Every finding on record at Arcadia Care on the Hill

Based on observation, interview, and record review, the facility failed to identify and treat a stage three pressure ulcer for one (R28) of three residents reviewed for wound care in a sample list of 121Findings include:R28's Face Sheet documents R28 has the diagnoses of Metabolic Encephalopathy, Major Depressive Disorder, Acute Kidney Failure, Severe Morbid Obesity, and Diabetes Mellitus Type two.R28's Braden Scale dated 4/30/26 documents a risk score of 13, indicating R28 is at moderate risk of skin breakdown.R28's Minimum Data Set (MDS) dated [DATE] documents R28 is alert and oriented and is dependent on staff for Activities of Daily Living, including turning and positioning. This MDS documents R28 had no pressure ulcers but was at risk for developing pressure ulcers.R28's Care Plan dated 11/12/25 documents, I am at risk for a skin impairment related to diabetes, diuretics, impaired mobility and incontinence. I was admitted with multiple wounds. The goal for this care plan documents, I will maintain or develop clean and intact skin by the review date of 9/27/26. Interventions for this care plan include assess/record changes in skin status, monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. to the Medical Doctor (MD). R28's Care Plan does not address the stage three pressure ulcer on R28's coccyx.R28's Order Summary Report dated 7/15/26 documents the following order dated 6/30/26: Treatment: Cleanse open area to coccyx with normal saline, pat dry, apply collagen particles to area and secure with bordered foam. Notify MD/Nurse Practitioner (NP) for signs and symptoms of infection one time a day and as needed. The orders include the order dated 1/30/26: Barrier cream to groin each shift, after incontinence episode and as needed.On 7/15/26 at 9:03 AM, R28 was lying on R28's back. V54 Certified Nursing Assistant (CNA) turned R28 over onto R28's side. R28 had a large open wound on R28's coccyx with a moist wound bed and a brownish/black area in the middle covering about 50% of the wound bed. There was no dressing on the wound.On 7/15/26 at 9:05 AM, V54 CNA stated the open wound to R28's coccyx is always left open without a dressing. V54 stated V54 is usually asked to apply barrier ointment to the area.On 7/15/26 at 3:39 PM, R28 was lying on R28's back. V61 CNA rolled R28 onto R28's side in bed. There was still no dressing on R28's coccyx wound.On 7/16/26 at 10:32 AM, V52 Wound Care Licensed Practical Nurse (LPN) rolled R28 onto R28's side and peeled back a dressing covering a wound to R28's right lower back. V52 stated V52 would not describe this wound to R28's right lower back as the coccyx. There was no dressing or ointment on R28's actual coccyx wound. V52 stated V52 was not aware of R28's wound to coccyx. V52 stated V52 would describe R28's coccyx wound as a pressure ulcer. V52 described R28's coccyx wound as having skin stripping and dark tissue. V52 stated V52 would not want a barrier ointment on this type of wound and stated this type of wound would require an actual dressing. V52 stated there was no order to treat the pressure ulcer on R28's coccyx.On 7/16/26 at 1:14 PM, V54 CNA stated V54 was asked by V52 Wound Care LPN around two and a half weeks ago to begin applying ointment to the area on R28's coccyx. V54 stated R28's coccyx wound began as an unopened reddened area. V54 stated two days ago V54 asked a nurse to reassess the coccyx wound because it had changed. V54 stated V54 is unsure whether anyone has reassessed the wound.On 7/16/26 at 3:14 PM, V52 Wound Care LPN and V19 Regional Nurse Consultant clarified that the wound referred to in R28's physician orders dated 6/30/26 and R28's Care Plan dated 11/12/25 was the wound on R28's right lower back and not R28's coccyx. V52 stated this wound location was documented incorrectly. V52 stated the treatment order dated 6/30/26 was to treat the right lower back wound, not the coccyx. V52 stated V52 does not remember looking at R28's coccyx two and a half weeks ago, does not remember instructing any CNA staff to apply ointment to the area.On 7/16/26 at 11:41 AM, V65 Wound Care NP assessed the wounds to R28's coccyx and right lower back. V65 measured the coccyx wound. V65 stated the measurements for the coccyx wound are 3.8 centