on August 07, 2026, and August 10, 2026. The treatment was completed once on August 11, 2026, August 12, 2026, and August 13, 2026. On August 15, 2026, at 1:20 PM, V3(Assistant Director of Nursing) said that an empty space on the TAR meant that the treatment was not signed off on. V3 said that she could conclude that the treatment was not completed. On August 15, 2026, at 1:53 PM, V2 (Director of Nursing) said that an empty space on the TAR showed that the task was not documented and not completed

Based on observation and interview, the facility failed to ensure that bathroom fixtures were properly secured and maintained in a safe and functioning condition for 1 of 4 residents (R3) reviewed for safe environment. The findings include: R3's face sheet showed R3 was admitted to the facility on [DATE], around 12:00PM and discharged the same day at 2:00 PM. R3's diagnoses were not listed in the medical record and there was no MDS assessment performed. On August 15, 2026, at 12:20 PM, R3 said that she entered the facility and was there for a short time due to feeling unsafe in the community. R3 said that she listed this on the AMA (against medical advice) paperwork that she completed. R3 said she arrived at the facility and asked to use the bathroom. R3 said she was placed on the toilet by two staff members who lifted her under her arms and placed her on the toilet. R3 said the staff did not use a gait belt or mechanical lift for the transfer, and she had entered the facility following a surgical procedure on her ankle. R3 said that as they placed her onto the toilet, the toilet fell and her ankle that she had surgery on twisted under her to the left. R3 said the staff were only concerned about obtaining a plumber to fix the toilet. R3 said that there were several people in the room when this occurred. On August 14, 2026, at 1:13 PM, V15 (Certified Nurse Assistant/CNA) said that R3 was admitted and discharged in the same day. R3 was brought in on a transport chair that did not fit in the bathroom. V15 said as she placed R3 on the toilet, the toilet shifted from the ground because it was not bolted down. V15 said that she had to use her thigh to keep R3 propped on the toilet while someone got maintenance to fix the situation. V15 said that they could not immediately remove R3 from the toilet because she started urinating as soon as she sat on the toilet. On August 15, 2026, at 12:55 PM, V23 (Licensed Practical Nurse/LPN), said that R3 entered the building and was in haste to get to the bathroom. The transport chair that R3 arrived in could not fit into the bathroom. V23 and V15 (CNA) transferred R3 into a chair that could fit into the bathroom. V23 said that R3 was a new admit and she was unsure of R3's transfer status but pivoted R3 to the toilet without the use of a mechanical lift or a gait belt. V23 said that normally they would wait for physical therapy to evaluate the resident before transporting them but R3 was in such a hurry. V23 said that as they transferred R3 to the toilet, the toilet shifted because it was not properly bolted down to the ground. V23 said that maintenance came to fix the toilet right away and that R3 did not sustain any injuries from the incident. V23 said that R3 was escorted to the dining area and R3 did not express any concerns of pain or discomfort. On August 14, 2026, at 2:45 PM, V16 (Maintenance Director), said that sometimes after an extended amount of usage the toilet bowls may become loose. V16 said this was the case with R3's toilet on July 11, 2026. V16 said that he was called to the room and observed that one side of the toilet had shifted. V16 said that they had to reseal the toilet and place new bolts to stabilize the toilet bowl. V16 said that the staff sends request through work orders on items that need to be fixed most of the time. V16 said that he is unaware of a malfunction if this process is not completed and he is not informed by staff. V16 said that R3 did not complain of any injuries or concerns during her stay. On August 15, 2026, at 1:20 PM, V3 (Assistant Director of Nursing) said that she was not aware of the incident with R3 and her toilet on July 11, 2026, however R3 had not complained of any pain or injuries while in the facility. On August 15, 2026, at 1:53 PM, V2 (DON) said that he was not originally aware of the incident with R3. On August 15, 2026, at 2:33 PM, V1 (Administrator), said she was aware of the incident with R3. V1 said that V16 fixed the toilet when the situation occurred. There were no additional nurses' notes or incident reports regarding the incident.

Based on observation, interview, and record review, the facility failed to provide sufficient staffing to safely meet the residents' care needs. This applies to 3 of 8 residents (R2, R7, R10) reviewed for staffing in a sample of 10. The findings include:1. R2's face sheet showed R2 was admitted on [DATE], and has diagnoses including peripheral vascular disease, muscle wasting and atrophy, morbid obesity, and osteomyelitis of vertebra.R2's MDS (Minimum Data Set) dated May 27, 2026, showed that the resident was cognitively intact.R2's active ADL (Activities of Daily living) care plan revised on November 11, 2025, showed that the resident had self-care performance deficit and requires assistance from the staff with ADLs (activities of Daily Living). The same care plan showed multiple interventions, including, The resident requires [full body mechanical] lift with 2 persons assist to transfer between surfaces.On July 18, 2026, at 11:00 AM, R2 was sitting up in her wheelchair. R2 said there are not enough staff, and she is regularly transferred in the [full body mechanical lift] by one CNA. R2 went on to say this morning V15 (Certified Nursing, CNA) transferred R2 by herself.On July 18, 2026, at 11:39 AM, V15 said she was the CNA for R2 for 10:00 PM on July 17, 2026, until 6:00 AM on the morning of July 18, 2026. V15 said that even though CNAs are supposed to have 2 staff when using the [full body mechanical lift] to transfer residents, V15 had to transfer R2 alone because no other staff was available to help, and the nurse assigned in her unit was passing medications.2. On July 17, 2026, at 11:03 AM, V9 (CNA) stated that she started her shift at around 6:00 AM and was scheduled to work in the 500 and 600 wings. V9 stated that she was the assigned staff for R7 that morning and because there was no other CNA assigned to her area, she had to transfer R7 from the bed to the wheelchair that morning by herself with the use of the full body mechanical lift. According to V9 she was aware that two staff should be transferring a resident using the full body mechanical lift but because the unit was short staffed, she had no choice but to do the unsafe transfer on her own. V9 stated that the nurse assigned in her unit was passing medications, and she had asked V3 (ADON, (Assistant Director of Nursing)) to send another CNA to her unit, but nobody came.On July 18, 2026, at 3:06 PM, R7 was in bed alert and oriented. R7 stated that on the morning of July 17, 2026, she was transferred by V9 from the bed to the wheelchair, using the full body mechanical lift, by herself. R7 stated, There was only one CNA working here. They were understaffed. R7's admission MDS (Minimum Data Set) dated July 13, 2026, showed that the resident was cognitively intact. R7's active care plan last revised on July 10, 2026, showed that the resident had decreased mobility and require assistance from the staff with ADLs (activities of Daily Living). The same care plan showed multiple interventions, including, The resident requires [full body mechanical] lift with 2 persons assist to transfer between surfaces.3. On July 18, 2026, at 9:00 AM, R10 said the facility does not have enough staff to meet the residents' needs and they always have to wait a long time for the nurse or CNA to answer the call light.R10's MDS dated [DATE], showed R10 was cognitively intact.On July 18, 2026, at 9:13 AM, V19 (CNA) said there are regularly not enough staff to safely and effectively care for the residents. V19 said on July 10, 2026, she was pulled to the Skilled unit (500 - 600 unit) around approximately 8:00 AM and was the only CNA working the Skilled unit all day. V19 went on to say she recalled that there were 6 residents requiring the use of a [mechanical] lift and she had to operate the lift by herself because she was the only CNA on the unit.On July 18, 2026, at 9:22 AM, V18 (CNA) said there is usually not enough staff, and they regularly have to transfer resident using a [full body mechanical lift] with only 1 staff.On July 17, 2026, the facility census was 72 residents. There were 57 residents on the long-term care unit and 15 residents on the Skilled unit.On July 18, 2026, at 10:10 AM, V2 (Director of Nursing) said the facility does not have adequate staffing, they do enough staff to effectively provide care to the residents. V2 went on to say that for example the long-term care unit needs to have 6 CNAs regularly scheduled instead of the 4 or 5 CNAs currently being scheduled, and the Skilled unit needs to have 2 CNAs scheduled but he has been provided with a daily staffing calculator that he must follow.On July 18, 2026, at 11:50 AM, V2 (Director of Nursing) said on July10, 2026, he was not the scheduler, but learned there was a call-off and V19 was moved to the Skilled unit at 7:40 AM. V2 also said on July17, 2026 there was a call off on the 6AM to 2PM shift and V10 did not go to the Skilled unit as the daily schedule had shown, V10's assignment was changed from the Skilled unit to the long-term care unit and V10 did not report to the Skilled unit until the 2PM- 10PM shift. V2 also said the one staff member who was scheduled to provide one-to-one care (1:1) was not there.On July 18, 2026, at separate times during the hours ranging from 10:00 AM through 3:00 PM, V2 provided corrected daily schedules for July 10, 2026, and July17, 2026, and July 18, 2026, that showed no additional staff were brought in as replacements for the missing staff.Daily staffing schedules dated July 3, 2026, through July 16, 2026, were reviewed and staffing discrepancies were noted.On July 10, 2026, the schedule 6AM to 2PM showed 5 CNAs covering the long-term care units 100 through 400 and the Skilled unit having one staff assigned to the 500/600 odd, one staff assigned to the 500/600 even, and one staff providing one-to-one care (1:1) with a resident. During a later interview it was found that the daily schedule was incorrect.On July 17, 2026, the daily schedule was reviewed and observations of the facility, conducted during both the 6Am - 2PM and 2PM to 10PM shifts showed that the verified schedule was incorrect and staff who were on the schedule were either not in the facility or were not working in the areas noted on the daily schedule.On July 17, 2026, the schedule 6AM to 2PM schedule showed two staff working the Skilled unit, one staff assigned to the 500/600 odd, one staff assigned to the 500/600 even, and one staff providing one-to-one care (1:1) with a resident, but V9 (CNA) was assigned to the entire unit alone covering both 500/600 odd and 500/600 even.On July 17, 2026, the daily schedule for the 2PM to 10PM shift showed one staff providing one-to-one care (1:1) that was not there.On July 18, 2026, the daily schedule showed 5 CNAs were assigned to the long-term care unit on the 6AM to 2PM shift, but in an observation of the unit only 4 CNAs were present.On July 18, 2026, at separate times during the hours ranging from 10:00 AM through 3:00 PM, V2 provided corrected daily schedules for July 10, 2026, and July17, 2026, and July 18, 2026, that showed no additional staff were brought in as replacements for the missing staff.On July 18, 2026, at 11:35 AM, V2 provided a Daily Staffing Calculator that showed the facility did not meet the requirements for the total direct care staff needed.Resident Council Meeting Minutes showed nursing concerns on May 6, 2026. June 2, 2026, and July 8, 2026, that the call lights are taking too long to be answered by staff.

Based on observation, interview, and record review, the facility failed to provide nail care for residents who require assistance with activities of daily living (ADL) care. This applies to 5 of 5 residents (R10, R21, R31, R32, R33) reviewed for nail care in the sample of 37.The findings include: The following residents' active Minimum Data Set (MDS) showed that they all required assistance with grooming and hygiene. 1. On June 30, 2026, at 10:57 AM, R10 was resting in bed, she displayed long uneven fingernails nails with black/brown substances underneath the nails. V10 said she would like to have her nails clipped and cleaned. 2. On July 1, 2026, at 12:35 PM, R32 was resting in bed, she was observed with long dirty fingernails, with black/brown substances underneath nails. R32 stated she wanted staff to clean her nails, file them, or clip them slightly, but not too short. R32 said she was okay with staff to clean her nails. 3. On July 1, 2026, at 12:45 PM, R33 was resting in bed, she has long dirty fingernails, with black/brown substances underneath her nails. R33 stated that she would love to have her nails clipped and cleaned. 4. On July 1, 2026, at 12:57 PM, R34 was resting in bed. R34 has right side weakness due to stroke, she has contracture to her right hand and wrist. R34's fingernails were long, jagged, uneven, and with brown discoloration on her nail beds. R34 said she needed her fingernails to be clipped, especially her right fingernails. R34 showed her right index fingernail that was overgrown and curved at the tip of the index finger ([NAME] like). R34 also showed her the 3rd and 4th fingernails were digging in to the palm of her right hand. On July 2, 2026, at 11:19 AM, V2 (Director of Nursing/DON) stated that nail care is part of grooming care for the residents. 5. R21's care plan showed he had an ADL self-care performance deficit related to multiple diagnoses including limited mobility, history or pressure ulcer, type 2 diabetes mellitus with diabetic polyneuropathy, chronic kidney disease, and morbid obesity. Furthermore, it showed he required one person assist with personal hygiene. R21's Minimum Data Set, dated [DATE], showed he required substantial/maximal assistance for personal hygiene and grooming. On July 1, 2026, at 3:28 PM, R21's fingernails were long and filled beyond his fingertips with brown and black substances. R21 stated that he would like to have his fingernails cleaned and cut. R21 stated no one offers to cut or clean his fingernails. On July 2, 2026, at 3:07 PM, R21's fingernails were still long and filled beyond his fingertips with brown and black substances.

Based on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to hand hygiene and gloving, placement of urinary drainage bag, soiled linen and clothes, and not wearing complete personal protective equipment (PPE) when providing care for residents under enhance barrier precautions (EBP). This applies to 10 of 10 residents (R1, R7, R10, R11, R12, R13, R15, R21, R28, R29) reviewed for infection control in the sample of 37. The findings include: 1. On June 30, 2026, R12's room door had an EBP (Enhanced Barrier Precautions) sign on the door stating that Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: wear gloves and a gown for the following: high-contact resident care activities, dressing, transferring, and changing linens. The fitted sheet on R12's bed was soiled with stool. V27 and V28 (Certified Nursing Assistant/CNAs) came into R12's room to change R12's bed linens without wearing gowns. V27 and V28 were wearing gloves. V27 and V28 removed the soiled bed linens and applied clean bed linens without disinfecting the mattress. Additionally, V27 and V28 did not perform hand hygiene before exiting R12's room. 2. On July 1, 2026, R28 had an EBP sign on the door stating Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: wear gloves and a gown for the following: high-contact resident care activities, dressing, transferring, and changing linens. V23 (Nurse) and V17 (CNA) entered R28's room and transferred R28 to bed without wearing gowns. On July 1, 2026, R28 said the facility staff members are supposed to wear a gown to protect his suprapubic catheter, but most of the time they do not. 3. On July 1, 2026, R29 had a sign on her door stating, STOP. CONTACT PRECAUTIONS. EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS MUST ALSO: Put on gloves before entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. V23 (Nurse) went into R29's room without wearing PPE (gown and gloves). V23 exited R29's room, returned to the medication cart outside R29's room, and touched items on and inside the cart without performing hand hygiene. 4. On June 28, 2026, at 12:40 PM, V33 (licensed practical nurse/LPN) performed wound care on R7. V33 entered R7's room and donned gloves without performing hand hygiene. V33 removed the old dressing from R7's right leg. V33 removed gloves and donned a new pair without performing hand hygiene. V33 cleansed the area with saline solution and applied a new dressing while wearing the same soiled gloves. V33 removed the soiled gloves and exited the room without performing hand hygiene. On July 1, 2026, V23 went into R7's room after exiting R29's room without performing hand hygiene. V23 checked R7's blood pressure without performing hand hygiene and exited the room without performing hand hygiene. V23 returned to the medication cart and touched different surfaces on and inside the medication cart without performing hand hygiene. V23 then returned to R7's room to administer medication. V23 exited R7's room without performing hand hygiene. V23 walked out of the resident's room with a cup of water, walked to the soiled utility room down the hallway, opened the door, and returned to the resident's room without performing hand hygiene. On July 2, 2026, V2 (Director of Nursing/DON) said that all staff providing direct care, such as transferring, showering, changing linens, and toileting residents, on EBP precautions are required to wear a gown and gloves. V2 said staff are required to use hand rub sanitizer, wear gowns and gloves before entering the rooms of residents in contact isolation precautions, and perform hand hygiene after exiting the room. V2 said staff must perform hand hygiene between all residents and before and after entering and exiting residents' rooms. V2 also said good hand hygiene is the number one prevention of infection and cross-contamination. 5. On June 30, 2026, at 10:57, R10's bedroom has a strong urine odor. R10's nephrostomy tube/catheter bag was inside a basin that was resting on the floor. The nephrostomy bag was leaking with urine that had formed into a gel-like sedimentation. On June 30, 26 11:30 AM, V11 and V12 (Both Certified Nursing Assistant/CNA) rendered incontinence care to R10 who was saturated with urine and had a bowel movement. V11 cleaned R10's perineum from front to back, while V12 assisted R10 to change incontinence brief, pad, and linen. They placed the soiled items inside a plastic bag and left the bedroom. V11 and V12 did not perform hand hygiene in between tasks and before leaving the bedroom. On July 1, 2026, at 10:45 AM, V11 (CNA) stated R10's nephrostomy catheter bag has been in the basin for about 2 months now, because the catheter has been leaking. V11 was not sure if the tube or the bag was leaking. The nurses knew about the nephrostomy bag on the floor and the leaking 6. On June 30, 2026, at 11:18 AM, there was an EBP signage posting outside R21's door due to his urinary catheter. On June 30, 2026, at 2:30 PM, V14 rendered incontinence care to R21 who had a bowel movement. V14 cleaned R21's back perineum, applied new brief, and straightened linen, wearing the same soiled gloves all throughout the care. V14 also did not wear a gown and did not perform hand hygiene in between tasks during the provision of care. 7. On July 1, 2026, at 1:16 PM, V12 and V19 (Both CNA) rendered incontinence care to R15 who was heavily saturated with urine and had a bowel movement. V12 cleaned R15 from front to back of the perineum, applied new incontinence pad, and put a new set of pants on R15 while wearing same soiled gloves all throughout the care. 8. On July 2, 2026, at 10:00 AM, V16 (CNA) provided perineum care to R11. R11 has an indwelling urinary catheter. V16 Cleaned R11 from front to back, applied new brief, and helped repositioned R11. V16 donned full PPE, she changed gloves in between tasks, however, she did not perform hand hygiene in between changes of gloves and tasks. On July 2, 2026, at 11:13 AM, V2 (Director of Nursing/DON) stated that when providing care for a resident on EBP the staff should be wearing gowns and gloves. When they are rendering peri-care they should perform hand hygiene and change gloves before and after care, and in between tasks from dirty to clean, and before exiting the room to prevent spread of infection. The staff should place soiled linen and clothes in a plastic bag and not on the floor. The urinary bag should be positioned below the bladder and should be hanging and not touching the floor as part of infection prevention. 9. On June 30th, 2026, at 9:02 AM, V16 (CNA) performed care on R1. V16 entered R1's room and donned gloves. V16 removed R1's soiled brief and cleansed R1's perineal area with wipes. Using the same soiled gloves, V16 applied a new brief to R1. Using the same soiled gloves, V16 moved R1's bedside table closer to her. V16 removed trash from R1's room and tossed it into a trash bin located in a resident's room diagonally across from R1's room. V16 removed gloves. V16 did not wash or sanitize her hands after performing care. 10. On June 29th, 2026, at 10:31 AM, R13 exited his bedroom in search of a CNA. R13 was experiencing diarrhea, which was leaking from his wheelchair and dripping along his bedroom floor and out toward the doorway. V34 (CNA) and V35 (CNA) responded to R13's call button and prepared to provide care. V35 obtained bleach wipes to clean the spill on the floor. V34 entered R13's room and donned gloves without performing hand hygiene. V34 gathered towels and warm water from the bathroom, placing them in a basin. V34 returned to the bedroom and removed a soiled gown from R13. V34 placed the soiled gown and other soiled garments on the floor next to R13's dresser. V34 removed soiled gloves and put on new gloves without performing hand hygiene. V34 removed R13's soiled brief and cleansed R13 with soap and water. V34 dried R13 with a towel. With the same gloves, V34 applied a new brief to R13. V34, still wearing the same gloves, continued to straighten items in R13's room before removing gloves and exiting the room without performing hand hygiene. The facility's Hand Hygiene/ Hand Washing policy, dated August 2026, states that soap and water are recommended for cleaning visibly dirty hands. Examples of when to perform hand hygiene include before eating, before and after having direct contact with the patients intact skin, after contact with blood body fluids or excretions, mucous membranes, non-intact skin, or wound dressings, after contact with inanimate objects in the immediate vicinity of the patient, if hands will be moving from a contaminated body site to a clean body site during patient care, before glove placement, after glove removal, and after using a restroom. The facility's titled Hand hygiene/Handwashing policy with an effective date of January 2026 showed Examples of When to Perform Hand Hygiene (Either Alcohol Based Hand Sanitizer or Handwashing): Before and after direct contact with a patient's intact skin taking a pulse or blood pressure, performing physical examination, lifting the patient in bed). After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. If hands will be moving from a contaminated-body site to a clean-body site during patient care. Before glove placement. After glove placement. The facility's titled Enhanced Barrier Precautions with an effective date of December 2025, showed, Policy: . Personal Protective Equipment. Standard Precautions must be followed with all cares. Additionally, gown and gloves must be worn when providing the following cares: dressing, Bathing/Showering, Providing Hygiene, Changing Linens, Incontinence Care, Medical Device Care, and Wound Care.

Based on observation, interview, and record review, the facility failed to ensure that indwelling urinary catheter and perineum care were provided in a manner that would prevent urinary tract infection (UTI). This applies to 4 of 4 residents (R10, R11, R15, R21) reviewed for catheter and perineum care in the sample of 37. The findings include:1. Face sheet showed R11 has multiple medical diagnoses including malignant neoplasm of the rectum, retroperitoneal abscess, colostomy status, type 2 diabetes mellitus, neuromuscular dysfunction of the bladder, muscle wasting, and obesity. Minimum Data Set (MDS) dated [DATE], showed R11 is alert and oriented and was totally dependent on staff for toileting and hygiene. On June 28, 2026, at 11:30AM and June 29, 2026, at 10:44 AM, R11 was observed lying in bed with indwelling urinary catheter draining to bedside bag that was cloudy yellow urine. Urinary tubing was unsecured with long clumps of solid sediments. On June 29, 2026, at 11:36 AM, R11 was lying in bed, her urinary catheter was draining with cloudy urine mixed with bright red blood. R11 stated that while the staff were cleaning her, she suddenly felt a sharp pain where the catheter was, she does not know why it suddenly hurt. R11 also said she has been hurting for a week now but during the provision of care it became more painful. On June 29, 2026, at 2:03 PM, V13 (Nurse) stated she was informed by CNA staff on duty that while they were taking care of R11 the catheter was slightly pulled causing the bleeding. V13 said she flushed the catheter and notified the physician. There was no anchor when she checked the catheter.On June 29, 2026, at 2:08 PM, R11's urinary bag was already emptied but there was still sign of bleeding in some of the urine. R11 verbalized that she still has pain/discomfort in her urethra and catheter remained unsecured. From June 30 to July 2, 2026, R11's urinary catheter remained unsecured or not anchored.2. Face sheet showed that R10 has multiple medical diagnoses including quadriplegia, multiple sclerosis, neuromuscular dysfunction of the bladder, weakness, hydronephrosis, cystostomy status, history of urinary tract infections (UTI), and muscle wasting and atrophy to multiple sites. On June 30, 26 11:30 AM, V11 and V12 (Both Certified Nursing Assistant/CNA) rendered incontinence care to R10 who had a pervasive urine odor. V11 stated that the last time she assisted R10 with incontinence care was at 6 AM. R10's frontal perineum, thighs, dressing to suprapubic and nephrostomy tubes were saturated with urine. The dressing of the suprapubic catheter and nephrostomy tube which was facing the skin was stained dark brown with urine and dated June 27, 2026. The suprapubic and nephrostomy tube were not anchored and dangling loosely. V12 stated that everyone knows that R10's catheters were both leaking. V11 cleaned R10's frontal perineum. As they turned V11 on her right side, V11's buttocks were noted to be covered with fecal matter, which was pasty, and already adhered to the skin. The incontinence pad and flat sheet were heavily saturated with urine which overflowed to the mattress. V11 cleaned R10 with wash cloth, repeatedly due to the stickiness of the fecal matter. V11 and V12 applied new incontinence brief, pad, and flat sheet, without cleaning the nephrostomy and suprapubic catheters. On June 30, 2026, at around 12:40 PM, V3 (Assistant Director of Nursing/ADON) and V6 (Wound Care Nurse) provided wound care and dressing change to R10's urinary catheters. When they started the catheter dressing change it was noted that there were still fecal matters that were on R10's right hip that were not totally cleaned off.3. Face sheet showed R21 has multiple diagnoses including type 2 diabetes mellitus, stage 3 B chronic kidney disease, polyuria, urinary retention, and morbid obesity. Minimum Data Set (MDS) dated [DATE], showed R21 was alert and oriented and requires substantial/maximal assistance for toileting and hygiene.On June 30, 2026, at 1:45 PM, R21 was noted with urinary catheter. R21 stated he needed someone to change his incontinence brief because he had a bowel movement before lunch time. V11 (CNA) was informed but she stated she was still busy. On June 30, 2026, at 2:00 PM, R21 said that his incontinence brief has not been changed yet. V11 already left and V14 (evening CNA) was informed. At 2:30 PM, V14 rendered incontinence care to R21 who had a bowel movement. R21's mid perineum was moist with redness and some open skin. V14 cleaned R21's back perineum and applied new brief without cleaning his frontal perineum and urinary catheter. 4. Face sheet showed that R15 has multiple medical diagnoses including type 2 diabetes mellitus and morbid obesity. MDS dated [DATE], showed R15 was alert and oriented and was totally dependent on staff for toileting and hygiene. On July 1, 2026, at 1:12 PM R15 was in her bedroom sitting on her reclining wheelchair. R15's pants and the bottom part of her blouse were wet with urine. R15 stated she needs assistance to go back to bed and change her pants and incontinence brief. R15 also said that her incontinence brief was changed early that morning and since then, R15 had two bowel movements and voided several times. R15 has been asking staff to change her incontinence brief.On July 1, 2026, at 1:16 PM, V12 and V19 (Both CNA) rendered incontinence care to R15 who was heavily saturated with urine and bowel movement. V12 used wash cloth to wipe R15's perineum from front to back. However, V12 did not clean R15's labial folds, urethra, and the inner folds of the groins. On July 2, 2026, at 10:43 AM, V2 (Director of Nursing/DON) stated when staff are providing catheter and incontinence care, expectation is to clean the catheter at least once every shift and as needed to prevent infection. The catheter should be secured to prevent being pulled or dislodged. It was not in the policy, but it was part of the management and protocol to ensure that the urinary catheter tube is secured. When providing peri-care, the staff must ensure that the full peri-care from front to back is cleaned. For female resident they should clean the whole vulva including labial folds and groins, check and change the resident for incontinence every 2 hours and as needed to prevent urinary tract infection (UTI). Facility's Incontinence Care Policy dated January 2026 showed: Purpose: To prevent excoriation and skin breakdown, discomfort, and maintain dignity. Guidelines: Incontinent resident will be checked periodically in accordance with the assessed incontinent episodes or approximately every 2 hours and provided perineal and genital care after each episode. Procedure: In the female, separate labia wash with strokes from top downward (with gloved hands), each side separately with a clean cloth. Keep labia separated with one hand. Wash labia first then groin areas.

Based on observations and interviews, the facility failed to provide residents with a clean and sanitary environment. This applies to 3 of 5 residents (R8, R12, R25) reviewed for Physical Environment in a sample of 37.The findings include:1. On June 30, 2026, at 2:15 PM, R12 was in her room. R12 had lots of crumbs on the floor and in the corners of her room. R12 also had brown stains on the hardwood floor, papers under her bed, and some brown powder on the floor next to her bed. V21 (Housekeeping) said she had already cleaned R12's room earlier the same day while R12 was not in her room. R12 said no housekeeping staff had been in her room to clean, and she had not left her room today. V20 (Housekeeping Director) said R12's room looked really bad and did not look like it had been cleaned by housekeeping on that day.2. On June 30, 2026, at 2:49 PM, R25 was lying in bed in her room. R25's room had lots of food crumbs all over the floor. R25's bathroom curtain had areas of black stains. R25 said her room only gets cleaned by the housekeeping staff about twice weekly, and they had not cleaned her room today. V20 (Housekeeping Director) said the black stains on R25's bathroom curtain looked like mold. V21 (Housekeeping) said she had already cleaned R12's room earlier the same day. V20 (Housekeeping Director) said R25's room did not look like it had been cleaned that day. 3. On July 1, 2026, at 10:16 AM, R8 was lying in bed. R8's room had lots of food crumbs, paper, and brownish-black stains on the hardwood floor. R8 said housekeeping does not clean her room daily, and she has to ask when she sees them cleaning nearby rooms. On July 1, 2026, at 11:30 AM, V1 (Administrator) stated that the facility's environment, including the residents' and dining rooms, is expected to be clean and sanitary. V1 also said there should not be black stains or mold on the residents' bathroom curtains for infection control and residents' dignity. V1 said every resident deserves to live in a clean and sanitary environment.

Based on observation, interview, and record review, the facility failed to provide skin treatment/dressing change according to physician order for a resident who was identified with skin breakdown. This applies to 1 of 4 residents (R10) reviewed for wound treatment in the sample of 37. The findings include:Face sheet showed that R10 has multiple medical diagnoses including quadriplegia, multiple sclerosis, neuromuscular dysfunction of the bladder, weakness, hydronephrosis, cystostomy status, history of urinary tract infections (UTI), and muscle wasting and atrophy to multiple sites. On June 30, 2026, at 10:57, R10 was resting in bed, R10 stated that she has 2 urinary catheter one in her right lower back (nephrostomy tube) and in her abdomen (suprapubic catheter). On June 30, 2026, 11:30 AM, V11 and V12 (Both Certified Nursing Assistant/CNA) rendered incontinence care to R10 who was heavily saturated with urine and had a bowel movement. V12 stated that everyone (staff) knows that R10's catheters were both leaking. V11's buttocks were noted to be covered with fecal matter, which was pasty, and already adhered to the skin. There was a wound dressing on R10's buttocks which was dated June 27, 2026. This wound dressing was heavily saturated with urine and fecal matter and was almost detached from R10. R10's skin was reddish, purplish, macerated, soggy, and shriveled due to urine exposure for an extended period. V11 cleaned R10 with wash cloth, repeatedly due to the stickiness of the fecal matter. On June 30, 2026, at around 12:40 PM, V6 (Wound Care Nurse) stated V6 rendered wound care treatment to R10. V6 stated that R10's wound treatment and dressing change was ordered twice daily and as needed. V6 described R10's skin as moisture-associated skin damage (MASD). On July 2, 2026, at 1:19 PM, V30 (Wound Care Physician) stated R10 has recurrent dermatitis to her bilateral buttocks, and posterior thighs. Nephrostomy and supra have been leaking, that's why she got wet. They had been using steroid cream and Silvadene to apply to irritated peri-skin of the buttocks and exterior thighs. V30 ordered treatment for R10's buttocks collagen and gauze. R10 was heavily incontinent, that's why V30 ordered treatment twice a day and as needed. MASD and dermatitis were caused by constant exposure to urine and feces. V30's expectation was to keep R10's skin clean and dry and to follow his wound care order.R10's wound evaluation and management summary dated June 18, 2026, showed R10 has skin tear wound of the left, bilateral buttocks full thickness, with treatment to apply Collagen sheet twice daily and as needed if saturated, soiled or dislodge.R10's Braden Scale assessment dated [DATE], showed R10 was a high risk for skin breakdown.R10's care plan with revision date of May 19, 2026, showed R10 was at risk for skin impairment MASD (Moisture Related Skin Disorder) to bilateral buttocks related to fragile skin, incontinence, non-compliance with turning and repositioning, history of pressure ulcers, secondary to multiple sclerosis, muscle weakness, diaper dermatitis. This same care plan showed interventions including keeping skin clean and dry.

Based on observations, interviews, and record review, the facility failed to provide sufficient staffing in accordance with its facility assessment tool and residents' care needs. This applies to 3 of 3 (R1, R31, R34) residents reviewed for sufficient staffing in a sample of 37.The findings include:1.R1's Face sheet showed R1 was admitted to the facility on [DATE]. R1 had multiple diagnoses, including multiple sclerosis, trigeminal neuralgia, convulsions, malnutrition, mitral valve insufficiency, depressive disorder, hypoxemia, chronic obstructive pulmonary disease, constipation, anxiety, hypotension, and epilepsy.R1's minimal data set (MDS) dated [DATE], indicated that R1 was cognitively intact and dependent on staff for activities of daily living (ADLs).On June 28, 2026, at 10:33 AM, R1 said the census is low and that staff are being cut. R1 believes this directly affects the care residents receive. R1 feels she is not receiving quality care. R1 reported an instance in which she sat in feces for 45 minutes because no one on the floor could assist her at the time. R1 believes this caused her current urinary tract infection (UTI). R1 said that if a call button is pushed during meal times, the resident will have to wait until the meal is complete because the aides are all feeding residents and no one is available to respond.On June 30, 2026, at 8:56 AM., V18 (Registered Nurse/RN) responded to R1's call button. R1 informed V18 that she needed to be changed. V18 informed R1 that she would have to wait until her (Certified Nursing Assistant/CNA) finished feeding residents, since V18 was in the middle of passing medications. R1 asked whether another CNA was available to assist her. V18 informed R1 that no one else was available, as all CNAs were currently feeding residents.2.R31's Face sheet showed R31 was admitted to the facility on [DATE]. R31 had multiple diagnoses, including hemiplegia, chronic pain, depression, and falls.R31's MDS dated [DATE], showed that R31 was cognitively intact. R31 was dependent on staff to complete activities of daily living.On June 28, 2026, at 10:21 AM, R31 said that the facility is short-staffed. R31 said the CNAs are stressed and cannot perform their jobs as they should. R31 said they can only do so much, and as a result, the residents are not receiving the care they need.3.R34's Face sheet showed that R34 was admitted to the facility on [DATE]. R34 had multiple diagnoses, including malignant neoplasm, dementia, diabetes, anxiety, and hypertension.R34's MDS dated [DATE], showed R34 was cognitively intact and required moderate assistance from staff to complete activities of daily living.On June 29, 2026, at 9:00AM, R34 said she feels the staff is sometimes short-staffed. R34 said there are many residents and few staff.On June 29, 2026, at 12:50 PM, V17 (CNA) stated that whenever she is on the schedule, she works in the villa alone. V17 stated that she was informed that no other CNA would be in the villa until the census was above 18. V17 stated that ten residents require two-person assistance with transfers. V17 stated that if the nurse is too busy to assist, she must wait until someone from another unit can come down to assist. V17 stated that she has discussed concerns with V3 (Assistant Director of Nursing/ADON). V17 stated that V3 informed her that V3 would discuss the issue with V2 (Director of Nursing).On July 01, 2026, at 11:46 AM, V15 (CNA) was asked whether there were enough staff at the facility and whether the problems they encountered were due to a lack of staffing. V15 said he has been working at the facility for 4 years and feels it is not well-staffed. In the Villa, there's only one person (CNA) working; the administration informed them that if there were fewer than 18 residents, they could have only one CNA. V15 also said they are trying to do the best they can, but he feels their best does not meet the expected standard of care due to insufficient staffing. V15 said that all the problems happening are due to a lack of staff. It doesn't give them (CNAs) the chance to help one another; there are not enough people monitoring and assisting with toileting, which is why people would go to the toilet by themselves, and incidents happen.On June 30, 2026, at 9:02 AM, V16 provided care for R1. V16 said she was supposed to be on break; however, staff rarely have time to take one. V16 said the morning shift had to change several residents who were soaked in urine because there was not enough staff overnight.On June 30, 2026, at 9:45AM, V11 (CNA) reported that hours have been cut short, which is causing a lack of care for the residents. There are not enough staff members or time to complete all tasks. V11 said that sometimes they are canceled on their scheduled days and sent home.On July 01, 2026, at 10:58 AM, V16 (CNA) reported that management has been cutting hours due to the low census. Residents don't receive proper care because the staff is short-staffed. Administrative staff set staffing levels based on what they believe is needed; however, this does not reflect residents' needs. The increase in fall incidents can be attributed to a lack of staffing. They used to have an extra staff member responsible for monitoring the hallways and bedrooms and answering call lights, especially during mealtime, when everyone is busy passing trays and setting up meals for residents.On July 01, 2026, at 11:53 AM, V19 (CNA) stated that she had been working at the facility for two weeks. V19 said she doesn't feel there are enough staff assigned to each shift. V19 said she has a heavy hallway, and half of her residents needed extensive assistance from 2 staff members. A resident had to wait a long time for help because everyone was busy, which delayed care for the residents. The care was completed, but it wasn't timely.On July 01, 2026, at 12:16 PM, V27 (CNA) reported that the facility is short-staffed. V27 stated that residents' care is affected because tasks are not always completed as scheduled. V27 also noted that it can take at least 25 minutes to respond to a call light, depending on the level of care a resident in another room is receiving. If a resident needed to use a mechanical lift, she would often have to wait until someone was available to help her. On July 01, 2026, at 3:30 PM, V32 (CNA) was exiting a residence room alone using a mechanical lift. V32 stated that she used the mechanical lift alone because no additional staff was available to assist. V32 further stated that the resident required two-person assistance and an additional person to operate the mechanical lift, but there was not enough staff present to do so.On July 2, 2026, at 11:50 AM, V2 (Director of Nursing) stated that he would like additional nurses and CNAs on the floor; however, he was informed that the current scheduling system needed to be implemented. V2 said he was told to cancel staff if the census drops. Upon reviewing the assessment tool, V2 noted that the facility is understaffed, with only 6 CNAs scheduled for the day and evening shifts, when 8 are needed. V2 said the schedule was changed from May to June due to a decrease in census. A review of the facility's fall list showed an increase in unwitnessed falls from May to June of 2026. There were three falls in May and fifteen in June.The facility's assessment tool indicated that the day shift should be staffed with 1 (Registered Nurse/RN), 2 (Licensed Practical Nurses/LPNs), and 8 CNAs. The evening shift should include 3 LPNs and 8 CNAs, and the night shift should include 3 CNAs and 2 additional staff members.The facility's nursing schedule was reviewed for the period from June 2026 to July 3, 2026. There were no days with 8 CNAs assigned to the day or evening shift. The day shift was typically scheduled with 5-6 CNAs. On June 11, 2026, the day shift was scheduled with 7 CNAs and 1 CNA for a 1:1. A note next to two names read, If all show, go home. This left only 5 CNAs on the floor to care for residents. On June 20, 2026, 3 CNAs covered the 100-400 units, and 1 CNA covered the villa. One CNA called off and was not replaced on the schedule.

Based on the interview and record review, the facility failed to provide a resident with the daily cost of services no longer covered by Medicare in order for resident to make an informed decision whether they wish to continue receiving skilled services that may not be covered by Medicare and to assume financial responsibility. This applies to 1 of 4 residents (R4) reviewed for Resident Rights in a sample of 4.The findings include: R4's EMR (Electronic Medical Record) showed R4 ([AGE] years old) was admitted to the facility on [DATE], with multiple diagnoses including, displaced Maisonneuve's fracture of left leg, subsequent encounter for closed fracture with routine healing, other fracture of upper and lower end of left fibula, subsequent encounter for closed fracture with routine healing, other fracture of left lower leg, subsequent encounter for closed fracture with routine healing, unspecified fall, subsequent encounter, and difficulty in walking, not elsewhere classified. R4 was discharged from the facility on April 10, 2026.R4's MDS (Minimum Data Set) dated March 9, 2026, showed R4 was cognitively intact, had impairment on one side of her upper and lower extremities, and required maximum assistance with transfers.R4's care plan initiated on March 4, 2026, showed R4 had an Activities of Daily Living self-care deficit due to displaced fracture of the leg, fracture of the upper and lower ends of the left Fibula, unspecified fall, and other abnormalities of gait/mobility. Interventions documented, included PT (Physical Therapy)/ OT (Occupational Therapy) evaluation and treatment as per physician orders. R4's care plan initiated on March 16, 2026, showed, R4, will discharge/transfer to [home address] with six steps to enter the home. The care plan interventions were documented, and no concerns were noted.On June 1, 2026, R4 said the Medicare-managed insurance company ended her coverage for PT and OT services at the facility on April 9, 2026, denied her appeal, and told her she had to either go home with home health services or pay for the facility privately if she chose to stay. R4 said the facility did not provide her with a copy of the NOMNC (Notice of Medicare Non-Coverage) form she signed on April 7, 2026, and she did not know there was a phone number to call to file a complaint about the insurance denying her appeal. R4 said the facility later gave her a copy of the form on March 19, 2026, when she went to the facility with her advocate (V6) to express her concerns about the discharge process. R4 said the facility informed her she had the option to file a second appeal, but she refused. R4 also said she would have considered paying privately until her next orthopedic appointment to determine whether she could bear weight on her leg, but the facility did not provide her with the daily rates. R4 said she still did not know the daily rate until today (June 1, 2026). R4 said she was discharged from the facility on Friday, April 10, 2026, and her orthopedic appointment was on Monday, April 13, 2026. R4 said the orthopedic doctor discontinued her non-weight bearing status, and she was able to bear weight on the leg. R4 said she did not think the managed Medicare insurance company knew what they were doing, and the facility did not advocate for her with the insurance company. R4 said she had 24 hours of home health services because she could not transfer herself in the home. She spent a lot of money on home health services, which she could have used for the facility's private-pay fees if they had provided her with information about the private-pay cost.On June 1, 2026, V2 (Social Services Director) said R4's managed Medicare insurance company sent the NOMNC form to be issued to R4 on April 7, 2026, because R4's Medicare coverage would end on April 9, 2026. V2 said he provided R4 with a copy of the NOMNC form. V2 said he offered R4 the option to pay privately and receive more therapy at the facility if she was willing, and R4 declined and opted to be discharged home. R4 said he did not provide R4 with the SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage) form. V4 said he had not issued the SNF ABN form to any residents at the facility. V2 said he did not document any conversations with V4.On June 1, 2026, V5 (Financial Coordinator) said she completed the facility's admission contract with R4 on an electronic device, and that R4 signed it. V5 said the admission contract was over 100 pages, and one of the documents stated the facility's daily rate. V5 said she usually emails a copy of the contract to the resident's or representative's email on file with the facility, but did not email V4 the contract to V4.On June 1, 2026, V4 (Regional Social Service Coordinator) said V5 (Financial Coordinator) completes an SNF ABN with residents on admission to the facility.According to the EMR as of June 1, 2026, at 2:00 PM, the SNF ABN documented for R4, which was signed by R4, showed, Medicare does not pay for everything, even some care that you or your health care provider thinks you need. The Skilled Nursing Facility (SNF) or its Utilization Review Committee believes that the care listed below does not meet Medicare coverage requirements. Beginning on March 3, 2026 (R4's admission date), you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. The care (s) you have been receiving during the Inpatient Skilled Nursing Facility include PT, OT, and Daily Skilled Nursing Care. These care (s) are no longer occurring daily. As a result, Medicare May Not Pay for your Inpatient Skilled Nursing facility due to the following reason (s): ________ [the line was left blank]. We estimate that these services will cost you $_________ [the line was left blank, no specific rate was listed] per day/item or service. Choose an option below about whether to get the care listed above. OPTIONS: Option 1 [selected] I want the daily skilled care listed above, which includes custodial services and room and board charges. I want Medicare to be billed for an official decision on payment, which will be sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare does not pay, I am responsible for paying but can appeal to Medicare by following the directions on MSN. The document was signed by R4, and the date signed showed March 10, 2026.As of 2:00 PM on June 1, 2026, the facility could not provide documentation to show that R4 was provided with the SNF ABN form outlining R4's options, including notation of the daily rates at the time the NOMNC form was issued to R4.The facility's policy titled, Charges to Personal Funds Covered & Non-Covered Items with a revised date of January 2026 showed, Guidelines; The facility will inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate.

Based on observation, interview, and record review, the facility failed to notify physicians of a resident's elevated Lithium level. This resulted in staff's continued administration of Lithium to the residents resulting in a resident's hospitalization with primary diagnosis of Lithium toxicity. The facility also failed to notify physicians and family members of a resident's injury (bruise) after an unwitnessed fall. This applies to 2 of the 6 residents (R1 and R5) reviewed for notification of change in condition and incident/accident in the sample of 9. The findings include:1. Face sheet shows R1 is 65 years-old who has multiple medical diagnoses including hypotension, unspecified, essential (primary) hypertension, hyperlipidemia, unspecified, atherosclerotic heart disease of native coronary artery without angina pectoris, paranoid schizophrenia, retention of urine, unspecified anxiety disorder, unspecified restlessness and agitation. R1's MDS (Minimum Data Set) dated February 16, 2026, shows that R1 is alert and oriented and requires substantial to maximum assistance with ADLs (Activities of Daily Living).R1's Progress Notes dated March 15, 2026, at 7:20 PM, showed R1 was very lethargic, unable to stand or transfer, and unable to answer questions. Vital signs were checked and recorded. V7 (Nurse) placed a call to the physician and V2 (Director of Nursing/DON). R1's progress note dated March 15, 2026, at 8:31 PM, showed R1 remained very lethargic, she was moaning but could not say or utter any words. R1 was unable to answer any questions, even the simple ones. R1's family was at bedside, physician, and V2 was notified. R1 was sent to the hospital via emergency services.R1's POS (Physician Order Summary) dated July 13, 2023, shows a physician's order to administer Lithium 150 mg (milligrams) once a day. On August 18, 2023, R1's Lithium was increased to 300 mg daily, then on March 4, 2026, R1's Lithium was increased to 300 mg twice daily.R1's laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L (millimoles per liter) which means that it was High. There was no documentation to show R1's physician was notified of the high Lithium level.R1's MAR (Medication Administration Record) showed R1 was administered Lithium 300 mg twice daily from March 5 to March 15, 2026.R1's hospital records showed R1 arrived at the hospital on March 15, 2026, and was admitted with primary diagnosis of Lithium Toxicity. On March 16, 2026, at 5:22 AM, R1's lithium level was 1.73 H* which means that it was critically high.On March 24, 2026, at 3:52 PM, V14 (R1's Psychiatrist) stated he was not aware of R1's elevated Lithium level. V14 also said they order Lithium level for residents who take Lithium, and the facility staff should notify V14 if the Lithium level is high or low. V14 continued to say if he was notified of the Lithium level, he could have changed the dose of Lithium and R1 could have been monitored for change in condition.On March 26, 2026, at 2:21 PM, V20 (Assistant Director of Nursing/ADON) stated that if a staff receives an abnormal or out of range laboratory result, the staff must immediately notify the physician because the resident may be sent to the hospital for a higher level of care or the resident might need adjustment to the dose of medication or need an added treatment.2. Face sheet shows that R5 is 64 years-old who has multiple medical diagnoses including altered mental status, Parkinson's disease without dyskinesia, lack of coordination, muscle wasting and atrophy, difficulty in walking, and unspecified lack of coordination. R5's MDS dated [DATE], shows that R5 requires total assistance from staff for toileting, hygiene, and dressing. On March 23, 2026, at 2:51 PM, V16 and V17 (Both Certified Nursing Assistant/CNA) assisted R5 to stand up to conduct a full body assessment. There was a big dark purple colored bruise noted that almost covered his whole right buttock. V19 (Power of Attorney/POA/wife) was at bedside during the assessment, she appeared surprised and stated she was not notified about R5's bruising.On March 23, 2026, at 3:05 PM, V6 (Nurse) stated R5 is a high risk for fall. V6 also stated she was not aware of R5's bruise on his right buttock.On March 26, 2026, at 2:45 PM, V6 changed her statement and said she noticed the bruise on R5's buttock and she notified V2 (Director of Nursing/DON).On March 26, 2026, at 3:11 PM, V17 (CNA) said she worked evening shift on March 22, 2026. V17 noticed the bruise which covered R5's whole right buttock and immediately notified V6.On March 26, 2026, at 2:50 PM, V21 (CNA) stated she knew about R5's bruise on his right buttock because V17 endorsed it to her during the shift change and according to V17, V6 was already notified of R5's bruise.On March 26, 2026, at 2:21 PM, V20 (Assistant Director of Nursing/ADON) stated when a staff observes bruising or any unusual change in a resident's condition, then the staff must immediately notify the physician and family.R5's incident report dated March 20, 2026, at 3:45 PM, shows R5 had a fall incident by the nurses' station. There was no injury noted initially, and family and physician were notified. However, R5's post fall follow up assessment of March 23, 2026, at 11:03 AM, does show any documentation that the physician and family member were notified of R5's bruise. Further review of R5's progress notes showed an incident report dated February 23, 2026. It shows that R5 had an unwitnessed fall that resulted in yellow discoloration to the left hip and an abrasion to posterior side of the head. R5's progress notes did not show any documentation that the physician and family member were notified about the above mentioned injury.Facility's Policy and Procedure for Physician-Family Notification- Change in Condition with revision date of December 2025 shows:Purpose: To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner.Guidelines: The facility will inform the residents; consult with the resident's physician or authorized designee such as Nurse Practitioner, and if known, notify the resident's legal representative or an interested family member when there is:B. A significant change in a resident's physical, mental, or psychosocial status (i.e. a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. C. A need to alter treatment significantly (i.e. a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment).

Based on observation, interview, and record review, the facility failed to assess and address a resident (R1) who was having a change in condition. The facility also failed to do a complete follow up (post-fall) body assessment for a resident (R5) who had a fall incident.This failure resulted in a resident (R1) being lethargic throughout the morning shift until the early evening shift without appropriate intervention and was later hospitalized with a primary diagnosis of Lithium toxicity.This applies to 2 of 6 residents (R1 and R5) reviewed for change in condition and accident in the sample of 9. The findings include:1. Face sheet shows R1 is 65 years-old who has multiple medical diagnoses including hypotension, unspecified, essential (primary) hypertension, hyperlipidemia, unspecified, atherosclerotic heart disease of native coronary artery without angina pectoris, paranoid schizophrenia, retention of urine, unspecified anxiety disorder, unspecified restlessness and agitation. R1's MDS (Minimum Data Set) dated February 16, 2026, shows that R1 is alert and oriented and requires substantial to maximum assistance with ADLs (Activities of Daily Living).R1's Progress Note dated March 15, 2026, at 1:47 PM, shows after breakfast, R1 was observed leaning to one side while sitting in her wheelchair. V5 (Nurse) instructed the CNA staff to put R1 to bed to prevent potential fall and to rest. V5 assessed R1 and he noticed a bruise on her left shoulder, but there was no further assessment documented about R1's condition. R1's Progress Note dated March 15, 2026, at 7:20 PM, showed R1 was very lethargic, unable to stand or transfer, and unable to answer questions. Vital signs were checked and recorded. V7 (Nurse) placed a call to the physician and V2 (Director of Nursing/DON). R1's progress note dated March 15, 2026, at 8:31 PM, showed R1 remained very lethargic, she was moaning but could not say or utter any words. R1 was unable to answer any questions, even the simple ones. R1's family was at bedside, physician, and V2 was notified. R1 was sent to the hospital via emergency services.R1's hospital records showed R1 arrived at the hospital on March 15, 2026, and was admitted with primary diagnosis of Lithium Toxicity. On March 16, 2026, at 5:22 AM, R1's lithium level was 1.73 H* which means that it was critically high.On March 23, 2026, at 1:40 PM, V5 (Nurse) stated that he took care of R1 on March 15, 2026, it was the first time he took care of her, he did not know R1's baseline. V5 noticed that R1 was leaning on her side while sitting in her wheelchair, she was confused and had difficulty swallowing her food and medication. V5 had to crush her medications, so she could take it. V5 stated nobody told V5 that it was not R1's baseline. The only thing the CNA staff told him was that R1 needed to be placed in bed.On March 23, 2026, at 12:51 PM, V9 (Certified Nursing Assistant/CNA) stated she worked on March 15, 2026, during the day shift. Although she was not assigned to R1 that day, she noticed the change in R1's condition because she used to take care of R1 regularly. V9 noticed that on March 15, 2026, R1 was very lethargic, she was leaning forward and to her side as if she was about to fall out of the wheelchair. V10 (R1's CNA) attempted to give her a shower but was unable to do so due to her severe lethargic condition. R1 was unable to sit up by herself, she was unable to swallow her donut during breakfast, V5 (Nurse) had to swipe out the donut with his fingers from R1's mouth. R1 had a difficult time swallowing the water. When they gave her water, R1 started gagging. R1 used to eat and drink without difficulty. R1 was very lethargic during the whole morning shift, so V5 instructed them to put R1 to bed to rest. They told V5 to assess R1 because that was not her normal self. R1 was later sent to the hospital during the evening shift, and she did not return back to the facility.On March 23, 2026, at 4:38 PM, V8 (CNA) said R1 used to propel herself in her wheelchair and was alert and oriented. On March 15, 2026, during the day shift R1 was very sluggish, she couldn't sit upright in her wheelchair. R1 was leaning forward and to her side as if she was about to fall. V8 notified V5 that R1 was having a change in condition, and that was not R1's normal self.On March 24, 2026, at 9:42 AM, V10 (CNA) stated R1 was alert and oriented and on March 15, 2026, V10 was assigned to R1. R1 couldn't stand up and kept wetting her incontinence briefs. R1 was continent, she uses the bedside commode. V10 informed V5 that R1 was acting differently. R1 was unable to sit up straight in her wheelchair, V9 and V10 told V5 to check R1. V5 went to R1's room to see her, but V10 was not sure what he did after he saw her. During breakfast R1 was having difficulty swallowing, V5 saw that she was having a hard time swallowing the donut, so he swiped it out from her mouth. R1 was having difficulty swallowing water. R1's eyes were open, but she seemed to be in a daze. V10 noticed that R1's condition has been deteriorating, that was the worst she had seen her.On March 23, 2026, at 4:06 PM, V7 (Nurse) stated, she saw R1 during shift change. V7 noticed R1's lethargic condition, V7 called out R1's name, but she barely responded. Since that was the first time, she took care of R1, V7 was not sure if that was R1's baseline or not. V7 did not receive any report about R1 having changed in condition. When R1's family came in, they were alarmed of R1's condition. Then V7 asked the CNA staff who were working with her that evening and they said that R1 usually gets up with assistance but that evening they tried to get her up, but she couldn't get up even with help. They also tried to put R1 on the commode, but she was unable to sit despite assistance by 3 staff. V7 took R1's vital signs and the vitals were stable, however, R1 remained lethargic. V7 called R1's physician but physician did not respond. V2 (Director of Nursing/DON) was notified, and he said to go ahead and send her to the hospital but try not to call the emergency services. V7 called four different private ambulances, but none of them were available. V7 called the DON again to let him know that she couldn't get any private ambulance, so V7 had to call emergency services. R1 was sent to the hospital. Later, V7 called the hospital to follow up on R1's status, they informed her that she was being admitted for encephalopathy and Lithium toxicity.R1's laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L (millimoles per liter) which means that it was High. There was no documentation to show R1's physician was notified of the high Lithium level.On March 24, 2026, at 3:52 PM, V14 (R1's Psychiatrist) stated he was not aware of R1's elevated Lithium level. V14 also said they order Lithium level for residents who take Lithium, and the facility staff should notify V14 if the Lithium level is high or low. V14 continued to say if he was notified of the Lithium level, he could have changed the dose of Lithium and R1 could have been monitored for change in condition.On March 26, 2026, at 2:21 PM, V20 (Assistant Director of Nursing/ADON) stated when a staff observed any unusual change in a resident's condition, the staff must immediately assess the resident, document and describe the residents' condition and notify the physician and family right away. If the staff does timely assessment, then residents will receive timely treatment or intervention. By monitoring changes in condition and notifying physicians, this would determine if residents needed to go to the hospital for a higher level of care.R1's progress notes on March 15, 2026, morning shift, did not show any detailed assessment and frequent monitoring of R1's condition even though the CNA staff were aware there was a change in R1's condition. 2. Face sheet shows that R5 is 64 years-old who has multiple medical diagnoses including altered mental status, Parkinson's disease without dyskinesia, lack of coordination, muscle wasting and atrophy, difficulty in walking, unspecified lack of coordination, dysphagia, oral phase, cognitive communication deficit. Minimum Data Set, dated [DATE], shows that R5 requires total assistance from staff for toileting, hygiene, and dressing. On March 23, 2026, at 2:51 PM, V16 and V17 (Both Certified Nursing Assistants/CNA) assisted R5 to stand up for a full body assessment. There was a big dark purple colored bruise noted that almost covered his whole right buttock.On March 26, 2026, at 12:14 PM, V5 (Nurse) stated he took care of R5 on March 23, 2026, during the morning shift. V5 stated he took R5's vital signs and he did the skin assessment. V5 said when he does skin assessment, he would document anything unusual like a bruise. When asked if he saw the big bruise on R5's right buttock, V5 said he did not see it because he only assessed R5's exposed skin.On March 23, 2026, at 3:05 PM, V6 (nurse who re-admitted R5 from the hospital) stated R5 is a high risk for fall. V6 was not aware of R5's bruise on his right buttock. V6 also said she watched R5 closely and she placed him by the nurses' station because she did not want R5 to fall under her watch. However, on March 26, 2026, at 2:45 PM, V6 changed her statement and said that she did a complete body check on R5 upon his arrival from the hospital on March 22, 2026, and she noted the bruise on R5's right buttock. On March 26, 2026, at 3:11 PM, V17 (CNA) said she worked the evening shift on March 22, 2026. R5 came back from the hospital before dinner time and was placed in a wheelchair by the nurses' station. V17 assisted R5 to the toilet after he ate dinner and that is when V17 saw R5's bruise which was dark purple in color and covered his whole right buttock. V17 immediately notified V6 about it.On March 26, 2026, at 2:50 PM, V21 (CNA) stated she knew about R5's bruise on his right buttock because V17 endorsed it to her during shift change, and she was also informed by V17 that V6 was already made aware of R5's bruise. On March 26, 2026, at 2:21 PM, V20 (Assistant Director of Nursing/ADON) stated when a staff member finds a bruise on a resident, the staff must document the size, location, color, and if it is tender or painful. The staff should notify the physician right away when there's an injury or a change in a resident's condition because the resident might need to be sent to the hospital for a higher level of care. R5's incident report dated March 20, 2026, at 3:45 PM, showed R5 had a fall incident by the nurses' station. Three staff members assisted R5 back to his wheelchair. There was no injury noted initially. Because it was an unwitnessed fall and R5 was on a blood thinner, the facility sent R5 to the hospital for further evaluation. However, R5's progress note dated March 22, 2026, at 9:48 PM, showed R5 returned to facility from the hospital. A full body assessment was conducted, and no new skin issues were noted. Further review of R5's post-fall assessments until March 23, 2026, at 11:03 AM, shows R5 has no skin issues noted.The Facility's Accident and Incident Policy and Procedure with revised date of May 2022 shows:Documentation in nurses' notes is to include A description of the occurrence, the extent of injury (if any), the assessment of the resident, vital signs, treatment rendered, and parties notified. A minimum of 72 hours (longer if indicated) of documentation per day on resident status after the incident. Vital signs, mental, and physical state, follow-up test, and findings are to be documented.

Based on observations, interviews, and record review the facility fail to revise and implement care plan interventions to prevent falls and provide safety for a resident identified as risks for falls. This applies to 1 (R47) of 3 residents reviewed for safety and supervision in the sample of 20.The findings include:R47 was admitted to the facility on [DATE], with multiple diagnosis including metabolic encephalopathy, acute cholecystitis, diabetes, lack of coordination, difficulty walking, cognitive communication deficit, muscle wasting, spinal stenosis, Parkinson's, history of falls and altered mental status. A nursing Progress note dated November 29, 2025, shows R47 was agitated following lunch and constantly moving via wheelchair through the halls. R47 was observed by staff bending over trying to fix attached footrest. R47 needed constant reminders to sit back in wheelchair to avoid falling. R47 bent forward in chair and was caught by nurse prior to falling to the ground. Per nurse R47 needed to be monitored at nurses' station and required constant queuing, reminding, and distractions for safety. One to one care was suggested. Progress notes from September 2025 to December 2025 show frequent episodes of agitation, restlessness, and behaviors that could have or resulted in a fall.On December 08, 2025, at 11:31AM, R47 was sitting in dining room in a high back wheelchair with four other residents including R13. There were no staff members present in dining room. R13 was sitting in a wheelchair nearby R47. R13 said that she watches over R47 when he is in the dining room because he gets up from his wheelchair and falls frequently. R47 was sitting at the edge of his wheelchair bending over and picking at the floor. R47 stood up from the wheelchair and attempted to lift his right leg over the right foot pedal. R13 called out to the nurses who were standing near a medication cart in the hall for help. R13 said that she often calls for help when this happens. R13 said there is not enough staff to sit with him, so she watches him. R47 attempted to stand and walk away from his chair at 11:39AM, 11:44AM, and 11:50AM. Each time R47 was redirected by R13 without the supervision of staff. On December 09, 2025, at 8:53AM, R47 was observed sitting in the dining room without supervision. R47 was sitting on edge of the wheelchair picking at the floor. Two puddles of clear liquid were noted on the floor behind the center of the wheelchair. There was also a puddle of light brown liquid noted on the floor near the right side of the wheelchair. There were no CNA's (Certified Nursing Assistants/CNA) or nurses in the nearby corridors or at the nurses' station. On December 10, 2025, at 9:55AM, R47 was observed propelling via wheelchair using his feet and holding on to objects along the way. R47's feet were placed under the footrest during this time. R47 stopped at the nurses' station. While sitting on the edge of the wheelchair, R47 bent over and began to pick at the foot pedals. R47 then continued to propel himself in his wheelchair using his feet. There were no nurses or CNAs at the nurses' station or in the corridors at this time. On December 10, 2025, at 10:08AM V16 (CNA) said that she was assigned to R47, and that staff observes them when they can, however this is hard to do as there are only two CNAs on the unit. V16 said that R47 had one to one care initially when he admitted to the facility, but that has since stopped as they no longer have the additional staff. V16 said that R47 does not engage in activities often and stays on the unit most of the time. On December 08, 2025, at 1:45PM, V19 (Family Member) said that R47 has had too many falls to count since being admitted to facility in September. R47's most recent fall was on December 07, 2025. V19 said she was informed that R47 would be kept at the nurses' station for supervision. V19 also said she is unaware of any additional interventions that have been put in place to prevent falls. R47's care plan dated September 29, 2025, shows R47 has impaired cognitive function and requires total assistance from staff for toileting, bed mobility, bathing, and transferring. R47's current fall care plan show's he experienced falls on September 29, November 14, November 19, November 26, December 04, and December 07 and does not include interventions for supervision/monitoring, fall risk behaviors, or personalized preventative interventions. An Active care plan dated September 29, 2025, shows R47 has impaired cognitive function and requires total assistance from staff for toileting, bed mobility, bathing, and transferring. R47's current fall care plan show's he experienced falls on September 29, November 14, November 19, November 26, December 04, and December 07 and does not include interventions for supervision/monitoring, fall risk behaviors, or personalized preventative interventions. The care plan interventions were not revised after fall incidents.On December 10, 2025, at 10:30AM, V20 (Care Plan Coordinator) said that she is responsible for putting fall interventions on the resident's care plans. V20 said if a resident continues to fall, it indicates that current interventions are not working. Interventions are adjusted as needed. On December 10, 2025, at 11:30AM, V2 (DON) said she is responsible for the Fall Prevention Program and that after a fall, immediate interventions are put in place by the nurse. The fall and interventions are then reviewed by the interdisciplinary team and adjustments to interventions are made if needed. V2 said that residents can be placed on safety monitoring if necessary. V2 said that she considers R47 to be a high fall risk and that he is not currently on safety monitoring. V2 said that R47 has never been on safety monitoring and that R47 should be monitored. V2 said she is unsure of when interventions are reviewed in care plan because V20 is responsible for care planning. On December 10, 2025, at 3:40PM, V1(Administrator) said that if a resident is agitated, the expectation is for staff to monitor, determine the source of the agitation, and intervene right away. The facility's Fall Prevention Program policy dated May 2025 shows the purpose is to ensure safety of all residents in the facility when possible. The program includes measures to determine individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision. The guidelines state that the care plan should incorporate identification of all risk/issues, addresses each fall, ensure interventions are changed with each fall as appropriate, and ensure preventative measures are put in place. The standards show that safety monitoring beyond two-hour checks can be put in place and can be as frequent as fifteen-to-thirty-minute checks with documentation records to validate observations. Safety monitoring is discontinued only when the risk factors requiring monitoring is no longer evident as determined by the supervising nurse or interdisciplinary care team.

Based on record review and interview, the facility failed to ensure that a resident's social security benefits from previous facility were transferred over and processed to the resident's present facility as representative payee of the resident's personal needs allowance (PNA). This applies to 1 of 3 residents (R1) reviewed for personal needs allowance (PNA) in the sample of 5. The findings include: Face sheet showed R1 was admitted to this facility on June 25, 2025. Minimum Data Set (MDS) dated [DATE], showed R1 is alert and oriented. On December 9, 2025, at 12:55 PM, R1 said that she was admitted here in June and since then she had not received her monthly $60 allowance. R1 approached V5 (Former Business Office Manager) multiple times about it but nothing happened. R1 only found out last week that the transfer of her social security benefit to this facility was not filed and it really upset her. R1 was informed by a staff that V5 did not file the transfer of her social security benefit to this facility. On December 3, 2025, at 2:31 PM, V4 (Regional Financial Coordinator) stated that R1's family brought concern about R1's money (personal needs allowance). However, V4 was not able to talk to R1 about it when she was last here. On December 3, 2025, at 2:37 PM, V1 (Administrator) stated R1's family said that they have concern that R1 has not received her PNA. It was still being sent by social security to the previous facility. According from the family, the previous facility informed them that they were sending R1's Social Security check back. This happened last Thanksgiving November 27. They called the previous facility, and they were informed that when they received the money from a discharge resident, they immediately returned it to the Social Security. V1 spoke to previous Business Office Manager who already step down from her position and she said that they applied for R1's social security to recognize that this facility is now representative payee but there is no response yet. On December 8, 2025, at 4:18 PM, V5 (Former Business Office Manager) stated when residents are admitted to the facility they check with the resident to see if they can manage their own funds. They also check if their family helps with managing their funds. If a resident came from another facility, they reach out to the previous facility about trust fund status. V4 called the previous facility multiple times and tried to get in touch with their business office manager but she was unable to reach anyone. V4 notified R1 that they couldn't get in touch with the facility. R1 said that her daughter was attempting to get in touch too. V4 called Social Security but could not remember if she was able to get in touch with anyone. Usually as soon as the person gets admitted , they start processing the benefits to be the resident's rep payee.On December 8, 2025, at 4:30 PM, V1 (Administrator) stated that they don't have a policy with regards to the representative payee. The Medicaid is paying for R1's stay here. The payment was only partial since her social security benefit has not yet been processed to be transferred over to them. On December 9, 2025, at 2:01 PM, V11 (Regional Director of Operations) stated when the resident admits into the facility, and they have pursued Medicaid support, the resident is given an option for the facility to become representative payee for their social security benefit. Facility is responsible for the transfer of the resident's social security benefits provided that the resident has requested for the facility to manage it for them. As for R1, she was already approved for social security benefits, however, the application for the advance notification of representative payment was only submitted on December 3, 2025. Facility presented a copy for R1's Advance Notification of Representative Payment which was dated December 3, 2025

Based on interview and record review, the facility failed to obtain orders and administer medications as prescribed.This applies to 1 of 3 (R1) resident reviewed for medication administration.The findings include: R1 was admitted to the facility on [DATE] with multiple diagnoses which included rhabdomyolysis, unspecified fall, bacteremia, acute kidney failure, unspecified multiple injuries, right shoulder osteoarthritis, and hypertension, per the face sheet. R1's MDS (Minimum Data Set) dated 07/07/25 showed R1 was cognitively intact and required partial/moderate assistance with ADL's (Activities of Daily Living). The same MDS showed R1 was admitted to the facility with an unstageable pressure ulcer. R1's Skin Impairment Care Plan showed a pressure injury to the right lateral hip.R1's Progress Notes dated 09/08/25 at 7:30 AM, showed Family called an ambulance and had the resident taken to (Hospital) ER (Emergency Room) related to her right hip wound. Progress Notes dated 09/08/25 at 11:11 AM, showed Resident returned from the hospital with family. Awaiting paperwork from family or hospital. Per family, hospital will fax the information to us. Progress Notes dated 09/08/25 12:00 PM, showed Family said they had discharge paperwork but didn't provide it as they felt that hospital should be faxing it over. Progress Notes dated 09/08/25 at 12:02 PM, showed Family is aware that we need the hospital paperwork. We still haven't received it from the family or the hospital. I let the family know that I still have not received a fax from the hospital. Progress Notes dated 09/08/25 at 9:44 PM, showed Family asking if orders were received yet and were informed, they were not received. Family gave this writer two pill bottles from (Doctor) and is requesting nurse to get verbal orders in AM, will endorse to oncoming shift nurse. Progress Notes dated 09/08/25 at 10:21 PM, showed Endorsed to oncoming shift nurse that orders are needed for two antibiotics in top drawer of medication cart as well as indications for both antibiotics, per AM shift nurse WBC (White Blood Cell) count at hospital was WNL (Within Normal Limits) but no labs or discharge paperwork are available in chart at this time. Progress Notes dated 09/09/25 at 9:02 AM, showed DC (Discharge) paperwork with antibiotic orders was not given to nurse by family when resident returned from hospital. Writer pulled DC paperwork from (Hospital) portal; orders entered. Resident to start PO (Oral) ABT (Antibiotic) x 2 for suspected wound infection. Cultures pending.R1's Patient Visit Information from (Hospital) dated 09/08/25 at 10:04 AM, showed You were seen today for Decubitus Ulcer, stage 3 with infection. Prescriptions: Cephalexin 1,000 mg oral every 12 hours for 10 days and Bactrim DS 800-160 mg 1 tablet oral every 12 hours.R1's MAR (Medication Administration Record) for September 2025 showed Bactrim DS 800-160 mg give one tablet by mouth every 12 hours for suspected wound infection for 10 days. Administration times 8:00 AM and 8:00 PM. The first administration time for Bactrim DS was on 09/09/25 at 12:08 PM. R1 was not given Bactrim DS on 09/08/25 at 8:00 PM or 09/09/25 at 8:00 AM as ordered. R1's MAR showed Cephalexin 500 mg give two tablets by mouth every 12 hours for suspected wound infection for 10 days. Administration times 8:00 AM and 8:00 PM. The first administration time for Cephalexin was on 09/09/25 at 12:07 PM. R1 was not given Cephalexin on 09/08/25 at 8:00 PM or 09/09/25 at 8:00 AM. On 09/16/25 at 1:32 PM, V5 (Registered Nurse) stated During my shift, I never received any paperwork or pills. It is not our procedure to call the hospital to get the paperwork. Normally family or paramedics bring us the paperwork back.On 09/16/25 at 2:11 PM, V2 (Director of Nursing) stated We could have called the hospital and asked for the orders. R1 should not have missed the first dose, and we had the medications here in the facility. The first dose was not administered at the appropriate time. V2 stated if medications are not given as prescribed, the residents infection can become worse. V2 stated the facility should follow the doctor's orders.The facility's Medication Administration policy dated 01/2015, next review 05/2025, showed Medications must be administered in accordance with a physician's order, e.g., the right resident, right medication, right dosage, right route, and right time.

Based on observation, interview, and record review, the facility failed to perform hand hygiene and follow enhanced barrier precautions. This applies to 3 of 3 (R6, R7 and R12) residents reviewed for infection control in a sample of 25. Findings include: 1. On 4/29/25 at 1:06 PM, observed R6 being wheeled into his room by V8 (CNA-Certified Nursing Assistant), followed by V10 (CNA) with a mechanical lift to transfer R6 from his wheelchair to bed. R6 had a urinary catheter. Outside of R6's room on the wall was a poster stating R6 is on EBP (Enhanced Barrier Precautions). Neither V8 nor V10 wore gowns. V8 provided perineal care to R6 without wearing a gown. After wiping the buttocks and genitals of R6, V8 did not remove the soiled gloves or perform hand hygiene and applied a fresh clean disposable brief. Wearing the same soiled gloves, V8 adjusted R6's bed linen and then, removed her gloves, tied up the garbage bag, touched the door and the doorknob, and left the room, all without performing hand hygiene. On 4/29/25 at 1:15 PM, V6 (LPN-Licensed Practical Nurse) walk into the room of R6 with wound supplies in her hand. V6 did not wear any gown. V6 donned gloves, cleaned the wound on R6's left leg, and placed the soiled gauze on the bedside table. Without changing her gloves, V6 applied a clean adhesive bordered dressing on the wound. Without changing her gloves, V6 handled R6's bedding and covered up R6, removed her gloves, took the soiled used gauze, and without performing any hand hygiene, touched the door and the doorknob on her way out of the room. V6 went to a clean caddy with PPE (Personal Protective Equipment), took a plastic bag from it, put all the soiled items in it, tied and discarded it in the trash can of the shower room at the end of the hallway and used hand sanitizer. On 4/25/25 at 1:14 PM, V5 (RN) stated, when a resident is on EBP, gown and gloves must be worn when providing care for residents with wounds or indwelling medical devices. On 5/1/25 at 9:30 AM, V2 (DON-Director of Nursing) stated transmission precautions and hand hygiene must be followed by all staff as per policy to prevent transmission of infections. 2. On 4/29/25 at 12:15 PM, V7 (LPN) performed blood sugar testing for R7 in his room with gloves on and no gown. R7 had a urinary catheter. Outside of R7's room on the wall was a poster stating he is on EBP. After checking the blood sugar, V7 removed her gloves and held them in her hands and did not perform any hand hygiene. V7 wheeled R7 out of the room and discarded the dirty gloves into the sharp's container on the med cart. Without performing any hand hygiene, V7 touched the laptop on the med cart, and handled a set of keys and put them into her pocket. V7 then placed the blood sugar testing machine back into the cart without cleaning it. Then without performing hand hygiene, V7 locked the cart and wheeled R7 to the dining room for lunch. 3. On 4/30/25 at 1:48 PM, V5 (RN-Registered Nurse) straightened R12's room. Outside R12's room on the wall is a poster stating she is on EBP. R12 had a urinary catheter. V5 came out of the room without performing any hand hygiene, wheeled her medication cart back to the nurse's station and started touching the med cart laptop. Facility policy on EBP revised on 03/2025 showed, .Personal Protective Equipment . Standard Precautions must be followed with all cares. Additionally, gown and gloves must be worn when providing cares like dressing, wound care, perineal care . Points to remember Handwashing (hand hygiene) is the single most important precaution to prevent the transmission of infection from one person to another

Based on observation, interview, and record review, the facility failed to follow their water management plan for legionella. The facility also failed to follow their policy for enhanced barrier precautions, transmission based precautions, and hand hygiene during provisions of care. This applies to all 72 residents residing in the facility. The findings include: 1. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated September 30, 2024, showed the facility's census was 72 residents. On October 1, 2024, at 3:18 PM, V27 (Environmental Services Director) said he does not keep documentation of the temperatures of the hot water boiler/storage tanks, the thermostat of the mixing valve, eye wash station inspections and flushing, ice machine inspections and cleaning, and cooling tower inspections. On October 2, 2024, at 9:40 AM, V27 provided the water temperatures he has documented from July 1, 2024, to present. V27 said these are the only water temperatures he records for the facility. The facility's Logbook Documentation did not show water temperatures were collected the week of July 8, 2024, September 16, 2024, and September 23, 2024. The facility does not have documentation to show the temperatures in the kitchen and laundry room were collected for the month of August and September. On October 2, 2024, at 10:11 AM, V27 said he is unsure if the facility has mixing valves. V27 continued to say the maintenance staff try to check the cooling tower every other week, depending on the weather. On October 2, 2024, at 10:46 AM, V1 (Administrator) said the expectation is V27 should be following the facility's water management plan for legionella and documenting the preventative maintenance as shown in the water management plan. The facility's policy titled Water Management Program for Prevention of Legionella Growth, dated May 2024, showed, Purpose: To identify and reduce the risk of Legionella growth and spread. Guidelines: Definition: Legionella is found naturally in [NAME] environments, like lakes and streams, but generally the low amounts in [NAME] do not lead to disease. Legionella can become a health problem in building water systems. To pose a health risk, Legionella first has to grow (increase in numbers). Then it has to be aerosolized so people can breathe in the small, contaminated water droplets. Factors internal to buildings that can lead to Legionella growth: . Preventative maintenance will be performed as applicable: The following will be verified and documented at least once weekly: The domestic hot water boiler/storage tanks verified to be set between 140 to 160 degrees Fahrenheit. Thermostat indicating the temperature of water entering the circulating system at the mixing valve is 120 degrees Fahrenheit or above. Eye was stations will be inspected and flushed weekly. Ice machines will be inspected and cleaned internally at least every three to six months and as needed for leakages or contamination. Cooling tower (if applicable) will be inspected at least weekly to ensure proper functioning and chemical distribution. Weekly sanitizing of medical devices such as CPAP (Continuous Positive Airway Pressure), hydrotherapy, etc. Environmental Services will monitor the identified areas of risk per guidelines above and implement corrective action as indicated . The facility does not have documentation to show the domestic hot water boiler/storage tanks were verified to be set between 140 to 160 degrees Fahrenheit, the thermostat at the mixing valve was 120 degrees Fahrenheit or above, the eye wash stations were inspected and flushed weekly, the ice machines were inspected and cleaned at least every three to six months, the cooling tower will be inspected at least weekly to ensure proper functioning and chemical distribution, and weekly sanitizing of medical devices. 2. The EMR (Electronic Medical Record) showed R27 was admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease, pressure ulcer of the sacral region, UTI (Urinary Tract Infection), and ESBL (Extended Spectrum Beta Lactamase) Resistance. R27's MDS (Minimum Data Set) dated July 1, 2024, showed R27 was cognitively intact. The MDS continued to show R27 could independently wheel 150 feet in her wheelchair. R27's order summary report dated October 2, 2024, at 12:22 PM, showed an order dated September 30, 2024, for Contact isolation for ESBL in the urine. R27's UTI care plan dated September 30, 2024, showed The resident has a UTI. The care plan continued to show multiple interventions dated September 30, 2024, including Contact isolation. On September 30, 2024, at 1:20 PM, R27 was sitting in her wheelchair in her room. The sign outside of R27's room showed Contact Isolation. R27 said no one has worn a gown when coming into her room to provide care, and R27 is allowed to leave her room whenever she would like. R27 said she has not been told she has to stay in her room. On October 1, 2024, at 11:15 AM, R27 propelled herself using her motorized wheelchair into the hallway. V26 (LPN/Licensed Practical Nurse) and V7 (Staffing Coordinator) stopped R27 and assisted R27 with repositioning her legs in her wheelchair and adjusting the cushion on R27's wheelchair. V26 and V7 were not wearing gloves or gowns when assisting R27. R27 continued to propel down the hallway, away from her room. On October 1, 2024, at 11:41 AM, V3 (Assistant Director of Nursing/Infection Preventionist) said residents on contact isolation are allowed outside of their rooms while on isolation. V3 continued to say the facility follows CDC (Centers for Disease Control and Prevention) guidelines for contact isolation. On October 2, 2024, at 11:09 AM, V3 said the CDC guidelines show a resident on contact precautions should be kept in their room unless medically necessary. V3 continued to say V26 and V7 should have been wearing gowns and gloves while repositioning R27 in her wheelchair. The facility's policy titled Infection Prevention and Control Program, dated March 2024, showed, Purpose: To comply with a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. To comply with the core elements of Antibiotic Stewardship to reduce the unnecessary use of antibiotics. Guidelines: .18. Contact precautions in addition to standard precautions will be initiated as specified in the specific isolation policy. Precautions should be the least restrictive possible for the resident under the circumstances. (Refer to CDC Recommended Precaution Guidelines by Organism) . The CDC's Appendix A: Type and Duration of Precautions Recommended for Selected Infections and Conditions, dated September 20, 2024, showed MDROs (Multidrug-Resistant Organisms) including ESBL should be on contact and standard precautions. The CDC's Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, dated September 2024, showed Contact Precautions: Use Contact Precautions as recommended in Appendix A for patients with known or suspected infections or evidence of syndromes that represent an increased risk for contact transmission . Patient transport: In acute care hospitals and long-term care and other residential settings, limit transport and movement of patients outside of the room to medically-necessary purposes . 36567 3. R41's face sheet included diagnoses of Parkinson's disease with dyskinesia, with fluctuations, acute kidney failure, unspecified, dependence on renal dialysis, urinary tract infection, site not specified, sepsis, unspecified organism, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance. R41's active POS (Physician Order Sheet) showed an order for contact isolation for VRE (Vancomycin-Resistant Enterococci) in the urine. R41's care plan revised on September 27, 2024, showed that R41 has a urinary tract infection related to VRE with interventions including contact isolation. R41's room entrance had posting for contact isolation with directions including, wearing gown and gloves before room entry and discard the gloves and gown before exit. On October 1, 2024, at 10:40 AM, R41 was wheeled to the unit on return from Dialysis by V20 (Transportation) and stationed near the nurse's station. On October 1, 2024, at 10:45 AM, V17 (Power of Attorney) joined him and was seen wheeling R41 to the common therapy room at a different area of the facility. V21 (Certified Occupational Therapy Assistant) was seen working with R41 in the therapy room. Multiple other residents were also seen in the therapy room. V21 put a gait belt around R41 and was assisting him at the stand up bars and with placing objects in a container, stating that it is helping him with his fine motor skills. V21 was called aside and asked whether she knew if R41 was on contact precautions based on information from R41's POS, and V21 responded that she was not aware of the same. V21 stated that she would have put on gloves and gown if she knew R41 was on contact precautions. On October 1, 2024, at around 12:00 PM, V2 (Director of Nursing) stated that for residents on contact isolation precautions, therapy should have been done in the resident's room with therapist wearing gloves and gown. 29562 4. On September 30, 2024, at 10:32 AM, during initial rounds of the facility, it was observed that R3 was on Enhanced Barrier Precaution (EBP) for her suprapubic catheter and nephrostomy catheter. Upon entering the bedroom, V22 and V23 (both CNA) were seen providing care to R3. V22 said they just finished the incontinence care and were repositioning R3 and straightening her bed linen. Both staff were wearing gloves, but they were not wearing isolation gown as part of the PPE (personal protective equipment). The Enhanced Barrier Precaution (EBP) signage shows: Providers and Staff must also: Wear gloves and a gown for the following high-contact resident care activities such as dressing, changing linens, and changing briefs. The device care use includes urinary catheter. 5. On September 30, 2024, at 1:13 PM, V18 rendered incontinence care to R38 who had a bowel movement and was wet with urine. V18 cleaned R38's perineum from front to back, she placed a new incontinence brief and helped repositioned R38 while wearing the same soiled gloves. After repositioning R38, V18 removed her gloves, she picked the soiled items from garbage bin then she tied the plastic bag to close it, and without hand hygiene, she picked up R38's drinking water and placed it within reached. 6. On October 1, 2024, at 10:30 AM, R50 was receiving wound care when he started having a bowel movement. V22 and V24 (both CNAs) provided the incontinence care. V22 cleaned R50's perineum from front to back, and while using the same gloves, V22 applied a barrier cream to R50's buttocks. On October 2, 2024, at 11:53 AM, V2 (Director of Nursing) stated that staff must perform hand hygiene and don gloves before they start providing the care. They should change gloves and do hand hygiene from dirty to clean task, and before leaving the bedroom. If the resident is on EBP, the staff are expected to wear gown and gloves when providing direct care to resident. These are all done to prevent the spread of infection. 16746 7. R124 was admitted to the facility on [DATE], with multiple diagnoses including osteomyelitis, type 2 diabetes mellitus with foot ulcer and non-pressure chronic ulcer of the right heel and midfoot with bone involvement without evidence of necrosis, based on the face sheet. R124's order summary report dated September 19, 2024, showed an order for enhanced barrier precautions every shift, related to wounds and PICC (Peripherally Inserted Central Catheter) line. On October 1, 2024, at 9:19 AM, a posted sign on the wall by the outside door of R124's room was observed. The posted sign showed EBP (Enhanced Barrier Precautions) with instructions for the providers and staff to wear gloves and a gown for high-contact resident care activities, including device care or use of central line. During this observation, V2 (Director of Nursing) prepared and administered R124's IV (intravenous) antibiotic via PICC line on the left inner upper arm. While wearing only gloves, V2 performed the following: spiked R124's IV antibiotic solution bag using the IV infusion set, primed the IV infusion set, placed the IV infusion line in the IV pump, cleaned the end of the PICC line lumen with an alcohol swab, attached the 10 ml syringe to the end of the PICC line lumen then flushed the PICC line with normal saline, connected the IV infusion line to the PICC line lumen and then started the IV antibiotic. V2 did not use a gown during this high contact care procedure. On October 1, 2024, at 10:33 AM, R124's IV antibiotic was completed. With her gloved hands V5 (Registered Nurse) removed the IV infusion line from the PICC line lumen, cleaned the end of the PICC line lumen using an alcohol swab, attached the 10 ml syringe to the end of the PICC line lumen then flushed the PICC line with normal saline. V5 did not use a gown during this high contact care procedure. On October 1, 2024, at 10:45 AM, both V2 and V5 acknowledged that they only used gloves and did not use gown during the administration of antibiotic to R124 via PICC line and during the PICC line care. V2 stated that they should have used the required enhanced barrier precaution equipment including gown and gloves when they handled R124's PICC line. According to V2, gown and gloves should be used to protect the resident from infection, to prevent cross contamination and to ensure that infection control was maintained. R124's active care plan initiated on September 19, 2024, showed that the resident was on EBP related to PICC line and wounds. The same care plan showed multiple interventions including using gown and gloves during high-contact resident care and to follow enhanced barrier protocol. The facility's policy regarding EBP last revised on March 2024 showed, Enhanced Barrier Precautions (EBP): recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. The policy showed in-part that EBP may be considered and implemented for indwelling medical devices including central line. The same policy showed, Standard Precautions must be followed with all cares. Additionally, gown and gloves must be worn when providing the following care: . Medical Device Care. 41855 8. R6's EMR (Electronic Medical Record) showed R6 was admitted to the facility on [DATE], with diagnoses that included cerebrovascular disease, dementia, benign prostatic hyperplasia with lower urinary tract symptoms, other obstruction reflux uropathy, and urinary retention. R6's MDS (Minimum Data Set) dated July 18, 2024, showed R6's cognition was severely impaired. R6 was dependent on staff for all ADLs (Activities of Daily Living). R6's care plan showed R6 has an ADL self-care performance deficit related to activity intolerance, confusion, dementia, fatigue, and difficulty walking. R6 has bladder incontinence with a long history of UTIs (urinary tract infections), urinary retention, chronic kidney disease, and history of chronic indwelling urinary catheter that was removed. Interventions included staff to clean peri-area after each incontinence episode. On October 2, 2024, at 10:30 AM, V18 (CNA/Certified Nurse Assistant) and V19 (CNA) gathered supplies needed to provide R6 incontinence care. V18 washed her hands and put on gloves, V19 was already in the room with the mechanical lift and was wearing gloves. Together they used a mechanical lift and placed R6 back into his bed. V18 removed R6's pants and V19 unfastened R6's incontinence brief. V18 used a disposable wipe and cleaned the left groin from front to back, folded wipe in half and wiped the right groin front to back, and folded wipe in half again to clean R6's penis. V18 removed her gloves and put on new gloves without washing hands with soap and water or using hand sanitizer. V19 turned R6 onto his side. V18 used a new wipe and cleaned his buttock from front to back removing a small amount of stool. V18 removed her gloves and without washing her hands with soap and water or using hand sanitizer, put on a new pair of gloves. V19 placed a new incontinence brief under R6 and with V18, they repositioned R6 onto his back, his pants were pulled up, V19 connected the mechanical lift sling to the mechanical lift while V18 removed her gloves and went into the bathroom to wash her hands with soap and water. V18 controlled the mechanical lift while V19 remained next to R6 until he was seated back into his chair. V18 pushed R6 out of the room in his high backed wheelchair, and V19 removed his gloves and pushed the mechanical lift out of the room without washing his hands with soap and water or using hand sanitizer. On October 2, 2024, at 11:45 A, V2 (DON/Director of Nursing) said when providing incontinence care, the staff should gather supplies, wash hands with soap and water or use hand sanitizer, and then put on gloves. V2 said after cleaning the front area, the staff member should remove their gloves, clean hands with soap and water or use hand sanitizer and put on new gloves before turning resident onto their side. The staff member should use a new washcloth or wipe, to clean the buttocks from front to back. V2 said it is ok to fold a wipe in half once to use the other side, but after that they need to use a new wipe to continue to clean the resident. After cleaning the back side of the resident, the staff member can remove the soiled incontinence brief and/or soiled linen from under the resident wearing the same gloves, but they need to remove those gloves, wash hands with soap and water or use hand sanitizer and put on new gloves before placing a new brief and/or linen under a resident. Once resident is repositioned, the staff need to remove gloves wash hands with soap and water or use hand sanitizer before leaving the room. Facility's policy titled, Enhanced Barrier Precautions with the last revision date of March 2024, showed Statement of Purpose: Enhanced Barrier Precautions (EBP): recommendations now include the use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status .Personal Protective Equipment: Gown and gloves .Personal Protective Equipment: Standard precautions must be followed with all cares. Additionally, gown and gloves must be worn when providing the following cares: providing hygiene, changing linens, incontinence care Facility's policy titled, Hand Hygiene/Handwashing with effective date of March 2024, Definition: Hand hygiene means cleaning your hands by using either handwashing (soap and water), antiseptic hand wash, or antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel) .Examples of When to Perform Hand Hygiene (Either Alcohol Based Hand Sanitizer or Handwashing): After contact with blood, body fluids or excretions, mucous membranes, non-intact skin or wound dressings If hands will be moving from a contaminated-body site to a clean-body site during patient care, before glove placement, after glove removal .

Based on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and grooming. This applies to 7 of 8 residents (R3, R8, R12, R30, R44, R63 and R67) reviewed for ADLs (activities of daily living) in the sample of 18. The findings include: 1. R8 had multiple diagnoses including dementia without behavioral disturbance and age related macular degeneration of both eyes, based on the face sheet. R8's quarterly MDS (minimum data set) dated July 25, 2024, showed that the resident was severely impaired with cognition and required assistance from the staff with personal hygiene. On September 30, 2024, at 10:42 AM, R8 was in bed, alert, verbally responsive but confused. V6 (Certified Nursing Assistance) was in the resident's room and had placed a blanket on the resident. V6 requested R8 to show her hands and fingers. R8's fingernails were long with black substances under most of her nails. During the lunch meal observation on September 30, 2024, at 1:06 PM, R8 was using her fingers to eat her peanut butter and jelly sandwich. R8 was observed licking her fingers to get the peanut butter and jelly off her fingers and nails. R8's fingernails remained long with black substances under most of her nails during this lunch meal observation. On October 1, 2024, at 9:59 AM, R8 was sitting in her wheelchair near the unit nursing station. R8's fingernails were long with black substances under the nails. V2 (Director of Nursing) was present during this observation and acknowledged that R8's fingernails were long and needed cleaning. According to V2, R8 needs the assistance of the staff to trim and clean her fingernails. R8's active care plan initiated on May 5, 2023, showed that the resident has ADL self-care performance deficit related to confusion and dementia. The same care plan showed multiple interventions including one staff assistance with personal hygiene. 2. R44 had multiple diagnoses including dementia without behavioral disturbance and weakness, based on the face sheet. R44's quarterly MDS dated [DATE], showed that the resident was moderately impaired with cognition and required assistance from the staff with personal hygiene. On September 30, 2024, at 10:42 AM, R44 was sitting in her wheelchair inside her room. R44 was alert and verbally responsive. R44's fingernails were long, jagged with black substances under some of the nails. R44 stated that she wanted the staff to trim and clean her fingernails because she cannot do it herself. On October 1, 2024, at 10:05 AM, R44 was inside her room, sitting in her wheelchair. R44 was alert and verbally responsive. R44's fingernails were long, jagged with black substances under some of the nails. R44 stated that she wanted the staff to trim and clean her fingernails. V2 was present during the observation and stated that R44's fingernails needed to be trimmed and cleaned by the staff because the resident needs the assistance to complete the said task. R44's active care plan initiated on July 28, 2022, showed that the resident has ADL self-care performance deficit. The same care plan showed multiple interventions including one staff assistance with personal hygiene. 3. R63 had multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and weakness, based on the face sheet. R63's quarterly MDS dated [DATE], showed that the resident was cognitively intact and required maximum assistance from the staff with personal hygiene. On September 30, 2024, at 11:04 AM, R63 was in bed, alert, oriented and verbally responsive. R63 had contracture of her right hand. R63's fingernails were long and jagged with some black substances under the nails. R63 also had accumulation of long, curling chin hair. R63 stated that she would like the staff to clean and trim or file her fingernails to prevent her from scratching herself and she wanted the staff to remove or shave her chin hair. R63 commented when asked if she needed staff assistance with removing her chin hair. R63 responded, yes please, it is embarrassing to have these long and curling chin hairs. On October 1, 2024, at 10:00 AM, R63 was in bed, alert, oriented and verbally responsive. R63's fingernails were long and jagged with some black substances under the nails. R63 also had accumulation of long, curling chin hair. R63 stated that she needs the staff assistance with trimming and cleaning her fingernails and she wanted the staff to remove her chin hair. V2 was present during the observation and heard R63's request. V2 stated that R63's fingernails need to be trimmed and cleaned and R63's chin hair needs to be removed. According to V2, R63 needs the assistance of the staff to trim and clean her fingernails and to remove her facial hair. R63's active care plan initiated on January 29, 2024, showed that the resident has ADL self-care performance deficit related to weakness, and hemiplegia and hemiparesis affecting the right dominant side. The same care plan showed multiple interventions including one staff assistance with personal hygiene. 4. R67 had multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, based on the face sheet. R67's quarterly MDS dated [DATE], showed that the resident was cognitively intact. The same MDS showed that R67 had functional limitation in range of motion to one side of his upper extremity and that he required assistance from the staff with personal hygiene. On September 30, 2024, at 11:33 AM, R67 was sitting in his wheelchair inside the unit activity/dining room. R67's fingernails were long, jagged with black and brown substances under some of the nails. According to R67 he cannot trim and clean his fingernails, and he would like the staff to do it for him. On October 1, 2024, at 10:07 AM, R67 was sitting in his wheelchair inside his room. R67's fingernails were long, jagged with black and brown substances under some of the nails. V2 was present during the observation and acknowledged that R67's fingernails needs trimming and cleaning. According to V2, R67 needs the assistance of the staff for nail care because the resident cannot do it himself due to his left sided weakness. R67's active care plan initiated on June 3, 2024, showed that the resident has ADL self-care performance deficit. The same care plan had multiple interventions including one staff assistance with personal hygiene. On October 1, 2024, at 10:56 AM, V2 (Director of Nursing) stated that it is part of the facility's nursing care and services to assist all residents needing assistance with ADLs including shaving/removal of unwanted facial hair, especially for female residents and nail care. V2 added that all residents needing assistance with ADLs should be assisted by the staff to ensure and maintain the resident's good hygiene and grooming. 29562 5. On September 30, 2024, at 10:41 AM, R3 was noted to have overgrown facial hair on her chin and long uneven nails, with brownish discoloration on top of the nail bed and underneath the fingernails. R3 said she wanted it to be clipped and wanted her facial hair shaven. R3's MDS dated [DATE], shows that R3 is alert and oriented, and is totally dependent of staff for her hygiene and grooming care. R3's active ADL care plan with a target date of October 14, 2024, shows R3 has an ADL self-care deficit related to musculoskeletal impairment. The same care plan shows multiple interventions which include to check nail length, trim, and clean on bath day and as necessary. 6. On October 1, 2024, at 10:56 AM, R12 was sitting in her reclining chair, alert and oriented. R12 was observed with chunk of dry substance the size of a small fist on the right upper side of her shirt. R12 stated that it was oatmeal which she spilled while eating breakfast in the dining room. It's been there since breakfast (around 8:30 AM). Aside from the chunk of dry oatmeal, her shirt had multiple food debris all over. On October 1, 2024, at 11:12 AM, V19 (CNA) and V5 (Nurse) provided incontinence care to R12. After the provision of incontinence care, V5 also cleaned R12's shirt by removing the chunk of oatmeal from the shirt instead of changing R12's shirt, then V5 and V19 transferred R12 back to the reclining wheelchair in preparation for lunch in the dining room. R12's MDS dated [DATE], shows R12 is alert and oriented and is totally dependent of staff for dressing and toileting hygiene. On October 1, 2024, at 2:35 PM, V33 (Ombudsman) stated she noticed that many of the residents are unkempt and with dirty fingernails during her visits. On October 2, 2024, at 12:13 PM, V2 stated that nail care and shaving are supposed to be offered during shower days. If the clothes are dirty the staff should assist the resident to change it for resident's dignity. 36567 7. R30's diagnoses on face sheet included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Alzheimer's disease, unspecified, dysarthria following cerebral infarction, extrapyramidal and movement disorder, unspecified. R30's quarterly MDS dated [DATE], showed that R30 was severely impaired in cognition and required assistance with personal hygiene. R30's care plan revised November 21, 2023, included that R30 has an ADL self-care performance deficit related to above diagnoses. Interventions for the same included that R30 needs 1 (one) assist with personal hygiene and oral care. On September 30, 2024, at 11:03 AM, R30 was seen in her room with her nails long and with some of them jagged and with blackish substance underneath the nails. R30 also had long facial hair on her chin. On October 1, 2024, at 10:34 AM, R30 was in her room and her nails remained long and jagged with blackish substance underneath the nails and R30's long facial hairs were still visible on her chin. This information was relayed to V12 (Registered Nurse) who stated that usually it is taken care of on shower days and that R30's shower days are on Saturdays and Wednesdays.

Based on observation, interview and record review, the facility failed to serve mechanical soft consistency mushrooms and potatoes and failed to serve pureed consistency chicken and vegetables for residents on mechanical soft and pureed diets. This applies to 9 of 9 residents (R1, R6, R10, R15, R24, R26, R30, R41 and R224) reviewed for mechanically altered diets in the sample of 18. The findings include: 1. On September 30, 2024, at 12:07 PM, during meal temperature monitoring of prepared foods prior to meal service, the pureed chicken on the tray line appeared grainy. On taste testing, there were parts of the pureed chicken that were not able to be swallowed without being chewed. V8 (Regional Dietary Certified Manager) who was in the vicinity was notified and was informed that the item was not safe to serve. V8 also taste tested the product and agreed with the consistency and stated that the pureed meat should not be uneven and should be like mashed potatoes. On October 1, 2024, at 11:53 AM, during tray line service for the lunch meal, V10 (Cook) was platting the food. The pureed vegetables were noted to have visible small pieces of carrots in it. On taste tasting, the carrots remained in small whole pieces which were unable to be swallowed without chewing. V9 (Contract Dietary Consultant) who was in the vicinity was showed the pureed vegetables and V9 agreed that the product should be pureed further. The vegetables that were pureed were identified as 'vegetable blend' that included carrots. When asked what the consistency should be like, V9 pointing to V10 and stated Ask him. V10 responded that the product should be like mashed potatoes. Facility guidelines (Dining Service Menu Guide, 2022) for pureed foods included to process hot or cold items in a food processor until they are fine and homogenous in texture. Add measured amounts of hot liquid for cooked food and cold liquid for cold foods (if required) and process until there is a smooth, pudding-like or smooth mashed potato consistency . Facility diet order listing showed that R1, R6, R10, R15 and R24 were on pureed consistency diets. 2. On September 30, 2024, starting at 12:09 PM, during tray line service, V10 was platting the food. R26, R30, R41 and R224 who had an order of dental soft diet on their meal ticket, received ground meat topped with whole sauteed mushroom slices and gravy and roasted potatoes with skin, with their meals. Menu diet spreadsheet for Monday, week 2 lunch meal showed to serve ground baked chicken and mushroom with sauce and mashed potatoes. Recipe for Ground Baked Chicken and Mushroom with Sauce included as follows: 1. Arrange chicken in a baking dish or steam table pan coated with cooking spray. Sprinkle with paprika. Bake, uncovered at 350 F (Fahrenheit) for 15 minutes. 2. Meanwhile in a large skillet, saute mushrooms in butter or margarine for 5 minutes. Add broth or [NAME], green onions, garlic, salt and pepper. Bring to boil. Pour over chicken. 3. Bake 10-15 minutes longer or until a final internal temperature of 165 F is reached. 4. Remove needed portions and place in a clean and sanitized food processor and grind to size and texture of fine hamburger. Place into a clean steam table pan On September 30, 2024, at 12:16 PM, V8 was notified that the above residents on mechanical soft diets received ground meat topped with whole sauteed mushroom slices and roasted potatoes with skin. V8 stated that the spread sheet for mechanical diet and recipe for ground baked chicken should have been followed. Facility guidance (Long Term Care Diet Manual, 2022) for Dental soft (Mechanical Soft) Diet showed that all vegetables should be chopped or diced into bite sized pieces (1/2 inch or smaller). Foods allowed included peeled cooked potatoes and that potato skins should be excluded. Facility diet order listing showed that R26, R30 and R224 were on mechanical soft, ground meat diet and that R41 was on mechanical soft diet.

Based on observation, interview, and record review, the facility failed to respond to a resident's call for help and failed to ensure that the call light was always within reach of the resident. This applies to 1 of 18 residents (R12) reviewed for call light accessibility in the sample of 18. The findings include: Face sheet shows that R12 has multiple medical diagnoses which include cervical disc degeneration unspecified cervical region, spinal stenosis cervical region, spondylosis without myelopathy or radiculopathy cervical region, fusion of spine cervical region, morbid (severe) obesity due to excess calories, other lack of coordination, abnormal posture, reduced mobility, and weakness. Minimum Data Set (MDS) dated [DATE], shows R12 is alert and oriented and is totally dependent of staff for dressing and toileting hygiene. On October 1, 2024, at 10:56 AM, R12 was observed repeatedly yelling for help. V25 (Housekeeper) was outside R12's bedroom cleaning and continued to do her chores despite R12's repeated call for help. R12 was inside her bedroom sitting in her reclining wheelchair. When asked what she needed, R12 stated she needed to get change because she had a bowel movement and was wet with urine. When asked why she was screaming, instead of using her call light, R12 replied she does not know where her call light was. R12's call light was observed on the floor at bedside a few feet behind R12's recliner. On October 2, 2024, at 12:10 PM, V2 (Director of Nursing) stated that everyone (all staff) is responsible to respond for a call for help. The call light is supposed to be always within reach, so that a resident will be able to call for help. Facility's policy and procedure for call light with a review date of June 2024 showed, To respond to resident's request and needs in a timely and courteous manner. The same policy showed under guidelines, 1. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location. 4. Listen to resident's request. Do not make him or her feel that you are too busy to help. 5. Respond to request. If item is not available, or request questionable, get assistance from charge nurse. Return to resident with prompt reply.

Based on interview and record review the facility failed to identify a pressure injury before becoming unstageable and failed to provide treatment to moisture associated dermatitis. These failures resulted in R4 developing an unstageable pressure injury to the sacrum. This applies to 1 of 4 residents (R4) reviewed for pressure injuries in the sample of 11. The findings include: On 3/15/24 at 11:34 AM, V10 Wound Licensed Practical Nurse (LPN) said R4 has pressure injury on her sacrum that was acquired at the facility and has been treated for a while. V10 said she is new to the facility and was not here when R4's wound was found. V10 said nursing staff does daily skin checks on residents during care and showers. V10 said she does weekly skin assessments for residents with wounds. V10 said any skin issue noted should be reported to the nurse and an assessment of the wound including measurements should be done and documented. V10 said interventions including treatments will then be implemented. R4's Admission Skin assessment dated [DATE] shows R4 was admitted on [DATE] with blanchable redness to her sacrum and shows R4 is at very high risk for skin impairment. R4's Admission Skin assessment dated [DATE] was done by V13 Previous Wound LPN and shows skin intact. R4's Care Plan dated 12/11/23 shows resident has activity of daily living self-care performance deficit related to general weakness post hospitalization , cerebral infarction due to thrombosis of middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting Right dominant side, altered mental status; requires assist of 2 staff members for bed mobility and transfers; incontinent of bowel and bladder; and is at risk for skin impairment. R4's Progress Note dated 12/11/23 by V13 shows skin intact. R4's Physician Note dated 12/13/23 shows Skin Common normals: no wounds. R4's Shower Sheet dated 12/17/23 shows R4's left buttocks is circled and labeled discolored. R4's Shower Sheet dated 12/20/23 shows R4's lower right and left buttock is circled and labeled 7 (indicating scratch per the assessment key). R4's Progress Notes from 12/14/23 to 12/27/23 does not contain progress notes or weekly skin assessments on R4's skin. R4's Weekly Skin Observation Progress Note dated 12/28/23 shows new wound noted. Wound 1 was acquired in-house. Wound 1 is a pressure injury. Wound 1 is unstageable. First observation for wound 1. No reference prior. R4's Treatment Administration Record (TAR) for December 2023 shows an order dated 12/22/23 Cleanse open area to right buttock with normal saline, pat dry and apply duoderm. Every day shift for right buttock and an order dated 12/22/23 Cleanse open area to left buttock with normal saline, pat dry and apply duoderm. Every day shift for left buttock. These orders were discontinued on 12/26/23. From 12/22/23 to 12/26/23 the treatment orders for the left and right buttock were only checked off as completed 2 days (12/24/23-12/25/23). New orders for the right and left buttock were started on 12/26/23. (R4 had no treatments completed on her right and left buttock 12/26/23 and 12/27/23.) R4's Skin-Pressure/Diabetic/Venous/Arterial Wound Report dated 12/28/23 by V13 shows R4 has a new wound to her coccyx, acquired in-house, Unstageable Pressure injury with measurements of 5.5 x 6.4 x 0.1 Centimeters. Tissue type: 60% necrotic, 10% slough, 30% granulation. R4's Initial Wound Evaluation and Management Summary dated 12/28/23 by V14 Wound Doctor shows Unstageable (due to necrosis) sacrum pressure measuring 5.5 x 6.4 x 0.1 centimeters, thick adherent black necrotic tissue 30%, thick adherent devitalized necrotic tissue 30%, slough 10%, granulation tissue 30%. R4's Wound Evaluation and Management Summary dated 1/15/24 by V14 Wound Doctor shows Addendum to previous visit note from 1/8/24: wound was not present on admission to facility. On 3/15/24 at 1:51 PM, V2 Director of Nursing said V13 was the wound care nurse at the time R4's wound was found. V2 said V13 no longer works here. V2 said she was not sure how R4's unstageable wound happened between 12/21/23 and 12/28/23. V2 said it is not typical for a wound to develop so quickly. V2 said absolutely the wound should have been identified before being unstageable. V2 said on 12/21/23, V13 noted open areas on the TAR but there were no measurements done or assessment charted, but the care plan indicated Moisture Associated Skin Damage (MASD). V2 said other than the shower sheets, she could not find any other skin assessments or notes. V2 said MASD makes a resident as risk for developing pressure. V2 said R4's treatments for the MASD or open skin areas on the left and right buttock were not completed as ordered on the TAR. V2 said not doing the treatments as ordered increases the risk of developing pressure injuries also. V2 said when R4's pressure wound was found it was one large area indicating the areas on the left and right buttocks turned into the large sacral wound. The facility's Pressure Injury and Skin Condition Assessment Policy dated 11/2023 shows Each resident will be observed for skin breakdown daily during care. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. Care givers are responsible for promptly notifying the charge nurse of skin breakdown. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes. Dressing will be checked daily for placement, cleanliness, and signs and symptoms of infection.

Based on observation, interview, and record review, the facility failed to monitor residents at risk for weight loss, offer nutritional supplements as ordered by the physician in order to prevent additional weight loss, and offer food substitutes for meals/snacks that were refused to prevent unplanned weight loss and maintain resident nutritional status. This failure resulted in R40 experiencing a 29.29% weight loss within 4 months of admission. This applies to 2 residents (R40 and R43) reviewed for weight loss in a sample of 31. The findings include: 1. R40's MDS (Minimum Data Set) dated 11/14/23 shows her cognition is intact. On 12/5/23 at 12:18 PM, R40 said, I have lost about 60 pounds since August. R40 said the facility was giving her mighty shake supplements, but she had not received one in almost a week. R40's lunch tray was then delivered in the presence of surveyor, and it did not have any supplement on it. On 12/6/23 at 12:30 PM, V22 (R40's spouse) said R40 lost 20 pounds in the last month. R40's Face sheet shows an admitted [DATE]. The facility's Weights and Vitals Summary report shows R40's weight has been measured 4 times between the dates of 8/8/23 and 12/7/23. R40's Admission weight on 8/8/23 was 198 pounds. R40's next weight recorded on 9/6/23 was 184.6 pounds, showing a 6.77% weight loss in 1 month. R40's weight was not recorded in the month of October. R40's next weight measured on 11/3/23 was 159.4 pounds, showing a 13.65% weight loss in 2 months. R40's next weight measured on 12/4/23 was 139.8 pounds, showing a 12.3% weight loss in 1 month. R40 lost 58.2 pounds since her admission four months earlier, showing a 29.39% total weight loss. R40's POS (Physician Order Sheet) shows an order dated 11/14/23 for weekly weight to be done every Wednesday for 4 weeks because of weight loss. R40's MAR (Medication Administration Record) shows weekly weights were not completed on Wednesday 11/15/23, Wednesday 11/22/23, Wednesday 11/29/23, or Wednesday 12/6/23. Nurse documentation on 11/22/23 shows weight not obtained and nurse documentation on 11/29/23 states to be done. On 12/7/23 at 12:54 PM, V2 (DON/Director of Nursing) said she is aware of R40's weight loss. V2 said there was no documentation of R40 refusing to be weighed in October. V2 said the nurse documented on 11/15/23 that R40 refused to be weighed, but on 11/22/23, 11/29/23, and 12/6/23 R40's weights were not obtained, and refusals were not documented. V2 said she thinks the doctor needs to do a medical work up on R40 to determine why she is losing weight. On 12/7/23 at 2:18 PM, V11 (Dietician) said R40's intakes are not very good and sometimes V22 (R40's spouse) brings her food to eat, but it is not enough to regain the weight she has lost. V11 said R40 was supposed to be getting weighed weekly in November, but the facility has been having issues with obtaining weekly weights. V11 said that residents are supposed to get weekly weights for the first 4 weeks after admission, but the facility has not been compliant. V11 said she does not know why R40 has not been getting weighed as ordered because R40 does not refuse to be weighed. V11 said when a resident has significant weight loss, V11 notifies the facility Administrator, Assistant Administrator, DON, and Dietary Manager by email and then it is the facility's responsibility to notify the physician. On 12/7/23 at 1:27 PM, V10 (R40's physician) said a 60-pound weight loss in 4 months is a lot. V10 said he was not personally notified of R40's weight loss. R40's Care Plan dated 11/20/23 shows R40 is at increased nutritional risk related to Anemia, Chronic Obstructive Pulmonary Disease, and Hypertension. Interventions include monitor monthly weights or per facility protocol and report significant changes to the physician and power of attorney. An additional Care Plan focus (initiated during this survey on 12/5/23) states R40 has an unplanned/unexpected significant weight loss and interventions include monitor weights per facility protocol. The facility's undated policy titled, Weight Assessment and Intervention states, Guideline: Weights are monitored monthly or more often as recommended by the interdisciplinary care team. The goal is to ensure adequate parameters of nutritional status are maintained by preventing unintentional weight loss .Procedure: 1. Nursing staff will record the resident weight upon admission and once a week for four weeks thereafter to establish a base weight and stability of weights. If no weight concerns are noted, the resident's weight will be recorded monthly thereafter or as indicated by the interdisciplinary care team .4. Any weight change of 5% or more since the previous weight assessment shall be re-taken to confirm. If the weight is verified, nursing will notify the appropriate designated individuals such as the physician, registered dietician, dining services manager, or other members of the interdisciplinary team .6. The threshold for significant unplanned and undesired weight loss shall be based on the following criteria: 1 month interval-significant loss 5%-severe loss greater than 5%, 3 month interval-significant loss 7.5%-severe loss greater than 7.5%, 6 month interval-significant loss 10%-severe loss greater than 10% .Analysis:1. Assessment information will be analyzed by the interdisciplinary team and conclusions shall be made .2. The physician along with the interdisciplinary team will identify conditions and medications that may be causing anorexia, weight loss, or an increased risk of weight loss . 48526 2. On 12/05/23 at 11:18 AM R43 stated he does not like the food the facility offers. On 12/07/23 at 10:20 AM R43's breakfast tray was observed. R43 consumed 25% of scrambled eggs and 100% of nonfat yogurt. R43 said, the meals are not good here and I have lost weight since being here because of the food. R43 said he does not receive any nutritional supplement drinks from the facility. R43 said he asked for Ensure Plus nutritional drink because he likes the taste of it but was told the facility does not carry that in stock. R43 said they offered him the house stock nutritional drink. R43 said he does not like the house stock and does not drink it. R43 said the nurses offer the house stock nutritional drink to him once a week and he refuses it. R43 said no other alternatives for nutritional supplements were offered to him. R43's face sheet showed R43 was admitted to the facility on [DATE] with diagnoses of Guillain-Barre Syndrome, essential hypertension, hypothyroidism, gastro-esophageal reflux disease without esophagitis, chronic obstructive pulmonary disease, atrial fibrillation, vitamin deficiency, constipation, major depressive disorder, abdominal aortic aneurysm without rupture, and diseases of the nervous system and sense organs. R43's MDS dated [DATE] showed R43 was cognitively intact. The same MDS showed R43's most current weight was 171 pounds. R43's care plan dated 05/24/23 showed R3 is at increased nutritional risk and to offer alternatives at mealtimes when appropriate, monthly weights, and to report significant weight changes to the MD (Medical Doctor) and POA (Power of Attorney). Per the weight summary, R43's admission weight on 05/15/23 was 183.9 pounds. No recorded weight for the month of June. On 07/10/23 R43's weight was 185.3, on 08/08/23 R43's weight was 175.0 (-5.56%), on 09/07/23 R43's weight was 170.6 (-2.51%), no recorded weights for October and November, and on 12/04/23 R43's was 170.4. The dietary assessment dated [DATE] showed R43 had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The same assessment stated R43 was not on a prescribed weight loss program. R43's weight change progress note dated 09/15/23 showed R43 was triggered for significant weight loss for two months and weight continues to trend down. The same note stated resident reports not liking food very much at the facility. Resident with additional Ensure supplement in place three times per day, however, resident states he has not been receiving supplements. On 12/07/23 at 2:10 PM V2 said she was aware of R43's insidious weight loss. V2 said she was not aware of R43 not liking the house stock nutritional drink. V2 said no alternative supplement was offered to R43 since he does not like the house stock nutritional drink. V2 said it is expected that when residents refuse supplements, the dietitian is notified for alternatives. V2 said the dietitian was not notified for any alternative supplements.

Based on observations, interviews and record reviews the facility failed to implement interventions to prevent a resident's fall. This failure resulted in R1 sustaining a bilateral subdural hematoma (brain bleed). This applies to 1 of 3 residents (R1) reviewed for falls. Findings include: R1's electronic health record showed that on May 4th, 2023, at 2:36 pm, R1 was observed on the floor with his wheelchair under him. R1's face sheet showed R1 was readmitted on [DATE]th, 2023, 5 days later. R1's May 4th, 2023, hospital CT scan of his head showed new bilateral subdural hematomas . The left subdural hematoma spans the entire left cerebral hemisphere.The right subdural hematoma extends along the right frontal and parietal lobes . There is approximately 5 millimeters of left to right midline shift at the level of the lateral ventricles. On April 4th, 2023, at 12:45pm, R1's progress notes showed R1 had a fall while he was in his wheelchair. On May 12th, 2023, at 2:41pm V2 (Director of Nursing) said that on May 4th, 2023, R1 had an anti-rollback device on his wheelchair, and V2 had determined that it was the root cause for his fall. V2 said that she made this determination after evaluating R1's wheelchair and deemed the anti-rollback device was not working properly. V2 said she also determined the anti-rollback device was the cause when she was told by V8 that R1 has a history of pushing himself backwards while in his wheelchair. V2 said that on May 9th, 2023, she took R1's wheelchair to maintenance and had maintenance removed the anti-rollback device and threw it away. V2 said that on April 4th, 2023, R1's anti-rollback device did not work properly, The same thing happened on April 4th, 2023. R1's April 5th, 2023, progress note showed that the IDT (Individual Treatment Team) reviewed R1's April 4th, 2023, fall and put an intervention in place to place a (rubber no-slip) cushion in R1's wheelchair. On May 17th, 2023, at 3:15pm, V2 said that she did not think that the facility had inspected R1's wheelchair and I feel strongly that if the wheelchair had been inspected according to the manufacturer's directions it would have prevented R1's wheelchair from tipping over on May 4th, 2023. V2 said that she doesn't know when the anti-rollback device was put on R1's wheelchair, or who put it on R1's wheelchair. On May 12th, 2023, at 3:07pm V6 (Certified Nurse's Assistant) said that R1 has a history of pushing himself forwards and backwards while he is in his wheelchair and that R1 likes to move a lot. On May 12th, 2023, at 3:21pm V7 (Occupational Therapist) said that on April 4th, 2023, she saw R1 sitting in the dining room, and R1 pushed back from the table and his wheelchair popped a wheelie. V7 said then R1 leaned forward and started to fall out of his chair. V7 said I don't recall the brakes being on. V7 said that R1 had a history of pushing himself backwards while he was in his wheelchair. On May 12th, 2023, at 3:41pm V1 (Administrator) said that he saw camera footage from R1's fall on May 4th, 2023, and he saw that R1 fell backwards in his wheelchair to the floor hitting his head. V1 said that the footage showed R1 reaching behind himself, pulling on the rail to pull his wheelchair backwards. V1 said when R1's wheelchair tipped backwards, R1 was still in the chair when his body hit the floor. V1 said that the facility's legal department does not allow him to show the footage to anyone. On May 17th, 2023, at 9:00am V1 was asked if he could view the footage again and tell the surveyor what he is viewing and V1 said that the facility no longer has the footage, it is erased after 7 days. On May 17th, 2023, at 9:21am, V8 (Nurse) said that R1 has a history of pushing himself forward and backwards while in his wheelchair, and there was an anti-rollback device on R1's chair on May 4th, 2023. On May 17th, 2023, at 12:03pm, V8 said that on May 4th, 2023, R1 was observed on the floor, his wheelchair had fallen backwards, . his buttocks were still in the wheelchair. V8 said R1's wheelchair was not pressed or caught on the wall or corner of the wall. V8's May 5th, 2023, witness statement showed that R1 moves around and adjusts himself a lot while he is in his wheelchair. On May 17th, 2023, at 10:01am V9 (Certified Nurse's Assistant) said that he works with R1 every day and sometimes the wheels on his wheelchair are locked and R1 will rock his wheelchair back and forth really fast . When this happens R1's front wheels will raise up off the ground really fast also. V9 said that when R1's wheelchair is unlocked he will try to propel his wheelchair forward and backwards as much as he can. On May 17th, 2023, at 12:15pm, V12 (R1's Primary Care Physician) said that on May 4th, 2023, R1 had a fall, and it caused bilateral subdural hematomas. V12 said that prior to May 4th, 2023, R1 had no signs or symptoms of any active bleeding in his brain and no neurological compromise. On May 17th, 2023, at 1:37pm, V4 (Director of Rehab) said that if the anti-rollback devices are installed improperly, it can cause the wheels on the wheelchair to lock and the wheelchair to tip back. V4 said that she has seen this happen on residents' wheelchairs while they were using them, and she has sent the wheelchair to maintenance to be fixed. On May 17th, 2023, at 2:00pm V13 (Environmental Service Director) said that the facility is to inspect every wheelchair every quarter and he has no knowledge or record of any wheelchair inspections being done in 2023. V13 could only provide wheelchair inspection documentation for 2022. R1's care plan with initiated date of April 5th, 2023, and revision date of April 12th, 2023, showed an intervention on May 9th, 2023, to remove the anti-rollback device from R1's wheelchair. R1's care plan did not show any interventions to use anti-rollback devices. The facility's instructions for wheelchair inspections shows that anti rollback brakes are to be checked for operation and adjustments for manufacturers specs. The facility's Wheelchair Inspection log only shows inspections for the year 2022. The facility's Fall Prevention Program with revised date of 05/2022, showed the program will include measures to determine the individuals needs of each resident by assessing the risk of falls and implementations of appropriate interventions to provide necessary supervision and assistive devices as necessary.

Based on observation, interview, and record review the facility failed to ensure supervision to prevent falls with injury for 1 resident (R45), failed to provide ambulation assistance for 1 resident (R61), and failed to implement updated fall prevention measures for a resident following a fall with a fracture for 1 resident (R2). These failures apply to 3 of 4 residents reviewed for safety and supervision. These failures resulted in R45 having 15 unwitnessed falls with 3 of those falls resulting in major injury and R2 sustaining a hip fracture. The findings include: 1. R45's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include traumatic subarachnoid hemorrhage without loss of consciousness, vascular dementia, cerebral infarction, hypertension, repeated falls, difficulty in walking, lack of coordination, and conversion disorder with seizures or convulsions. R45's facility assessment dated [DATE] showed she has severe cognitive impairment and requires physical assistance of one staff member for most cares. R45's medical record showed 15 unwitnessed falls occurring as follows: 9/22/22, 9/26/22, 9/29/22 (Sustained Major Injury), 10/19/22 (Sustained Major Injury), 10/20/22, 10/28/22, 10/29/22, 10/31/22, 11/1/22 (Sustained Major Injury), 11/13/22, 11/26/22, 12/9/22 (Sustained Major Injury), 12/28/22, 1/30/23, and 2/15/23. R45's record showed 2 witnessed falls occurring as follows: 10/11/22 and 1/9/23. R45's 9/22/22 fall report showed an unwitnessed fall in the resident's room which resulted in her being sent to the acute care hospital for evaluation. R45's 9/22/22 fall resulted in a small abrasion to her forehead. R45's 9/26/22 nursing note showed, Resident observed on the floor in bathroom in sitting position. Resident stated, 'I lost my balance as I was going to sit on the toilet.' Physical assessment reveals no apparent injury . R45's 9/29/22 fall report showed an unwitnessed fall in the resident's room with no injuries sustained. R45's nursing note dated 9/30/22 showed, IDT (Interdisciplinary Team) met to discuss resident's fall on 9/29/22. Root cause determined to be resident trying to sit herself on the side of the bed .new intervention is placing 'Call don't fall' signs on either side of the bed. R45's 9/30/22 nursing note entered at 2:51 PM showed, Resident admitted [to acute care hospital], diagnoses 4 left chest rib fractures. R45's acute care hospital discharge documents dated 10/1/22 showed, Reason for visit: Rib fractures, fall, history of frequent falls . Chief Complaint: .left sided chest pain. The patient has a history of dementia and CVA (Cerebral Vascular Accident) . history of frequent falls and has been seen numerous times for the same this month. Patient now resides at a local nursing home where she suffered a fall on Monday and again last night injuring the left rib area . She has bruises to her face in different stages of healing . Notes: . Patient's daughter present and stated that [R45] had fallen in the bathroom on Monday night and again last night.X-ray shows fractures of 4 ribs . R45's 10/11/22 fall report showed a witnessed fall in the resident's bathroom. The report showed, This nurse was sitting at the nurse's station getting report and heard a loud noise and the CNA yell for assistance. Per CNA she was in the bathroom with the resident when the resident stood up to get off the toilet and the resident fell to the left side. Resident states, 'I was just trying to pull up my pants.' . R45's 10/19/22 fall report showed an unwitnessed fall in R45's room. The fall report showed, Writer called to room by CNA, per CNA resident is lying on the floor under the table, writer went to room, noted resident lying on the floor under bed, with laceration to back of the right side of head .laceration to back of head on the right side 0.5 cm deep and 4.5 cm length . Paramedics called . R45's 10/19/22 nursing note showed, . at 5:40 AM: Resident returned from [acute care hospital] . resident noted with 2 staples . R45's 10/20/22 nursing note showed (unwitnessed fall in R45's bathroom), Resident observed on the floor in bathroom in sitting position. Resident stated, 'I was trying to get up off the toilet and fell .' Physical assessment reveals no apparent injury . R45's 10/26/22 Nurse Practitioner note showed, .Frequent falls - no changes to current medications. Patient was made a priority return to bed after meals to help avoid recurrent falls. Close monitoring and fall precautions . R45's 10/28/22 fall report showed an unwitnessed fall in the resident's room. The fall report showed, Resident observed on the floor at bedside . Resident stated, 'I'm not sure what happened, I woke up sitting up on the floor.' .No injuries observed at the time of incident . R45's 10/29/22 fall report showed an unwitnessed fall in the resident's room. The fall report showed, .Resident is observed sitting on the floor next to the bed. Resident had just finished eating lunch and propelled herself to her room . On assessment, no apparent injury noted . (Three days after the intervention regarding making R45 a priority return to bed after meals.) R45's 10/31/22 nursing note showed an unwitnessed fall in her room. This note showed, Resident observed on floor at bedside in sitting position . Resident stated, 'I was getting up to use the bathroom and forgot to use the call light . R45's nursing note dated 10/31/22 showed, Spoke with resident regarding falls . Reports that she thinks she is going to the bathroom when she gets up but doesn't really know. Resident says she knows she needs to ask for help but is used to doing it alone . R45's 11/1/22 fall report showed an unwitnessed fall in the resident's room. The fall report showed, .Resident was found sitting on the floor by the door of her bathroom by staff member. A laceration 3-5 cm was noted on the right side of her forehead . Pressure on the laceration with sterile gauze . R45's nursing note dated 11/2/22 showed, Resident returned to facility, laceration with sutures: 2 anterior sutures and 8 exterior sutures. R45's acute care hospital documentation dated 11/1/22 showed, .Patient comes into the emergency room via emergency medical services with complaint of falling. Patient has a 3 cm laceration to the forehead. She also has a small skin tear to the left arm . Patient is able to state her name, date of birth, and the fact that she fell . She states she hit her head on the door frame . R45's 11/13/22 fall report showed an unwitnessed fall in the resident's room. The fall report showed, .Resident observed on the floor in sitting position in front of the wheelchair . Resident stated, 'I was getting up to go to the bathroom and fell on the floor.' .Physical assessment reveals no apparent injury . R45's 11/26/22 fall report showed an unwitnessed fall in the resident's room. The fall report showed, .Resident observed on the floor at bedside laying on her right side . Resident stated, 'I was getting up to go to the bathroom and fell on the floor . Physical assessment reveals no apparent injury . R45's 12/9/22 fall report showed an unwitnessed fall in the resident's room. The fall report showed, .Resident observed on the floor in sitting position . Resident stated 'I was getting up to go to the bathroom and fell and hit the bedside dresser, I forgot to use the call light . Physical assessment reveals a 2 inch laceration to mid-forehead, dark red blood noted on the resident's face/hands and on the floor near the resident .received order to send resident to [acute care hospital] for evaluation . R45's acute care hospital documentation dated 12/9/22 showed, .Diagnoses: Primary: Fall, Additional closed head injury, forehead laceration .presents with head injury . Per nursing home staff she was found on the ground this morning. It is unclear how long she was down for but it had been about 30 minutes since she was last checked on. She has a laceration to the right forehead and complains of pain there . Laceration - Single Repair . 10 sutures . R45's 12/28/22 fall report showed an unwitnessed fall in the resident's bathroom. The fall report showed, .The CNA was making rounds and observed the resident sitting on the floor in her bathroom. Resident description: 'I walked to the bathroom and fell .' .Resident was assessed and bruise noted to the right hand . R45's 1/9/23 fall report showed a witnessed fall in the resident's room. The fall report showed, .CNA stated she witnessed resident sliding out of bed onto mat and sitting on buttocks . Resident told CNA she was looking for a brownie . No injuries noted at this time . R45's 1/30/23 fall report showed an unwitnessed fall in the resident's room. The fall report showed, Resident was last observed during routine medication administration by the nurse on duty. Nurse on duty was called to resident's room by facility staff around 7:50 PM. Resident was sitting upright on the floor. Resident with laceration to back of head . Resident was unable to give description of incident . Nurse on duty placed pressure dressing on resident head with assistance of peer nurse . Nurse on duty placed call to 911 emergency medical services . R45's 1/30/23 acute care hospital documentation showed, .Diagnosis: Primary: closed head injury, Additional, scalp laceration .history of frequent falls, vascular dementia who presents to the emergency department with complaints of fall. Patient state she stood up and fell .she states she hit her head . The patient states that she loses her balance frequently and this is what happened this time . R45's 2/15/23 fall report showed an unwitnessed fall in the resident's room. The fall report showed, .The resident was sitting next to the wheelchair by her dresser in her room . Resident unable to give description . The resident was assisted to her feet after assessment, no signs or symptoms of pain . On 2/17/23 at 12:56 PM, V7 (Assistant Director of Nursing/ADON) said she does the fall investigations. V7 said R45 is a frequent faller at the facility. V7 said, We discuss as a team either that day or next morning and talk to the resident and put an intervention into place. Changes to the interventions are put into the care plan and also into the tasks section for the CNAs. She uses her call light when she wants to, there are times when she has said she forgot to use it, that is why we are trying to make it as visible as possible. Reeducate family and resident on non-compliance and the risks involved. I think she can be reeducated, she is very much with it, slow to respond but very with it, she is on the dementia unit to keep a better eye on her. We reevaluate the interventions on the care plan by literally continuing to follow up with her and see if they are working. If that isn't working, we would figure out something else. 41639 2. R2's electronic face sheet printed on 2/14/23 showed R2 has diagnoses including but not limited to fracture of left femur, spondylosis, Alzheimer's disease, and history of falls. R2's facility assessment dated [DATE] showed R2 has severe cognitive impairment and is a 2 person assist for transfers. R2's fall occurrence report dated 1/27/23 showed, 12:30 AM resident observed on floor near dresser in supine position, appropriate footwear in use walker near resident. Resident stated 'I was going towards my dresser and lost my balance.' Physical assessment reveals left leg shorter than the right leg and left foot inverted inward. Sent to ER and left hip fracture noted. R2's fall risk assessment dated [DATE] showed R2 is not at risk for falls. (Immediately following R2's fall resulting in a left hip fracture.) R2's fall occurrence report dated 2/9/23 showed, 1500 [3:00 PM] Resident observed on floor on bedside safety mat on right side. Appropriate footwear noted on resident at time of incident, call light within reach and functioning properly. Physical assessment reveals no apparent injury. Staples intact to 3 separate surgical areas left hip. Resident offers no complaints of pain or discomfort at time of incident. R2's care plan updated 1/19/23 showed, The resident is at risk for falls related to confusion, gait/balance problems, debility, history of falls and vision/hearing problems. No interventions or increased monitoring were added to R2's fall care plan following her fall resulting in a left hip fracture on 1/27/23. On 2/14/23 at 10:57 AM, R2's room was observed towards the far end of the hallway. R2 was sitting up in her wheelchair with the right foot pedal pushed to the right side of her wheelchair. R2's left foot pedal was placed in a neutral position under her left leg and foot. R2 was sleeping with her head on her bedside table. R2's call light was secured on her bed rail on the other side of the room and out of reach for R2 to utilize. R2's fall mat was placed in front of her bed so she was unable to get her wheelchair over to the bed. R2 had a sign in her room across from the bed on that stated, Yell for help don't stand alone. On 2/17/23 at 2:05 PM, V7 (Assistant Director of Nursing) stated, When (R2) fell it was thought to be a result of a medication, so we changed the medication to attempt to decrease fall risk. I don't see any documentation in her chart about it, but we did do it. I'm sure we did. Anytime we change a medication or attempt a new intervention related to falls it should be documented in the progress notes or on the care plan, ideally it would be put in both places but that doesn't always happen. I know R2 doesn't always use her call light so that's why she has the sign in her room to yell for help; however, she should always have her call light available to her for her to utilize if she remembers to use it. 3. R61's electronic face sheet printed on 2/17/23 showed R61 has diagnoses including but not limited to fracture of T7-T8 vertebra, hypertensive heart disease, insomnia, anxiety disorder, lack of coordination, and repeated falls. R61's facility assessment dated [DATE] showed R61 has no cognitive impairment and requires 2 staff assist for transfers. R61's care plan dated 1/4/23 showed, The resident is at risk for falls related to gait/balance problems, history of falls, and psychoactive drug use. R61's nursing notes dated 1/29/23 showed, At 3:25 AM, Certified Nursing Assistant (CNA) answered resident's call light. Resident was walking in her room and asked the CNA to ask the nurse for a pain pill because she was in pain and could not get comfortable or rest. As CNA was walking down the hallway to get Registered Nurse (RN), a loud noise was observed and the resident was found by the CNA on the floor of her room. The CNA got the RN and the RN walked into the room with resident on the floor in a fetal position with her right arm back, left arm forward, as resident stated she braced herself from falling and hitting their head .the resident stated she was trying to sit down in her wheelchair while waiting for her pain medication and forgot to lock the brakes on her wheelchair .no injuries noted from fall. On 2/17/23 at 12:13 PM, V17 (Physical Therapy Assistant) stated, [R61] transfers now with supervision and a walker. When she first came here our initial evaluation on 1/4/23 showed she was unable to stand due to fatigue, on 1/27/23 she was a contact guard, hands on assist for all transfers. We never deemed her appropriate to be independent in her room and she still isn't independent. If staff observe her up on her own they are to assist her with hands on assistance with a gait belt. If the CNA saw her walking in her room, she should have assisted her immediately and could have prevented this fall. On 2/17/23 at 12:09 PM, R61 stated, It was about 3:00 AM and I wasn't able to sleep so I thought I would get up in the chair. I was standing up and the CNA had just been in the room with me. She left and I went to sit down in my wheelchair to wait for my pain medication and one brake was locked and the other one wasn't. I didn't have injuries. It's nobody's fault but my own. I shouldn't have been standing up on my own. On 2/17/23 at 2:05 PM, V7 (Assistant Director of Nursing) stated, [R61] needs assistance with ambulation. If a staff member saw her ambulating on her own, they should have immediately provided assistance to her. This fall could have been prevented if the CNA would have assisted her to sit down in her wheelchair. The facility's policy titled, Fall Prevention Program revised on 05/2022 showed, Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary .Standards: .Safety interventions will be implemented for each resident identified at risk .all assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained .Fall/safety interventions may include but are not limited to .The nurse call device will be placed within the resident's reach at all times .residents will be observed approximately every 2 hours to ensure the resident is safely positioned in the bed or a chair .nursing personnel will be informed of resident who are at risk of falling. The fall risk interventions will be identified on the care plan .

Based on interview and record review the facility failed to ensure pain medications were available to a resident for 1 of 1 resident (R39) reviewed for pain in the sample of 22. This failure resulted in R39 experiencing sleeplessness and narcotic medication withdrawal symptoms. The findings include: R39's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include secondary malignant neoplasm of bone, malignant neoplasm of brain, panlobular emphysema, neoplasm related acute and chronic pain, and major depressive disorder. R39's facility assessment dated [DATE] showed he has no cognitive impairment. On 2/15/23 at 10:05 AM, R39 said, They ran out of my narcotic a couple months ago and it took 3-4 days for them to get it back in. I have a lot of pain. I have a pain patch and I take the other medication twice a day. I was going through withdrawals, and I couldn't sleep because of the pain. R39 said he has cancer and they weren't going to operate because the cancer was so bad. R39 said after he had some chemotherapy treatments the doctors decided they could go ahead and do a surgery to remove a large tumor out of his back. R39 said he now has a lot of pain due to the cancer and the surgery. R39 said he has a steel rod in his back and the cancer had eroded part of his spine and ribs. R39 said if he has his pain medications on time his pain is controlled. R39's care plan revised 10/4/21 showed, [R39] is on pain medication therapy related to palliative care for mediastinum Cancer with metastatic disease to bone and brain, neoplasm related chronic pain, and spinal stenosis . Interventions: Administer analgesic medications as ordered by physician . R39's December 2022 MAR (Medication Administration Record) showed an order started 8/2/22 for Methadone Hcl 5 mg, Give 5 mg by mouth two times a day for pain. R39's MAR showed R39 missed 7 consecutive doses of his Methadone from 12/18/22 at 8:00 PM through 12/21/22 at 8:00 PM. R39 resumed his Methadone pain treatment on 12/22/22 at 8:00 AM. R39's 12/19/22 nursing note showed his Methadone was not administered because it had not arrived from the pharmacy. R39's 12/20/22 nursing note documents, Writer spoke with pharmacy in regards to methadone prescription .that was faxed to them on 12/13. Pharmacy stated it was a 'refill too soon' and they were not able to fill it at that time and it needed to be resent. Writer refaxed methadone prescription . Pharmacy received methadone script and will be sending it out. R39's 12/20/22 and 12/21/22 Medication Administration notes showed the methadone was not administered because it had not been delivered from the pharmacy. On 2/17/23 at 1:05 PM, V2 (Director of Nursing) stated, We tried to get [R39's] pain medication from our pharmacy but they said it was a 'refill too soon'. Then when he ran out, we called the pharmacy again and they told us they never got the script, so we sent it again. I personally sent the prescription to the pharmacy and told the floor nurse I sent it in. It didn't come until a couple days later and I'm not sure why. We have a convenience box, but it doesn't have his particular medication in it. We can either get orders STAT [immediately] from our pharmacy or they will contact a local pharmacy to have the medication delivered to us. I guess we thought maybe the palliative care nurse would be handling the medication refills, but they weren't able to get it here either. We dropped the ball on getting his medications and we should have been following it more closely and being more persistent with the pharmacy so he wouldn't run out. The facility's Pain Assessment policy and procedure with effective date of 10/2022, showed, Purpose: To establish guidelines for appropriate assessment and intervention to manage pain. To respect and support the resident's right to optimal pain management .

Based on interview and record review the facility failed to assess, evaluate, and treat a surgical hip wound for a newly admitted resident. This applies to 1 of 4 residents (R2) reviewed for surgical wounds. This failure resulted in resident (R2) being hospitalized for surgical intervention to surgical site and intravenous antibiotic therapy for infection. The findings include: R2 was admitted to the facility November 11, 2022, per the admission face sheet. R2 was discharged from the facility December 14, 2022 and was reviewed as a closed record. The physician orders dated December 1, 2022, showed that R2 had diagnoses of fractured right hip, orthopedic after care, history of falls, difficulty walking and lack of coordination. The MDS (Minimum Data Set) dated November 16, 2022, showed that R2 is not cognitively impaired. The electronic healthcare record for R2 showed that on November 11, 2022, V8 RN (Registered Nurse) admitted R2 to the facility. The admission assessment skin documentation dated November 11, 2022, showed R2 had a surgical wound to the right hip. There was no documentation of sutures or staples. There was no description of the wound itself. A second note written on November 12, 2022, by V4 (LPN/Wound care nurse) showed a second assessment of the skin was free of injury at this time. Throughout all progress notes November 12, 2022, until discharge there is no documentation of the surgical wound to R2's right hip. There were no physician orders for care of the surgical wound to R2's right hip. The MAR (Medication Administration Record) showed no treatments or assessments were done to the right hip wound. Wound care was not addressed in the care plan. R2's hospital discharge papers provided to the facility showed that if a patient had sutures or staples, they need to be removed in 1 to 2 weeks. There were instructions for wound care including showering and dressing changes. On December 20, 2022, at 11:50am V2 (Acting Director of Nursing/Assistant Director of Nursing) stated, R2 was brought to the facility and stayed a short time. She was a surgical admission. The admitting nurse should document the wound in the admission assessment or progress notes. The physician should be notified and orders for wound care should have been obtained. On December 20, 2022, at 12:15pm V4 stated, I did not see R2 when she was admitted . I did see her when her room was changed to the villa side. I don't recall seeing any staples to her skin. When we do an admission, we count the staples and document it in the admission assessment. I usually do a head-to-toe assessment and I describe what I see. I do not recall any incision or wound. I would also measure the length of the wound, the color and if there was any drainage. On December 21, 2022, at 9:52am V6 (Orthopedic Surgeon) stated, R2 was supposed to come back in 1 or 2 weeks to have the staples removed. No one from the facility called us to schedule. When R2 did come in the staples were harder to remove. Now R2 is back in the hospital for an infection of the wound and surrounding tissue. She is on intravenous antibiotics. I have had problems with the facility lately and am thinking of not letting my patients go there anymore. V6's hospital progress note (dated 12/14/22) showed that V6 removed R2's staples 5 weeks and 2 days following surgery. Clinical note: Suture removal . Number of sutures removed: 31 . V6's 12/22/2022 faxed response to surveyor showed, Patient (R2) was not seen here for 5 weeks and there was no mention of her staples or wound care during her 5 weeks stay at the nursing home. She did come in to see us week 5 with staples still in. She had some irritation staples were removed at that time she subsequently after this at 6 weeks in delayed fashion got a superficial infection that does appear this is spread to the subcuticular tissues. On December 21, 2022, at 4:45pm V7 (Medical Director) stated, No one ever contacted me for wound care orders for this resident. This should never happen. I looked at R2's chart and she did have staples. The staff are to notify me, and I give them wound care orders. Lack of wound care could cause infection. On December 22, 2022, at 11:20 V8 (Practicing Manager on the orthopedic ward at the community hospital) stated, R2 is on intravenous antibiotics. The infection is at the suture line. R2 required surgical intervention today to debride the wound. In communication with V6 it is likely the infection is from both lack of dressing changes and wound care and the length of time the staples were left in. On December 23, 2022 at 3:00pm V9 RN (Registered Nurse) stated, I remember R2. She came to our unit several days after she was admitted . She originally was admitted to the 400 unit I think. I do not recall a wound on her backside. The wound care nurse is V4 LPN. I just mark off the weekly skin checks when I check the bath sheets.

Based on interview and record review, the facility failed to provide safe wheelchair transport. This failure resulted in R4 incurring a left prosthetic knee dislocation, a forehead laceration, a left knee tibial plateaus fracture, and right knee distal femur peri-prostetic fracture. This applies to 1 of 3 residents (R4) reviewed for injuries in a sample of 24. Findings include: R4's Admission Record dated 9/1/2022 documents R4 with diagnoses including Covid-19 (5/31/2022), [CONDITION(S)] (fluid build up causing swelling), [CONDITION(S)] and hemipariesis affecting the right side following a stroke. The facility's incident report dated 6/24/2022, completed by V10 (Nurse), documents R4 was being propelled in her wheelchair by staff when she leaned forward, causing her to fall to the floor in the hallway, hitting her forehead and nose. R4 was bleeding from the nostril and forehead and she was transported to the hospital. V17's (Occupational Therapist) Treatment Encounter Note dated 6/24/2022 documents upon transporting R4 back to room in a wheelchair, R4's foot/feet became caught under the wheelchair and as result, R4 fell forward out of the wheelchair and onto the floor. On 9/1/2022 at 12:10 V10 stated, V17 (Occupational Therapist) was pushing R4 in her wheelchair without footrests present and R4's feet got caught underneath the wheelchair, causing her to fall forward and hit her head. V10 stated R4 did not have the strength to break her fall and R4 usually had footrests on her chair because she was not able to hold up her legs when she was propelled. V10 also stated R4 required a mechanical lift to get out bed and had gross [CONDITION(S)] to her entire body. On 9/2/2022 at 9:57 AM V17 (Occupational Therapist) stated R4 did not have the footrests on her wheelchair when she was brought into therapy after bingo on 6/24/2022. V17 stated she was pushing R4 to her room and R4 had items on her lap, which included supplies to work on oral hygiene and bingo prizes. V17 stated the accident happened quickly and she is unsure of the cause, but thinks R4 may have leaned forward to prevent things from her lap falling and her feet got caught underneath the chair, causing the fall. On 9/1/2022 12:20 V14 (Director of Rehabilitation/Physical Therapy Assistant) stated, .I suspect she (R4) was being pushed too fast and unable to keep up . V14 further stated, R4 was leaving therapy and the distance between therapy and her room was quite a ways to hold up her feet in the wheelchair without footrests. On 9/1/2022 at 9:33 AM, V7 (Nursing Assistant) stated that before R4 fell , she was total assist for ADLs (Activities of Daily Living) and used a mechanical lift for transfers between the bed and wheelchair. V7 said R4 had declined significantly prior to the fall to the point that she was requiring two people for assistance for her ADL's. V7 further stated, R4 would not even lift her legs and required staff to lift her legs to put on her pants and dress her. V7 stated R4 needed assistance to and from therapy and her wheelchair footrests were being kept on at all times, even in her room where she spent most of the time, because she was no longer using her feet to move her wheelchair. On 9/2/2022 at V19 (Nurse Practitioner) stated, R4 was an extensive assist for her ADLs. V19 stated, R4 should have had the footrests on the wheelchair when being transported. V19 further stated, I think all residents should have footrests on when being transported for safety purposes to prevent falls. R4's Occupational Evaluation and Treatment Plan dated 6/15/2022 documents an initial referral being completed due to a decline in function after COVID 19 which caused R4 to have increased complications with mobility for ADLs and ADLs performed. This assessment also documents R4 requiring the use of a mechanical lift for transfers. R4's Minimum Data Set, dated dated dated [DATE] documents R4 as requiring the extensive assistance of one person for movement while in a wheelchair, requiring the extensive assistance of one person for dressing, the extensive assist of 2 staff and with bilateral lower extremity impairments. R4 is documented in this assessment as cognitively intact. R4's Hospital emergency room record dated 6/24/2022 documents R4 reporting she got her legs caught in the wheelchair and she fell forward onto her knees and head. Her Final Diagnosis is documented as left prosthetic knee posterior dislocation, a forehead laceration (stitches applied), left knee tibial plateaus fracture, right knee distal femur peri-prosthetic fracture. This note documents R4 was transferred to higher level hospital for further treatment after 4 failed attempts to correct the dislocated left knee failed.

Based on observation, interview, and record review the facility failed to protect a resident with dementia from unwanted touching of the breast. The resident is dependent on staff for all care and is not able to communicate with staff. This failure resulted in sexual abuse and repeated verbal abuse from R8 when R1's breast was touched and from the times R8 repeatedly cursed at her. Using the reasonable person concept, this failure would result in humiliation and degradation. The Immediate Jeopardy began on July 18, 2022, when the facility failed to ensure R1 was protected from unwanted sexual contact by another resident with a history of inappropriate sexual contact with other female residents. V1 (Administrator) was notified of the Immediate Jeopardy on August 11, 2022, at 4:02 PM. V1 was provided with the Immediate Jeopardy Template outlining the failures. Although the immediacy was removed on August 12, 2022, at 1:29 PM, the facility remains out of compliance at a Severity Level II because additional time is needed to evaluate the implementation and effectiveness of the plan of correction, including in-service training of staff, implementation of the resident monitoring, and completion of resident assessments for other female residents. This applies to 1 of 3 residents (R1) reviewed for abuse in a sample of 23. The findings include: According to the Electronic Health Record (EHR) R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] showed R1 needed extensive assistance of two staff for bed mobility, transfers, dressing, hygiene, and toilet use; and needed extensive assistance of one person for eating. The MDS showed R1's cognition was severely impaired. A Care Plan initiated 04/11/2022, showed R1 was at risk for aggression from other residents related to behavior of wandering, calling out, yelling, confusion, and the inability to understand others. Interventions to protect R1 include to keep R1 beyond arms distance from other residents and to monitor R1 for safety when around other residents. The Care Plan showed R1 was a wanderer, was disoriented to place, and had impaired safety awareness. R1 has a behavior problem initiated on 07/28/2022 (during the survey) of yelling for prolonged periods of time when distressed or upset and a behavioral problem of pulling her shirt up in social areas. A Capacity for Sexual Consent assessment dated [DATE], at 3:04 PM (one day after the abuse) showed R1 was not aware of who was initiating sexual contact and she could not determine what level of sexual intimacy she would be comfortable with. R1 did not have the capacity to say no to uninvited sexual contact and did not have the capacity to consent to a sexual relationship. On 08/08/2022, at 3:32 PM, V16 (Certified Nursing Assistant/CNA) said on 07/18/2022 around 6:30 PM and 7:00 PM, V16 noticed R1 and R8 sitting in the main dining room near the television. R1 was sitting in her wheelchair with her back toward the window and R8 was sitting in his wheelchair facing R1. R1's pant legs were rolled up above her knees and her shirt was pulled up exposing both breasts. V16 stated R8 had his right hand on (R1's) left leg and I saw his left hand moving away from (R1's) breast. V16 said she went in and took R1 out of the dining room. V16 stated she asked V1 (Administrator) to look at the video camera and verify what she saw had actually happened. V16 said she was nervous to accuse someone if it didn't happen. V16 said nobody had ever told her what was seen on the video footage. V16 said V1 had called her several times to clarify things she wrote in her witness report regarding the incident. On 08/08/2022 at 2:41 PM, V9 (CNA) said while V9 was changing R8's incontinence brief on 07/28/2022 around 2:30 AM, V9 was standing on R8's left side and when she rolled R8 toward her, R8 had reached up, grabbed my right boob and squeezed it twice. V9 stated she was told by the agency nurse to document it in her charting which she did. V9 said she told V3 (Assistant Director of Nursing/ADON) about the incident in the morning and V3 (ADON) giggled and said Ok, well at least it's not another resident. V9 said she felt like she was sexually assaulted and didn't feel V3 had taken it seriously. V9 stated, After I told (V3) nobody from the facility has reached out to me. On 08/11/2022 at 10:49 AM, V12 (Nurse Practitioner/NP Psychiatry) said she had seen R8 on 07/18/2022 but was not sure if the incident had occurred yet. V12 could not remember the date but said she was contacted by V3 (Assistant Director of Nursing/ADON) regarding an incident involving R8 touching R1. V12 stated she believed V3 said it was discovered on camera where they saw R8 reach out and touch R1's breast. V12 said there was another incident in the past one or two weeks in which R8 had reached out and touched a CNA's breast. V12 said she asked V3 (ADON) if a police report was filed and if R8 had been sent out to the hospital for evaluation. V12 stated I told V3 over the telephone R8 should be sent to a local hospital and V3 said she would try. V12 could not recall what was done. V12 said the Psychiatry office has a laminated protocol regarding resident incidents at every nurse's station. When the facility called V12 to notify her of the incident, V12 told them to call the office since she was at a different facility every day. V12 said the psychiatrist could probably make medication changes over the phone if needed. According to V12, the protocol after an incident was to call the office, and to call Local Hospital's inpatient Behavioral Health to have the resident sent there so the psychiatrists can still follow the residents. V12 said she did discuss R8's placement in a different facility on 08/01/2022 with V1 (Administrator), V3 (ADON), and possibly also V2 (DON) present. V12 said R8 needed to be separated from female residents and she was unsure if the facility had the manpower to ensure it happens. V12 said R8 had been educated several times about not touching other resident's and he knows it is inappropriate. A Psychiatric Nurse Practitioner Note dated 08/01/2022, written by V12 (NP Psychiatry) included the staff reported that (R8's) behaviors have deteriorated. R8 was recently observed touching another patient inappropriately. Medication changes were made. Recommend placing patient in a facility that is more appropriate for his psychiatric concerns. The undated Psychiatric hospitalization Protocol provided by the facility showed to call the office (number provided), Fax (number provided) a Petition for Involuntary Admission, Face Sheet, Medication List, and Doctor's verbal admission order; Call (local hospital) for acceptance (number provided); Arrange ambulance transport once patient is accepted by hospital. On 08/10/2022 at 11:44 AM, V19 (Social Services Director), said according to the Risk Assessments, R8 had a physical altercation with R11 in the dining room on 06/23/2022 and a physical altercation with R10 who was found on the floor in R8's room on 07/08/2022. V19 said an incident of R8 inappropriately touching R1 was dated 07/18/2022. V19 said the Risk Assessment for the incident involving inappropriate touching with R1 did not address whether R1's shirt was up or if R1's breasts were exposed. V19 said she watched part of the video footage with V1 (Administrator) regarding the incident on 07/18/2022. V19 said in the video, R1 was sitting in a wheelchair facing R8 who was also in a wheelchair in the main dining room. V19 said she could not remember if R1's shirt was down or up exposing her breasts. V19 said she did not watch the entire video footage. V1 (Administrator) stopped the video and told V19 to start an investigation. V19 said it was difficult to see R1 and R8 since they were in the back corner of the dining room, however, there wasn't anything blocking the view, she could see a popcorn machine and could see R1 and R8 fully from a side view. V19 could not recall verbatim what R8 had said to her but said he just shrugged his shoulders. V19 could not remember if she asked R8 if he had touched R1. V19 said she did not document her interaction with R8 or any details regarding the incident on 07/18/2022, involving R1. V19 said there was an incident last year on 08/24/2021 of R8 having inappropriate touching with another female resident (R12) who was no longer in the facility. The EHR showed R12 needed extensive assistance of two people for bed mobility and transfers. R12 needed limited assistance of one person for walking and locomotion. R12 used a walker and a wheelchair. The MDS dated [DATE], showed R12's cognition was severely impaired. A Care Plan showed R12 had limited physical mobility. The care plan showed R12 wandered aimlessly, including into other resident rooms and lay on their beds, was disoriented to place, and had impaired safety awareness. The EHR showed R12 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing Progress Note dated 12/09/2021, at 4:32 PM (written by DON) showed This RN was walking behind the long-term nurse's station and witnessed the resident (R8) inappropriately touch a female resident. The note included R8 was directed back to his room and was started on a one on one. RN and the social worker spoke with R8 a few minutes later was asked if knew why they were talking to him. R8 stated cause I grabbed her [NAME]. On 08/10/2022 at 4:10 PM, V2 (Director of Nursing/DON) said she was not available during the investigation on 07/18/2022 regarding the incident between R1 and R8 and denied watching the video footage of the interaction. When asked about the allegation of inappropriate intimate touching between R8 and another female resident (R12) which had happened in August 2021, V2 said she was a floor nurse at the time and recalled V8 had inappropriately touched R12. V2 said she remembered walking around the nurse's station and thought she had seen R8 touch a female resident (R12) again around the arm area. V2 stated, I was overly cautious and thought that was what I saw had happened. V2 could not recall what interventions were put in place at the time in December 2021. V2 said the facility recently moved R8 to another room in the facility with a private room allowing him the ability to pleasure himself in private if he had sexual urges. On 08/09/2022 at 12:06 PM, V27 (CNA) said R8 can be rude and will yell and swear at the staff. V27 said he will also scream at the residents, but it seemed like he really focused his yelling toward (R1). V27 said most of the residents will get annoyed with R1 in general, but R1 doesn't understand what she was doing. V27 stated if R1 was in the hallway, R8 will usually scream at R1 to Get the hell out of the way or get the f*** out of the way. V27 said she has heard R8 call R1 a racial slur. V27 said once R1 was sitting in the doorway to the dining room and R8 told R1 something to the extent of Move the hell out of the way, I'm trying to get through. On 08/08/2022 at 12:45 PM, V24 (Registered Nurse/RN) said approximately three weeks ago, R8 had knocked another resident (R10) out of his wheelchair when R10 had wandered into R8's room. On 08/09/2022 at 12:51 PM, V34 (RN), with V7 (Licensed Practical Nurse/LPN) present, said approximately one year ago there was an incident whereV8 was caught touching another female resident's breasts (R12). V7 and V34 said with the incident of August 2021 they were just told to watch R8 better. V34 said she had received report several weeks ago (around 7/19/2022) R8 had inappropriately touched R1's breast. V7 and V34 said the new intervention with this new incident was to move R8 away from R1's room and to another hallway which still had female residents residing there. On 08/09/2022 at 2:17 PM, V30 (CNA) said he had started working at the facility in May 2022. V30 said he was not aware of any specific instances but had been told around May or June 2022, R8 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . V30 said he was not aware of the incident between R8 and R1 on 07/18/2022. On 08/09/2022 at 4:12 PM, V29 (RN) said R1 was not coherent and becomes more confused if someone yells at her. V29 said R8 will yell at residents to Get the f*** out of my way and will yell at R1 daily. V29 said she will keep a closer eye on R8 since R8 had an incident in the summer of 2021 of touching a female resident's breast. On 08/10/2022 at 1:56 PM, V35 (CNA) said she was aware of an incident where R8 had touched a female resident's breast. The female resident (R12) was no longer in the facility. V35 said she recently had heard of an incident in which R8 had touched R1's breast. V35 said R1 will pull her top up at least once a day but she does not realize she is exposing herself. V35 said R8 would tell R1 to shut the F*** up often. The Progress Notes for R1 dated 07/18/2022 at 9:25 PM, written by V1 (Administrator) showed Notified MD, Ombudsman and [NAME] PD (Police department) of investigation initiated. No description of the incident was documented in the progress notes. A Skin assessment dated [DATE] at 9:25 PM written by V6 (RN) showed it was a Weekly Status Report with no new skin issues. No description of the incident was documented in the Assessments. On 08/10/2022 at 1:12 PM, V37 (Nurse Practitioner/NP) said she was not aware or told of R8 having any inappropriate sexual contact with a female resident. V37 said she had heard R8 had attempted to grab a CNA's breast and they had moved him to another room in the facility. V37 said when she couldn't find R8 in his room on 8/04/2022, one of the CNA's had said R8 had been moved to another room because he had an incident of grabbing someone's breast. V37 said she did not see or examine R8 that day or any day since then. V37 said she had been seeing R8 for years and recalled psychiatry had made medication changes several years ago because R8 was going closer to women. V37 said if R8 was getting his strength back and was having more behaviors, then he should probably be in a facility where the male and female residents were separated, and they can treat more mental health residents. On 08/10/2022 at 2:54 PM, V36 (Medical Doctor/MD and Medical Director) said from what he remembers, R8 has been having one or two behavior episodes with residents and making advances toward staff. V36 said he did not watch the video camera footage of the incident between R1 and R8. V36 said R8 has had these episodes and he had suggested giving R8 fake breasts to keep in his room. V36 said psychiatry should have been dealing with the behaviors and treated as necessary. V36 said obviously R8 was still having issues and believed psychiatry should do an evaluation and determine if R8 needed to be in an inpatient setting or be placed in another facility which would be more appropriate. V36 said he has never been provided with any information from psychiatry regarding recommendations for R8. V36 said he would support sending R8 to another facility if psychiatry had given that recommendation. A Final Abuse Investigation Report dated 07/25/2022 showed an allegation of resident-to-resident inappropriate touch occurred on 07/18/2022. The report showed a CNA had observed R1 and R8 facing each other in the dining room and R1's shirt was pulled up. The CNA called out loudly for assistance and R8 backed away from R1 as the CNA was approaching them. The report included V1 (Administrator) had reviewed the video footage which showed R8 had propelled himself across from R1. Due to camera view partially obstructed, the only contact that can be seen is (R1) reached out to touch (R8) softly on the arm. On 08/09/2022 at 4:37 PM, V1 (Administrator) said he had been advised by the Corporate Lawyers he could not disclose the video to the surveyor. V1 said he also had looked this morning and saw the video had only been available for ten days and was no longer available to view. According to the EHR R8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) dated [DATE] showed R8 needed limited assistance for moving around unit and R8 used a wheelchair. A care plan showed R8 has the potential to be verbally and physically aggressive with poor impulse control. R8 has inappropriate behavior with other residents and staff behavior initiated on 08/25/2021 with interventions including to explain why behavior is inappropriate, remove the resident to another location as needed, R8 returned to the facility with hourly location monitoring for 48 hours to ensure the safety of others, was educated on the importance of personal space which R8 voiced understanding, and was provided a fake breast. An intervention implemented on 09/06/2021 included transferring R8 to a room closer to the nurse's station for monitoring. The facility's Abuse Policy dated 04/2022 included Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual must have acted deliberately. Any forced, coerced or extorted sexual activity with a resident is considered to be sexual abuse. The Abuse Policy will take steps to prevent potential abuse while the investigation is underway. Residents who allegedly abused another resident will be removed from contact with other residents during the course of the investigation. The facility's Physician-Family Notification Change in Condition policy dated 05/2022 included the facility will consult with the resident's physician or Nurse Practitioner when there is a significant change in the resident's physical, mental, or psychosocial status or a decision to transfer or discharge the resident from the facility. Through observation, interview and record review conducted on August 15, 2022 the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation: R1 was immediately examined head to toe and no noted physical injury. No mental distress noted. All residents reviewed - no residents with similar tendencies at this time. If any are identified in the future, they will be assessed immediately, interventions put in place and proper notifications made. Sample of females and other residents on unit were interviewed for any history of concerns with R8. No findings. Resident moved to own room and provided fake breast as sexual outlet. Care in Pairs added to Care Plan. Resident (R8) started on [MEDICATION(S)]. No sexual behaviors observed since. Administrator and DON in-serviced on Abuse Policy. Abuse in-servicing for all staff completed. All female residents with both dementia and BIMS < 12, head to toe assessments completed - 100% completed. All staff Abuse in-servicing initiated - 50% completed. No staff to work until in-serviced and at 100%. Schedule created for 1:1 supervision of R8 until planned discharge occurs. If/when staffing difficulties arise, all staff - up to and including management - will assist with compliance of 1:1. IDT will review R8's behavior and status of 1:1.

Based on observation, interview, and record review, the facility failed to identify a pressure ulcer prior to becoming a stage 3 for one resident (R2), failed to identify one wound prior to stage 2 for two residents (R2, R3), failed to implement physician orders for wound care for one resident (R3). These failures resulted in R2 obtaining an avoidable Stage 3 pressure ulcer. These failures apply to 2 of 3 residents (R2, R3) reviewed for pressure ulcer care in the sample of 3. The findings include: 1. R2's electronic face sheet printed on 12/28/21 showed R2 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's facility assessment dated [DATE] showed R2 has mild cognitive impairment and has (1) stage 2 pressure ulcer. R2's care plan dated 11/18/21 showed, (R2) has an activities of daily living self-care performance deficit related to fluctuating endurance, strength, balance, and fatigue. The resident requires limited assistance by staff to reposition in bed as necessary. The resident requires skin inspection. Observed for redness, open area, scratches, cuts, and report to nurse. R2's care plan dated 12/9/21 (21 days after admission) showed, (R2) admitted with stage 2 pressure ulcer to right buttock and remains at increased risk for additional skin breakdown and delayed wound healing. Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's discontinued orders dated 11/18/21 showed, Coccyx: cleanse with normal saline, pat dry, apply foam and cover with dry dressing 3 times per week and as needed. Discontinue once healed. R2's weekly wound evaluation dated 12/6/21 showed, Facility acquired Stage 3 pressure ulcer to right buttock identified on 12/6/21. R2's weekly skin observations dated 12/11/21 and 12/18/21 showed open area to right upper buttock with treatment in place. No new skin issues identified. R2's wound physician evaluation and management summary dated 12/22/21 showed, Stage 3 pressure wound of the right buttock, duration greater than 16 days. Surgical excisional debridement today. Stage 2 pressure wound of the left buttock; duration greater than 7 days. The facility's weekly pressure/non-pressure injury log dated 12/17/21 showed, Acquired Pressure Ulcers: (R2) identified on 12/6/21 right buttock stage 3, left buttock stage 2 identified on 12/15/21. R2's physician orders dated 12/1/21 showed, Cleanse superior right buttock with normal saline, pat dry, and apply calcium alginate to wound bed and cover with island dressing. No wound care orders were documented for R2's left buttock pressure ulcer. On 12/22/21 at 10:46 AM, R2 stated, I have been here 2-3 months and have sores on my butt. I'm not sure how many I have but they don't take good care of the sores as far as I can tell. I never should have gotten them; my family are the ones that finally had them look at my butt and they found the first sore. After that, I don't know how many others I have right now. They finally got me a cushion for my recliner that I sit on and that seems to be helping. On 12/22/21 at 10:15 AM, V5 (Licensed Practical Nurse-LPN) stated, We do skin checks weekly and check all wounds daily and on shower days. Any new skin concerns are documented and forwarded to the wound care nurse. We notify the doctor if the wound care nurse isn't here and put an initial treatment in place until wound care can assess it. The aides see residents' skin multiple times each day so there's really no reason why we shouldn't be able to prevent wounds from occurring unless a resident refuses care or something like that but we would have to document that. On 12/22/21 at 11:05 AM, V4 (LPN) stated, Any new wounds identified should be reported to the nurse immediately who then notifies the resident's physician and begins treatment right away. Failure to do this could result in the wound getting worse. On 12/28/21 at 10:48 AM, V7 (wound care nurse) stated, (R2) has one wound on each buttock and they were both acquired here at the facility. Wounds should definitely be identified prior to a stage 3 but he never notified us of any discomfort. His family actually asked us to assess his skin and that's when we found the first wound on 12/6/21. The second wound was identified on 12/15/21. We do skin checks weekly and on shower days for every resident. I'm not sure why his weren't found earlier. On 12/29/21 at 10:00 AM, V13 (wound physician) stated, (R2) has a stage 3 pressure ulcer on his right buttock and a stage 2 pressure ulcer on his left buttock. My first visit with him was on 12/6/21 when he acquired a stage 3 ulcer on his right buttock. On 12/15/21 another wound was discovered on his left buttock and is a stage 2. He was not admitted with either of these wounds, they were both acquired at the facility. These wounds are avoidable and should have been found before a stage 2 or stage 3. He sits in his recliner all day and didn't have a cushion, so we have added that on for him. I think any pressure ulcer can be avoidable if the prevention measures are being done. These wounds probably started as a moisture associated skin breakdown and unfortunately progressed before they were identified. The facility's policy titled, Pressure Ulcer Prevention Guidelines dated 7/25/2018 showed, Policy: To prevent the formation of avoidable pressure ulcers and to promote healing of existing pressure ulcers, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure ulcer present .Preventive Skin Care: 1. Inspect skin while providing care, paying close attention to bony prominences .3. Avoid positioning the resident on an area of redness whenever possible. 2) R3's electronic face sheet printed on 12/28/21 showed R3 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's facility assessment dated [DATE] showed R3 has no cognitive impairment. On 12/28/21 at 9:54 AM, R3 stated, I have a sore on my left buttocks that is healing but it's a skin tag that gets caught at times. It comes and goes. I know I have another area back there but I am overweight so I can't see it. I didn't have the second open area when I came here. R3's care plan dated 12/19/21 showed, (R3) admitted with Stage 2 to her sacrum, with increased risk for additional skin breakdown and wound healing. Inform the resident/family/caregivers of any new area of skin breakdown. V7 (wound care nurse) confirmed that R3 did not come into the facility with a Stage 2 pressure ulcer to her sacrum and only had an open blister to her left buttock upon admission. R3's shower sheets dated 12/16/21 and 12/19/21 showed no open areas or skin tears to R3's skin. R3's undated weekly wound evaluation showed, Sacrum pressure ulcer stage 2 acquired in facility on 12/15/21, first observation. R3's weekly skin observation dated 12/20/21 showed, Sacral wound, treatment in place. The facility's weekly pressure/non-pressure injury log showed, Acquired: (R3) stage 2 pressure ulcer on sacrum identified on 12/15/21. R3's wound physician evaluation and summary dated 12/22/21 showed, Stage 2 pressure wound to sacrum with a duration of greater than 8 days. R3's physician orders showed no treatment in place for R3's sacral wound from 12/15/21 thru 12/22/21. On 12/29/21 at 10:00 AM, V13 (wound physician stated, I saw (R3) for the first time on 12/15/21, 2 days after she was admitted , for a Stage 2 pressure ulcer to her sacrum. I initiated treatment on 12/15/21 for her. On 12/28/21 at 10:48 AM, V7 (wound care nurse) stated, (R3) has a stage 2 pressure ulcer to her sacrum, the wound care physician saw her 2 days after she admitted (12/15/21) and started treatment right away. I'm not sure why it doesn't show that we started treatment but I'm sure we did. (R3) is obese so we didn't catch her wound right away but we should have.

Based on interview and record review, the facility failed to assess, document and treat a resident's (R1) post-surgical wound on the left hip (Hip Arthroplasty). This failure resulted in the wound becoming infected (Infected left total hip arthroplasty) requiring the resident to be hospitalized and undergo a surgical procedure due to the infection and receive antibiotic therpy. This applies to 1 of 3 residents (R4) reviewed for wound care in the sample of 8. The findings include: Facility's Wound Treatment Guidelines showed: Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standard of practice and physicians order. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician's orders [REDACTED]. 2. In the absence of treatment orders, the license nurse will notify the physician to obtain treatment orders. This may be the treatment nurse or the assigned licensed nurse in the absence of treatment nurse. R4's face sheet showed that R4 is an [AGE] year-old who admitted to the facility on [DATE] and has multiple medical [DIAGNOSES REDACTED]. R4's Minimum Data Set ((MDS) dated [DATE] showed that R4 is alert and oriented. Hospital Record (Prior to Facility's Admission 9/15/20-9/18/20) showed that R4 a had left total hip arthroplasty on 9/15/20 and was discharged to the facility on [DATE]. It also indicated multiple instructions which includes, keeping the wound clean and dry, changing the dressing in one week, following up with physician as directed in 2 weeks and suture/staple removal in 2 weeks. Facility's admission notes dated 9/18/20 showed: R4 was admitted from the hospital after a recent left hip arthroplasty. R4 is alert and oriented to name, time, place and situation. R4 complained of pain in the left hip but is managed well with her [MEDICATION NAME]. R4's Care Plan showed: R4 has a Left [MEDICAL CONDITION] related to fall. Goal: R4's surgical incision will heal without signs and symptoms of infection or breakdown by review date. Intervention: Monitor/document/report as needed for signs and symptoms of [MEDICAL CONDITION] complications such as contracture formation, embolism signs and symptoms (cyanosis, pain, petechiae, increased heart rate ([MEDICAL CONDITION], tachypnea, difficulty breathing (Dyspnea)), infection at surgical site, impaired mobility, unrelieved pain, Pneumonia/poor air exchange, incontinence. R4 stated on 11/17/2020, that two days before she was sent out to the hospital, that she reported to the nursing staff that her wound was leaking and bleeding. R4 stated that she cannot recall who she spoke with regarding her wound. R4 added that on10/14/2020 she again reported to the nursing staff that her wound was bleeding and that later that day she went to see her own doctor and was admitted to the hospital for wound care. R4's skilled nursing notes and assessments from 9/19/20 through 10/13/20 does not have any evidence of documentation of wound assessment, there was no description of the wound whether the wound was healing or deteriorating. There was only one documentation in the nursing notes dated 10/6/20 which showed that the staples from left hip incision were removed, incision was well approximated and pink/healthy. Another documentation in the weekly skin observation notes dated 10/9/20 indicated that the surgical incision was covered by bandage. However, there was no further follow up documentation about the surgical site. There was no evidence of documentation with regards to following up with physician related to post-surgical wound management. A nursing note on 10/14/20 at 5:40 AM showed, that R4 approached V10 (Nurse) asking for a shower before her appointment. R4 had sero-sanguinous drainage dripping down the left leg. R4 assisted to the shower. The steri-strips were wet with drainage. There was a small purple hematoma under top fold of left hip and abscess to lower incision with purulent drainage. The area was cleansed, and foam dressings applied. Bed sheets were changed that were soiled with drainage. In addition, there was no site of administration found in the treatment administration record (TAR) related to wound care. On 11/17/20 at 1:36 PM, V3 (LPN/Wound Care Nurse) stated, she (V3) had never assessed R4's wound or changed her dressing because R4 was being seen by her orthopedic surgeon at an outpatient clinic. On 10/6/20, R4 had an orthopedic appointment and her staples were removed. It said in the note that the incision was well approximated and pink/healthy. V3 also stated that she works full time in the unit/floor and only does wound rounds with the physician every Friday. V3 added, the floor nurses should be monitoring the residents with wounds and document their assessments. When R4 was admitted from the hospital, her wounds should have been monitored/documented for any signs of drainage, pain or signs and symptoms of infection. On 11/17/20 at 1:45 PM, upon review of R4's documentation, V3 stated/confirmed that there was not an assessment of the wound. V3 added, it doesn't look like wound has been monitored. On 11/18/20 at 4:17 PM, V2 (Director of Nursing/DON) stated that when nursing staff admit a resident in the facility with post-surgical wound the staff is expected to follow up orders, do a baseline documentation of the wound. Usually when there's order not to open a wound dressing until seen by the follow up physician, the staff should document the condition of surrounding skin/area of the wound. On 11/18/20 at 4:46 PM, V6 (Medical Doctor) gave the following statement: It is basic knowledge that when a post-op patient goes to rehab, the staff should monitor the condition of the wound. Change the dressing when it is needed. Even when the staples/sutures were removed the staff should continue to monitor it. That's why R4 went there not just for the therapy but also for the wound. A surgical wound has the potential to develop infection. However, had they (facility staff) been monitoring the wound, it would have been caught early, but it was caught late. It could have been addressed a little sooner. The change of the wound condition in two weeks since the staple removal was drastic. That infection did not develop right away. It could have started about 3 days prior to V6 seeing R4 (on 10/14/20). R4 even told V6's staff that her wound started bleeding a few days prior to being seen. Hospital Record dated 10/15/20 showed: Pre-operative Diagnosis: [REDACTED]. Post-operative Diagnoses: [REDACTED]. Infected left total hip arthroplasty. 2. Trochanteric avulsion. Indications: On R4's first post-operative visit approximately 2 weeks after surgery (left total hip arthroplasty on 9/15/20), her wound looked fine and the sutures were removed. R4 was at the facility. On 10/14/20, V6 (Orthopedic Doctor) received a call that the wound was looking bad. Facility staff brought R4 in for evaluation. R4 had obvious pus coming out with bullae formation and just a very bad-looking wound. V6 immediately admitted V4 in the hospital and felt that R4 needed to be brought to the operating room for the above mentioned procedure. V6 explained to R4 this was obviously a setback and she would need some antibiotics. Infectious Disease Consultation note dated 10/16/20 showed: R4 reported that there was some pus and bleeding from the wound a few days before visiting V6. On 10/15/20, V6 performed incision and drainage of the left hip with extensive debridement. V6 also performed a partial excision of the greater trochanter with direct repair of the gluteus medius to the remaining trochanter. Upon admission, R4's white blood cell (WBC) was 10,400 per microliter and rose to 25,900 the next day (indicating infection). R4's Erythro-sedimentation rate (ESR) was 120 (normal for females is 1-20, elevated level indicates possible infection). R4 was started on a antibiotic [MEDICATION NAME] IV, (Intravenous route). V6 performed wound cultures prior to surgery. Wound cultures results showed [MEDICAL CONDITION]-resistant Staphylococcus Aureus (MRSA).

Based on observation, interview and record review the facility failed to safely transport a resident in a wheelchair. This applies to 1 of 4 residents (R9) reviewed for accidents in a sample of 16. Findings include: 01/02/18 10:55 AM R9 was transported from nurses station to activities by V16 (Activity Aide) in a wheelchair. R9's feet, with shoes with non-slip soles on both feet, were dragging on floor while being transported. 01/02/18 12:19 PM R9 was transported from the unit 3 hallway to the dining room by V5 (Nursing Assistant). R9's feet, with shoes with non-slip soles on both feet, were dragging on the floor while being transported. 01/04/18 11:24 AM V8 (Restorative Nurse) staff should not transport R9 with feet dragging because it could cause R9 to fall out of the wheelchair or cause an injury. The Minimum Data Set, dated dated dated (MONTH) 6, (YEAR) documents R9 as requiring extensive staff assistance of one staff in the wheelchair.

Based on observation, interview and record review the facility failed to implement measures to prevent the development of skin integrity issues. This applies to 2 of 5 residents (R20,R57) reviewed for bowel and bladder incontinence in a sample of 16. This failure resulted in R20 and R57 developing Moisture Associated Skin Deterioration (MASD). Findings include: 1. 01/02/18 11:23 AM V5 (Nursing Assistant) assisted V4 (Nursing Assistant) with the provision of incontinence care to Resident #57; Resident #57 had been incontinent of stool. As V5 and V4 cleansed the stool off of Resident #57's scrotal area had multiple pea sized open areas and redness to the scrotum. 01/02/18 11:52 AM V6 (Wound Nurse) stated the open areas and redness to Resident #57's scrotum is newly acquired. V5 stated 1/2/18 Resident #57 was put in the wheelchair and changed at 5:55 am and Resident #57 had not been checked or changed since 5:55 am. V4 stated incontinent residents are to be checked for incontinence and changed every two hours R57's Weekly Wound Evaluation, completed by V6, documents R57 developed facility acquired Moisture Associated Skin Deterioration (MASD) on 01/02/18. R57's Care Plan dated (MONTH) 20, (YEAR) documents R57 at risk for skin integrity impairment related to fragile skin . R57 Minimum Data Set, dated dated dated (MONTH) 7, (YEAR) documents R57 as severely impaired and always incontinent of bowel. 01/05/18 08:48 AM V23 (Nurse Practitioner) stated R57's skin is fragile and R57 is at risk for breakdown due to poor nutrition and overall decline related to advanced dementia. V23 stated the facility should implement measures to keep R57 clean and dry to prevent the development of skin issues such as MASD and Pressure Ulcers. 2. Face Sheet documents R20 was admitted on [DATE] with the following pertinent Diagnosis: [REDACTED]. 01/02/18 at 10:59 AM R20 was laying in bed and said it takes hours to answer the call light and I had a pressure sore on the butt and it healed . R20 said sometimes I have to sit in my feces and urine because they are short of staff. On 01/02/18 at 01:29 PM R20 was laying in the same position and said R20 has not been changed(incontinent brief) since 8 am this morning . On 01/02/18 at 01:36 PM, V15(Activity Aide) entered the room to hang an activity calendar and went out, R20 told V15 before V15 exited the room that R20 is waiting for an incontinent brief change. On 1/2/18 at 1:45 PM, V13(Certified Nursing Assistant) and V14(CNA) both entered R20 room and changed R20's incontinent brief. R20's incontinent brief was heavily soiled and R20's buttock was very red with incontinent brief lines marked on R20's skin. R20's inguinal area had reddened abrasions. On 01/04/18 at 09:14 AM V6(Wound Care Nurse) said R20 developed moisture associated skin damage related to untimely incontinent care issues. V6 said we noted the new skin breakdown on 1/3/2018. Weekly Wound Evaluation Form dated 1/3/2018 states, R20 developed bilateral buttock skin breakdown measuring .5 cm in length by .3 cm in width by .1 cm in depth. The documentation states that R20 is incontinent of bladder and can feel when R20 is wet. BIMS score dated 10/27/2017 documents that R20 is conitive alert (15).

Based on observation, interview and record review the facility failed to provide timely incontinence care. This applies to 3 of 5 residents (R20, R57, R61) reviewed for bowel and bladder incontinence in a sample of 16 and 1 resident (R22) in the supplemental sample. This failure resulted in R57 developing Moisture Associated Skin Deterioration (MASD) to the scrotum and R20 to the buttocks area. Findings include: 1. 01/02/18 11:23 AM V5 (Nursing Assistant) assisted V4 (Nursing Assistant) with the provision of incontinence care to Resident #57; Resident #57 had been incontinent of stool. As V5 and V4 cleansed the stool off of Resident #57's scrotal area had multiple pea sized open areas and redness to the scrotum. 01/02/18 11:52 AM V6 (Wound Nurse) stated the open areas and redness to Resident #57's scrotum is newly acquired. V5 stated 1/2/18 Resident #57 was put in the wheelchair and changed at 5:55 am and Resident #57 had not been checked or changed since 5:55 am. V4 stated incontinent residents are to be checked for incontinence and changed every two hours R57's Weekly Wound Evaluation, completed by V6 on (MONTH) 2, (YEAR), documents R57 developed facility acquired Moisture Associated Skin Deterioration (MASD) occurring on 01/02/18. R57's Care Plan dated (MONTH) 20, (YEAR) documents R57 at risk for skin integrity impairment related to fragile skin. R57's Minimum Data Set, dated dated dated (MONTH) 7, (YEAR) documents R57 as severely impaired and always incontinent of bowel. 01/05/18 08:48 AM V23 (Nurse Practitioner) stated R57 skin is fragile and at risk for breakdown due to poor nutrition and overall decline related to advanced dementia. V23 stated the facility should follow R57's plan of care to keep R57 clean and dry to prevent the development of skin issues such as MASD and Pressure Ulcers. 2. 01/02/18 11:11 AM V4 (Nursing Assistant) provided incontinence care to R22. V4 stated R22 was last changed at 8 am and confirmed residents are to be checked and changed every 2 hours. R22's Car Plan dated (MONTH) 3, (YEAR) documents R22 incontinent of bowel and bladder and at risk for skin integrity issues related to incontinence with interventions to keep skin clean and dry and cleanse after incontinence episodes. 3. 01/02/18 12:22 PM R61 stuck R61 right hand in R61's incontinence briefs and removed R61's hand which then had stool on the side of R61's right hand and fingers. 01/02/18 12:41 PM V4 brought R61 into the shower room to provide incontinence care after V4 noticed R61 with stool on R61's fingers and hand. V4 confirmed this was the first time incontinence care was provided to R61 since 6 am. R61's MDS dated (MONTH) 14, (YEAR) documents R 61 with severely impaired cognitive skills and always incontinent of bowel. 4. Face Sheet documents R20 was admitted on [DATE] with the following pertinent Diagnosis: [REDACTED]. 01/02/18 at 10:59 AM R20 was laying in bed and said it takes hours to answer the call light and I had a pressure sore on the butt and it healed . R20 said sometimes I have to sit in my feces and urine because they are short of staff. On 01/02/18 at 01:29 PM R20 was laying in the same position and said R20 has not been changed since 8 am this morning . On 01/02/18 at 01:36 PM, V15(Activity Aide) entered the room to hang calendar and went out, R20 told V15 R20 is waiting for an incontinent brief change. On 1/2/108 at 1:45 PM, V13(Certified Nursing Assistant) and V14(CNA) both entered R20 room and changed R20's incontinent brief. R20's incontinent brief was heavily soiled and R20's buttock was very red with incontinent brief lines marked on R20's skin. R20's inguinal area had reddened abrasions. On 01/04/18 at 09:14 AM V6(Wound Care Nurse) said R20 developed moisture associated skin damage related to untimely incontinent care issues. V6 said we noted the new skin breakdown on 1/3/2018. Bowel and Bladder Program Screener dated 11/15/2017 states, R20 is incontinent of bowel and bladder. R20 has no care plan for bladder/bowel incontinence. Care Plan for risk for infection initiated 11/8/2017 was reviewed. The Care plan states R20 is at risk related to being bed bound, skin issues and history of urinary tract infections. This care plan does not address incontinence or elimination patterns. On 1/4/2018 at 3:02 PM, V8(Restorative Nurse) said R20 should have a care plan for bowel/bladder incontinence because R20 is incontinent and prone to skin alterations due to the incontinence. Weekly Wound Evaluation Form dated 1/3/2018 states, R20 developed bilateral buttock skin breakdown measuring .5 cm in length by .3 cm in width by .1 cm in depth. The documentation states that R20 is incontinent of bladder and can feel when R20 is wet. BIMS score dated 10/27/2017 documents that R20 is conitive alert (15).

Based on observation, interview and record review the facility failed to provide a sufficient number of effective staff to meet the care needs of the residents. This applies to 4 of 16 residents (R20, R22, R57, R61) reviewed for care planned needs in a sample of 16 and 2 resident (R11, R44) in the supplemental sample. This failure resulted in R20and R57 developing Moisture Associated Skin Deterioration (MASD). Findings include: 1. 01/02/18 11:23 AM V5 (Nursing Assistant) assisted V4 (Nursing Assistant) with the provision of incontinence care to R57; R57 had been incontinent of stool. As V5 and V4 cleansed the stool off of R57's scrotal area open areas and redness were observed to the scrotum. 01/02/18 11:52 AM V6 (Wound Nurse) stated the open area and redness to R57's scrotum is newly acquired; V6 measured this area as 30 x 15 x 0.1 centimeters. V5 stated R57 was put in the wheelchair and changed at 5:55 am and R57 had not been checked or changed since 5:55 am due to not having enough time to get it done. V4 stated incontinent residents are to be checked for incontinence and changed every two hours. R57's Weekly Wound Evaluation, completed by V6 on (MONTH) 2, (YEAR), documents R57 developed facility acquired Moisture Associated Skin Deterioration (MASD) occurring on 01/02/18. R57's Care Plan dated (MONTH) 20, (YEAR) documents R57 at risk for skin integrity impairment related to fragile skin. R57 Minimum Data Set, dated dated dated (MONTH) 7, (YEAR) documents R57 as severely impaired and always incontinent of bowel. 01/05/18 08:48 AM V23 (Nurse Practitioner) stated R57 skin is fragile and at risk for breakdown due to poor nutrition and overall decline related to advanced dementia. V23 stated the facility should follow R57's plan of care to keep R57 clean and dry to prevent the development of skin issues such as MASD and Pressure Ulcers. 2. 01/02/18 11:11 AM V4 (Nursing Assistant) provided incontinence care to R22. V4 stated R22 was last changed at 8 am and confirmed residents are to be checked and changed every 2 hours. V4 further stated, We are doing the best we can-not enough Nursing Assistants. R22's Care Plan dated (MONTH) 3, (YEAR) documents R22 incontinent of bowel and bladder and at risk for skin integrity issues related to incontinence with interventions to keep skin clean and dry and cleanse after incontinence episodes. 3. 01/02/18 12:22 PM, R61 stuck R61's right hand in R61's incontinence briefs and removed R61's hand which then had stool on the side of R61's right hand and fingers. 01/02/18 12:41 PM V4 brought R61 into the shower room to provide incontinence care after V4 noticed R61 with stool on R61's fingers and hand. V4 confirmed this was the first time incontinence care was provided to R61 since 6 am. 01/04/18 01:42 PM V4 stated it is difficult to provide good care when short staffed. On 01/02/18 we were doing the best we could do-we only had two CNA's. R61's MDS dated (MONTH) 14, (YEAR) documents R61 with severely impaired cognitive skills and always incontinent of bowel. 4. 01/02/18 V7 (Nurse) between 12:40-1:11 PM V7 assisted in one of the dining rooms. V7 stated they were short and only had 2 CNA's. V7 stated V7 had one noon medication left to give to R11 and it would be late if V7 was unable to get another staff to assist in the dining room- supervising in the dining room was a priority over timely medication administration. V7 stated medications are to be administered no more than one hour before or after the prescribed time. On 01/02/18 V7 prepared and administered R11's medications ([MEDICATION NAME] 100 milligrams, [MEDICATION NAME] 10 milligrams, and Geri-[MEDICATION NAME] Syrup 2 teaspoons) for administration via a feeding tube then started Glucerna 1.5 at 63 milliliters per hour. R11's (MONTH) (YEAR) Physician order [REDACTED]. This medication was administered at 1:24 PM. 5. 01/03/18 at 10 am, R44 stated there is not enough staff at the facility which sometimes causes delays in receipt of meals and medications timely. 6. 01/02/18 at 11 am, V26 (Ombudsman) stated V26 felt the facility was short of staff based on residents waiting long times to get assistance. 7. 01/02/18 02:11 PM V24 (Nurse) stated we usually have 2-3 nurses for the 100, 300, and 400 hallway and the facility is trying to staff with 6 CNA's for the entire facility. V24 stated 3 Nursing Assistants called off, Today we had 2 CNAs and one nurse working as a CNA (V21-Care Plan Coordinator). 8. Grievance Complaint Record of Investigation dated 11/16/17 documents the facility was short staffed and it takes up to an hour to get call lights answered. Grievance Complaint Record of Investigation dated 11/06/17 documents water does not get passed on the night shift when short of staff. 9. The Facility Assessment Tool dated 01/03/18 documents a 10 resident to 1 Nursing Assistant ratio. The Midnight Census Report dated 01/02/18 documents a total of 51 residents residing on the 100, 300, and 400 hallway with a total of 51 residents. Nursing Assistants observed working 01/02/08 between 9:20 a.m.-2:00 p.m. were V4 and V5. 10. Face Sheet documents R20 was admitted on [DATE] with the following pertinent Diagnosis: [REDACTED]. On 01/02/18 11:04 AM R20 said R20 has not had a shower in 3 months. R20's hair was disheveled. R20 said the certified nursing assistants won't even brush my damn hair, I have [DIAGNOSES REDACTED] and can not raise my arms. I would be lucky if I get my face washed. R20's face was not washed and R20 had a hospital gown on while laying in bed. R20 said they do not brush my teeth either. R20 said this is a consistent and ongoing problem, no staff to do it. 01/02/18 at 01:25 PM R20 was lying in bed in the same position, hair not combed and had the same hospital gown on. R20 said I have not got my incontinent brief changed yet. R20 said R20 receives a tray to feed for pleasure and R20 was hungry and has not gotten a lunch tray yet. R20 said R20 can not stand not having R20's teeth brushed, makes R20's food taste bad. At this time there was no lunch tray in R20's room. 01/02/18 at 01:42 PM the call light was pulled and V13(Certified Nursing Assistant) and V14(Certified Nursing Assistant) entered the room and said they work the 2nd shift and had been called in early because there is no staff today. Both V13 and V14 acknowledged that R20's hair was not combed, teeth not brushed and R20 was soiled and needed assistance eating the just delivered lunch tray. Upon performing incontinent care redness and abrasions were noted to R20's sacral and inguinal area. On 01/04/18 at 09:14 AM V6(Wound Care Nurse) said R20 developed moisture associated skin damage related to untimely incontinent care issues. V6 said we noted the new skin breakdown on 1/3/2018. Weekly Wound Evaluation Form dated 1/3/2018 states, R20 developed bilateral buttock skin breakdown measuring .5 cm in length by .3 cm in width by .1 cm in depth. The documentation states that R20 is incontinent of bladder and can feel when R20 is wet.

Based on observation, interview and record review the facility failed to identify declining wounds, notify the doctor and treat wound deterioration for residents with pressure sores. As a result R1 was hospitalized and diagnosed with [REDACTED]. This applies to 2 of 3 residents (R1, R2) reviewed for pressure sores. The Findings Include: 1). Face Sheet documents R1 was admitted on [DATE] with the following pertinent [DIAGNOSES REDACTED]. On May 23, 2017 at 9:07 AM, Z2 said R1 was admitted with a left heel wound which according to the wound care nurse was healing. Z2 said R1 is now hospitalized with a left heel infected and necrotic wound. Wound Care Notes were reviewed from March 2017 through May of 2017. Wound Care Note dated March 10, 2017 states, R1 was admitted with an unstageable left heel wound on December 16, 2016. Wound Care Note dated May 15, 2017 documents R1's left heel wound was healing, developed 10% necrosis with beefy red granulation tissue and measured 3.0 centimeters in length by 3.0 centimeters in width by .3cm in depth with decreased slough. Physician order [REDACTED]. The physicians order was changed on May 16, 2017 to clean the left heel deep tissue injury with normal saline, skin prep, apply medi-honey to area, cover with alginate and secure with kerlix every 3 days and as needed. The Medication Administration Records's were reviewed from April 1 to May 18, 2017. The records document the last time R1's left heel wound was treated was May 16, 2017. There was no assessment of the wound on the May 17 or May 18, 2017. Nursing Progress Notes dated May 18, 2017 document R1's roommate alerted staff to R1's loud breathing, R1 observed in respiratory distress, vitals, 79% oxygen saturation on room air, respirations 32, Temperature 104.2 axillary. Oxygen supplied, [MEDICATION NAME] given, cool wash cloth place on forehead, bilateral axillary and in groin area. Medical Doctor paged returned call to send to the emergency room via ambulance. Power of attorney notified emergency room Record dated May 18, 2017 was reviewed. The Record documents R1 was admitted with [MEDICAL CONDITION], Septic Shock and Urinary Tract Infection. The emergency room Report contained Pictures of R1's wounds. The Left heel wound was necrotic and infected. The wound covered the entire left heel. On May 24, 2016 at 8:36AM, E15 (Nurse) said she was the nurse who sent R1 out on May 18, 2017 and the care she provided was documented in the note. E15 worked with R1 as the assigned nurse from May 16, 2017 through May18, 2017. E15 had no response for treatment of [REDACTED]. On May 24, 2016 at 9:12AM, R1 was in the hospital sitting in an adult recliner, with bilateral heel dressings on. R1 was confused and did not communicate. On May 24, 2016 at 9:17AM, Z1 (Hospital Nurse) said R1 came into the hospital with a necrotic left heel wound that was severely infected, someone at the nursing home should have known about the condition of the left heel wound. On May 24, 2017 at 10:20AM, E3 (Wound Care Nurse) said if the wound was not improving the physician should have been contacted to get orders. After viewing pictures of R1's left heel wound from the hospital, E3 could not explain what happened to the healing wound. E3 said the last wound description was on May 16, 2017 and the floor nurse should have treated the wound afterwards. The Treatment Administration Record dated May 2017 documents the last time the wound was treated was on May 16, 2017, there was no assessment or treatment noted on May 17, or May 18, 2017. On May 25, 2017 at 11:03AM, Z3 (Medical Doctor) hospital and nursing home physician said R1's wound deteriorated quickly because it was infected, R1 was admitted to the hospital with [REDACTED]. When R1 was admitted to the hospital mutiple bacteria were infecting the left heel wound. R1 is currently treated with antibiotics in the hospital . Z3 said he was not made aware of the status of the wound, had he been made aware he would have prescribed treatment. The Facilitys' Policy titled Pressure Injury Prevention and Management undated states, Treatment decisions will be based on characteristics of the wound, including the stage, size, amount of exeduate and presence of pain, infection, or non-viable tissue. The attending physician will be notified of the presence, progression towards healing or lack of healing of any pressure injuries upon identification of the injuries and at least weekly thereafter. 2). Face Sheet doucuements R2 was admitted on [DATE] with the following pertinent diagnosis, unstageable pressure ulcer to the sacral region. Weekly Wound Report dated May 15, 2017 documents a left ischuim stage 3 wound. On May 23, 2017 at 10:54AM, R2 was laying in bed, there was a pervasive foul odor throughut the room. R2 said he was admitted with a sacral wound and he did not know how it looks because it is on his bottom. On May 23, 2017 at 11:06AM, E4 (Infection Control Nurse) said she was going to do the treatment for [REDACTED]. R1 was laying in bed, again with a very foul smell. E4 removed a heavily saturated dressing from R1's large sacral wound.The dressing and wound contained fecal and wound drain material. The padding under R2's bottom was soiled with large amounts of serousanguineous drainage. The smell was overtly poignant. E4 said she was not the regular nurse. E4 changed the dressing and made no comment about the smell or saturation of the dressing/padding. E8(CNA) and E9 (CNA) entered the room to assist with transferring R2 from the bed to the wheelchair. On May 23, 2017 at 12:24PM, E9 (CNA) said she could not smell R2's wound because she was congested. E9 said R2's wound weeps constantly throughout the night and he has to lay in it until we change him in the morning. On May 23, 2017 at 2:32PM, R2 said his sense of smell is off and he does not know the status of his wound. R2 said they will leave him in bed all day sometimes. On May 23, 2017 at 3:13PM, E4 (Infection Control Nurse) said she did not smell anything other than a bowel movement with R2. E2 (DON) was present and said we will notify the doctor of the odor.

Based on observation, interview and record review the facility failed to administer oxygen as ordered to one resident with severely compromised respiratory status (R25). This failure resulted in R25 experiencing an episode of respiratory distress and nausea. The facility also failed to evaluate and document R25's respiratory status during and after an episode of respiratory distress, failed to implement interventions developed for R25's respiratory distress, and failed to notify R25's physician of R25's respiratory status. This applies to 1 of 1 residents (R25) in the supplemental sample reviewed for respiratory distress. The findings include; R25 was admitted to facility 12/18/13 at 4:00 PM from the hospital. R25's admitting [DIAGNOSES REDACTED]. R25's 12/18/13 hospital discharge records, 12/18/13 physician orders, and admission/ interim care plan, documents the need to: - administer Oxygen at 2 - 3 litters per minute per nasal cannula continuously, - monitor oxygen saturation levels every shift and maintain saturation level at 93 % or greater. On 12/18/13 at 4:30PM, R25 was observed in a wheelchair in the 300 unit hallway with E4 (nurse aide). R25 was complaining of respiratory distress and severe nausea. E4 called E3 (Assistant Director of Nurses), to assist R25. E3 immediately obtained emergency oxygen and applied it to R25 at 3 liters per minute via nasal cannula. At 4:40PM R25 stated she was starting to feel better but she is not supposed to be without her oxygen. R25's 12/18/13 nurses note documents resident as alert and oriented to person, place and time. During 12/19/13 11:15AM interviews, R25 and her family (at bedside) stated R25 cannot be without oxygen at any time. During 12/19/13, 10:40AM and 11:54AM interview's, E3 stated, On 12/18/13, E4 had taken R25 from the Villa section of facility to the other side of the building to be weighed. E3 observed R25 on the 300 unit without oxygen and complaining of shortness of breath and nausea. During 12/19/13, 12:15PM interview E5 (nurse), said R25 was admitted to facility on 12/18/13 on the afternoon shift. R25 has a severe respiratory condition, has a pleural drainage tube, and should have oxygen on at all times. E5 stated "I was never notified on 12/18/13 that R25 had an episode of dyspnea while off the Villa unit". E5 also said, "If I had been notified, I would have done a full assessment of R25 and called the physician." R25's 12/18/13 4:00PM through 12/19/13, 12:15PM nurses progress notes did not include documentation about the 12/18/13 4:30PM respiratory distress episode. Nursing documentation also showed R25's physician had not been notified of R25's episode of respiratory distress. *

Based on observation, record review, and interview the facility failed to ensure nursing and therapy staff followed the policy and procedure for safely transferring residents and/or providing care for residents. As a result of this failure R1 sustained skin tears to her legs, R2 sustained skin tears to her legs and feet, R3 sustained a skin tear to his left arm, and R4 fell from her wheel chair when transported by a CNA (Certified Nurses Aide) This is for 4 of 4 sampled residents investigated for improper nursing care. (R1, R2, R3, and R4). The findings include: 1. Review of R1's closed record admission face sheet showed R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R1's physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of the facility's incident reports showed R1 had 5 incidents with resultant skin tears from 9/22/13 to 10/23/13. Two of R1's skin tears were sustained while R1 was in the care of a family member. Three of the skin tears were sustained while R1 was in the care of facility staff. On 10/17 and 10/21/13 R1 sustained skin tears while in the care of CNA's, and on 10/23/13 R1 sustained a skin tear while in the care of a physical therapy assistant. The incident report dated 10/17/13 at 11:23 a.m. showed R1 sustained a 5.4 cm "U" shaped skin tear to the right lower extremity during a 1 person assist transfer from the toilet to the wheel chair. The incident showed R1's leg was "bumped on the wheel chair where the pedal attaches." On 12/4/13 at 11:00 a.m. during a phone interview E6 (CNA) stated, " On 10/17/13 I was transferring R1 to her wheel chair from the toilet. R1 didn't straighten her leg out. Her leg got snagged on the area where the leg rest go on the wheel chair. R1 has fragile skin. R1 wasn't a 2 person assist for transfers before this incident." Review of R1's 30 day Medicare MDS (Minimum Data Set) dated 9/19/13 showed R1 should have extensive 2 + person assist for transfers. The incident report dated 10/21/13 at 3:15 p.m. showed R1 sustained a 6 cm x 4 cm skin tear to the right inner calf while in the care of E4 (PTA - Physical Therapy Assistant). On 12/4/13 at 11:55 a.m. E4 stated, "On 10/21/13 I was performing a 1 person transfer from bed to wheel chair with R1 because I was going to walk her. During the transfer R1 had trouble scooting her leg back. Her leg turned outward. I grabbed her on her calf to adjust her foot and her skin stuck to my middle finger." E4 stated, "No one told me about her skin and/or how to handle R1's fragile skin." Again, the MDS dated [DATE] showed R1 should have extensive 2 + person assist for transfers. The incident report dated 10/23/13 at 2:53 p.m. showed R1 received a 8.5 cm x 4.5 cm skin tear to her left outer calf when E5 (CNA) lifted R1's legs when transferring R1 to bed. On 12/4/13 at 2:35 p.m. E5 stated, "On 10/23/13 I had just toileted R1 and she asked to lay down. I had my hands on the bottom of her legs. She still had her shoes on and her foot got caught on the foam memory pad. When I put my hand under her legs she got this skin tear. She was a 1 person transfer." Again as per the MDS of 9/19/13, R1 was an extensive 2 + person transfer. Review of R1's plan of care addressing skin tears/bruising/anticoagulant therapy showed R1 was a 2 person assist for transfers. Review of the facility's policy on Transferring Residents showed documentation "You can plan how to transfer a resident safely by asking yourself the following questions: The questions included: How much assistance do you need? 2. Review of R2's admission face sheet showed R2 is a [AGE] year old female readmitted to the facility on [DATE]. Review of the facility's incident reports showed R2 had 3 incidents with skin tears (from 10/5 to 11/9/13) while in the care of CNA's. On 10/5/13 R2 sustained a 0.5 cm skin tear while being transferred with a 1 person CNA assist. On 10/20/13 scarce documentation on an incident report and scarce nursing note documentation (no times documented) showed R2 sustained a skin tear to the left leg when she hit her left leg on the wheel chair while getting out of bed. On 11/9/13 (no time documented) an incident report showed R2 sustained 5 cm arch shaped skin tear to the right leg upon transfer. Review of R2's Annual MDS dated [DATE] and Quarterly MDS dated [DATE] showed R2 is an extensive 2 + person assist for transfers. Review of R2's plan of care addressing skin tears showed R2 is "extensive assist of 2 + persons with mobility, skills, etc... On 12/4/13 at 2:20 p.m. E3 (Assistant Director of Nurses) stated, "With each of these transfers for R2 the staff used a 1 person assist transfer. They should have used 2 person assists for these transfers." Observation of R2 on 12/4/13 at 3:05 p.m. and 12/5/13 at 11/15/13 noted R2 up in her wheel chair sleeping. R2 was observed with protective sleeves to both arms and both legs. On 12/5/13 at 1:00 p.m. R2 was again observed with the protective sleeves to both arms and legs. R2 stated, I'm not getting injured anymore. They put these sleeves on me and they use 2 people to transfer me now." 3. Review of R3's admission face sheet showed R3 was admitted to the facility with [DIAGNOSES REDACTED]. Review of an incident and nursing note documentation for R3 dated 12/2/13 showed R3 sustained a 2 cm circular skin tear to the left inner forearm during a shower. Review of R3's physician's orders [REDACTED]. On 12/4/13 at 2:25 p.m. during interview with E3, E3 stated, "R3 did not have the protective sleeves on his arms when this incident happened. R3 was in the shower room with staff. The staff were undressing R3 for his shower. The staff took off the protective sleeves from R3's arms, then pulled R3's shirt off, which rubbed R3's skin and caused the skin tear. The staff should have removed the shirt first, then removed the protective sleeves to prevent the skin tear." Observation of R3 on 12/4/13 at 3:00 p.m. and 12/5/13 at 11:00 a.m. noted R3 to have the protective sleeves in place to both arms. On 12/5/13 at 11:00 a.m. R3 stated, "I don't have any more skin tears. They put vaseline on me, then put these sleeves on me to protect my skin." 4. Review of an incident report for R4 dated 10/17/13 at 4:00 p.m. showed a CNA was pushing R4 in her wheel chair to the bathroom and bumped the wall with the wheel chair. When R4's wheel chair bumped the wall, R4 slipped out of the wheel chair on to the floor. Review of post fall documentation dated 10/20/13 showed R4 had a bruise to the left upper extremity. No follow up documentation was noted on the fall analysis/investigation as to recommendations to minizmize/prevent further falls. On 12/5/13 at 10:00 a.m. R4 stated she did not remember the fall and stated, "I don't remember hurting myself when I fell ." On 12/4/13 at 2:25 p.m. E3 (Assistant Director of Nurses) admitted that staff are not using 2 person assists when needed and that staff has to be more careful when transporting residents.

Based on observation, interview and record review, the facility failed to ensure nursing staff transferred 1 resident with fragile skin (R5) using a mechanical lift in a manner which would prevent injury. This applies to 1 resident (R5) out of 4 residents reviewed for injuries, out of a sample of 5. Findings include: E2 (Acting DON) provided a list of residents with skin tears/bruises dated January 2014. This was provided on 1/28/14. This list indicates that R5 sustained a bruise to her left breast during a mechanical lift transfer on 1/8/14. Facility Incident Report for R5 dated 1/8/14 timed at 12:00 pm documents that R5 sustained a bruise to her left breast while being lifted in a sit-to stand mechanical lift. This section of the form entitled, "New Recommendations to minimize resident injury", states, "monitor placement of arms in relation to sling and breasts.". On 1/28/14 at 2:00 pm, E2 stated that she believed this occurred because staff had crossed R5's arms over her chest during the transfer. She stated that she believed R5 has fragile skin and is on blood-thinners, which could cause R5 to bruise easily. This incident report also indicates with a check mark that no further action is necessary. On 1/29/14 at 2:30 pm, E2 stated during interview that she reviewed the incident report, and got her information about the incident from the nurse who completed the report. E2 stated that she had not interviewed the staff involved and had not gotten any staff statements about this incident. E2 also denied ensuring that staff involved had received any additional training in transfers. E2 stated that usually, there are narrative nursing notes accompanying the incident report, but she stated she was unable to find any nursing notes about this bruising incident. E2 stated that she did not do any investigation other than getting the information from the nurse. She stated, "I could do better". Care plan for R5 with a handwritten date of 1/8/14 identifies risk factors for R5 as history of previous skin tears, dry, fragile skin, ecchymosis and poor nutrition/hydration. A goal for R5 is written by hand and states that R5 will have a decrease in bruising related to medication therapy and transfer techniques. A goal was handwritten in on 1/8/14 which states, D/C (discontinue) sit to stand transfers and change to other type of mechanical lift. The evaluation column across from this handwritten goal states, "cause of ecchymosis (bruising) sit to stand d/c r/t (related to) "too tight" in chest/rib region.". On 1/29/14 at 1:20 pm, E9 (CNA) stated that several weeks ago she assisted transferring R5 using a mechanical lift. E9 stated that at that time, she was told that R5 had a bruise under her left breast from a prior transfer using a sit-to-stand lift for transfer. That is not the type of lift being used when E9 assisted with the transfer. E9 denied any problems during R5's transfer. On 1/29/14 at 3:40 pm, Z3 (caregiver for R5) stated that several weeks ago, 2 CNAs (certified nursing assistants) that she had never seen before came in to take R5 down the hall to use another washroom, because at the time, due to the cold weather, R5 had no running water in her room. Z3 stated that it seemed that they had R5 out of the room for a long time, and upon their return, R5 was very quiet. When the 2 staff left the room, Z3 stated that R5 had tears in her eyes, and told her "they hurt me". Z3 stated that she was not present during the transfer in the washroom, but she stated she believed the staff may not have protected R5's skin by making sure the sling was placed over R5's clothes. Z3 felt this way because R5's shirt was not pulled down upon her return. Z3 stated she has worked as a CNA (not at facility) and is familiar with transfers and is aware that the sling is to be placed over the clothes. Z3 stated that she asked R5 where she was hurt, and R5 indicated her left upper arm and under her left breast. Z3 stated that she examined R5 then, and saw new bruising on R5's left ribs, in the area of R5's left rib/flank area. Z3 stated that she reported this to Z2 (Physical therapy aide) the next day. Also the next day, she examined R5 again and noted increased bruising which now covered the entire left breast, and R5 still had left arm pain. Z3 stated that she believes Z2 reported this to his supervisor. Z3 stated that no one ever questioned her about the injury other then Z3 and the nurse. Z3 stated that she is present in the facility with R5 generally 6 days a week. Z3 stated she told staff that she didn't want the two staff to care for R5 again, and she has not seen them since. She could not identify the staff in question. On 1/30/14 at 9:55 am, E43 (RN) stated that she generally works 6:00 am to 2:00 pm. She stated that earlier in the month, Z2 came to her and told her that R5 had bruising on her left breast. She stated that she went to check R5, and did find bruising. At that time, the caregiver told E43 that R5 had had pain during a transfer; Z3 told her that when they had lifted R5 in the lift, that she had pain, and they had let her back down. According to E43, R5 had bruising under her left breast, and the breast itself was bruised also. R5 complained of mild pain, but did not want pain medication. The color of the bruising was light purple when E43 saw it. She could not recall if she documented her assessment in nursing notes, but did recall completing an incident report. E43 stated she told E2 about this incident. E43 stated she faxed notification to R5's physician, and that Z3 was already on the phone reporting the issue to R5's family. On 1/29/14 at 3:55 pm, R5 stated that she recalled being in pain after a transfer, and she pointed to her left arm and under her left breast. She stated that it was several weeks ago, and she could not recall if she complained of pain during the transfer. Upon observation, no bruising remained. On 1/30/14 at 10:00 am, E20 (CNA) stated that she recalls transferring R5 with the sit to stand lift several weeks ago, on the day shift. E20 recalls she and E29 (CNA) transferred R5, and that they put the sling under R5's armpits, which is where it is to be placed. E20 recalled that R5 expressed pain during the time when she was being raised by the machine, E20 stated that she assumed that this was due to the sling, which has no padding on it. So, they lowered R5 back down and E20 placed a pillow under R5's arm. E20 states they lifted her again and R5 did not complain of pain. E20 states that she assumed that the sling was cutting into R5 because it has no padding on it. E20 stated that her next day to work was 5 days later, and R5 did have bruising under the left breast and going around to her back. E20 states that no one from the facility has questioned her in relation to any bruising on R5. E20 stated that she has had no recent training on transfers. According to E20, "I can't even say the last time I was really trained". On 1/30/14 at 9:45 am, E29 stated that she recalled assisting E20 with a sit to stand transfer for R5 several weeks ago. E29 did not recall any incident or any complaints made by R5. E29 stated she could not recall the last training on transfers that she received at the facility regarding the sit-to stand. She stated she recalled being trained on another type of mechanical lift last year. Nursing assessment note dated 1/14/14 timed at 12:29 am documents, "bruising oon chest". Nursing assessment note dated 1/21/14 at 1:07 am reflects "bruise to left chest (improving)". On 1/29/14 at 4:00 pm, Z2 stated that several weeks ago, Z3 told him that R5 had had a transfer by 2 staff using the sit to stand that lift which resulted in bruising under her left breast and around her rib area. Z2 stated that R5 had been assessed by therapy who recommended the sit to stand lift. After this bruisng incident, R5 was reassessed and a different type of mechanical lift was recommended. Z2 stated that he did not view this as an allegation of abuse, but viewed it as an improper transfer. Z2 stated he reported this to his boss, Z4. (Certified occupational Therapy Assistant).Z2 stated he had not been involved in any staff training regarding transfers, and was not asked to do any re-training of any CNA since this incident. At 4:05 pm on 1/29/14, Z4 stated that she reported this issue to E1 (Administrator) and E2 (Acting DON). Facility Plan of Correction with a completion date of 12/26/14 documents that all staff were inserviced on 12/9/13 on care of resiodents with fragile skin. This plan of correction also documents that all staff were inserviced on 12/9/13 on proper transfer techniques for residents with fragile skin. Nurse's sign in sheet provided by facility dated 12/9/13 indicates subject discussed was Proper transfer techniques for residents with fragile skin and proper care of residents with fragile skin, and resident care cards for individualized care. The Nurses's sign in sheet lists 7 nurses as having received this training, which is indicated by their signiature. This form contains blanks with no signature for 5 nurses, (E15-E19). This lack of signature indicates the staff did not receive the training. The CNA Inservice Sign in sheet, which also indicates discussion on proper transfer techniques for residents with fragile skin, proper care of resident with fragile skin, reading of resident care cards for individualized care, resident rights and abuse, and proper positioning at dining time. These forms contain staff names and a space for staff to sign indicating they received the training. These forms contain 24 blanks by staff names, with no signatures, indicating these staff (E9, E20-E41, E44) were not trained, despite the facility plan of correction which states that all staff were trained. E20 and E29, who were both involved in the above-referenced transfer of R5, did not receive this training.

Based on Observation, Record Review, and Interview, the facility failed to monitor worsening pressure ulcers, on a daily basis, and keep the physician updated of these changes, for one (R1) of four residents sampled for pressure ulcers. This failure resulted in R1 not receiving adequate treatment for [REDACTED]. This has the potential to affect all residents in this facility. Findings include: On 05/10/11 between 10: 00am and 10:30am E5, the treatment nurse was observed treating the wounds of three residents with pressure ulcers. E5 maintained a log that documented whether the wound was facility acquired or present prior to facility admission. This log tracked size, odor, drainage, and treatment. E5 stated that the treatment nurse measures and documents on a weekly basis. R1's Medical Record documented that R1 was a [AGE] year old resident with a history of multiple admissions; the last admission to the facility was 03/08/11. R1's Nursing Notes documented R1 as having [DIAGNOSES REDACTED]. The facility utilizes the Braden Scale for predicting pressure ulcer risk. On 03/08/11, R1 scored a 14 which is a moderate risk for pressure ulcers. R1's Care Plan, dated 3/9/11 for the Problem of Diabetes, documented that R1 was at risk for impaired skin integrity. Interventions included providing foot care, monitoring skin integrity, and reporting as observed. R1's Care Plan, dated 03/09/11, for the Problem Alteration in skin integrity included daily skin checks during care, to report abnormalities such as open areas, [MEDICAL CONDITION], discoloration, and to refer to the physician as necessary.` A treatment nurse assessed R1's skin on admitted 03/08/11. A blackened area was noted to the right pinky toe and a reddened area was noted to the left heel. The next note by the treatment nurse was dated 03/18/11. This note documented several blisters to the right foot without drainage. A deep tissue injury was noted to the left heel. There was no further documentation of the foot ulcers prior to discharge to a local hospital on [DATE]. The 3/8/11 physician orders [REDACTED]. ( blackened areas. ) The facility Treatment and Protocol/Considerations, reviewed 01/03/11 documents," Assess the wound with each treatment and document any significant changes." " Notify physician and responsible party of changes and document physician response to the notification..." Hospital Intensive Care Notes, dated 03/23/11, documented [MEDICAL CONDITION] to bilateral lower extremities and that Pressure Ulcers were blackened ... unapproximated. On 03/26/11, the notes documented there was foul odor from left heel...necrotic with brown drainage. On 05/11/11 at 02:00pm , E1, Certified Nursing Assistant, ( CNA ) stated," R1 was a big lady. R1 had poor circulation. R1 had antiembolism stockings that were to be taken off at night. I am not sure if she had pressure ulcers on her feet." On 05/11/11 at 10:15am, E9, Nurse stated, "I am not aware of pressure ulcers. I know R1 had fragile skin. Another nurse is the treatment nurse." On 05/11/11 at 01:30pm E2, the Director of Nursing, stated, "I have known R1 for a long time. She was a large lady and have never seen her when her legs have not been swollen. I do not know when the change in the foot ulcers occurred." On 05/12/11 at 11:10am, Z1, Physician, was interviewed. He stated, " I know R1 very well. R1 was admitted to the hospital in February, 2011. She had pressure ulcers in the creases from adult incontinence briefs. They healed while in the hospital. R1's last admission to the facility was on 03/08/11. On 03/23/11 R1 was admitted to the hospital with [REDACTED]. The foot ulcers occurred within two weeks after readmission to the facility on [DATE]. I was not apprised of the rapid deterioration of the foot ulcers. Ulcer treatment would have changed."

Based on observation, interviews and record review the facility failed to ensure one resident (R1) was transferred from bed to wheelchair without injury. This is for 1of 5 residents (R1) in the sample. This failure resulted in R1 sustaining a 5 cm. skin tear requiring 11 sutures at the hospital. The examples include: On 1/20/11 at approximately 10:30am, surveyor walked into R1's room and observed several staff members in her room, R1 sitting in her wheelchair crying and blood all over the floor. The wound nurse was attempting to apply a large pressure dressing to R1's left lower leg. E2 (DON) explained to surveyor that E5 (CNA) and E6 (CNA) had transferred R1 from bed to her wheelchair. R1 sustained a laceration to her lower left leg when E6 was applying the leg rest to the wheelchair. E2 said R1 was going to the hospital for sutures. R1 was crying and saying that it hurts really bad. Interview with E6 on 1/20/11 at 11:00am, E6 said she was bringing R1's leg rest around to put it in place on the wheelchair when she heard R1 yell, "Ow!" . E6 said she then saw blood and there was a vertical cut on R1's leg along her calf. Review of the 24 hour incident investigation report documents: On January 20, 2011 at 10:20am in resident's room, R1 received a laceration to her left lateral calf from her wheelchair foot rest. R1 sustained a 5 cm skin tear requiring 11 sutures at the hospital. R1 returned to the facility at 2:00 pm on 1/20/11.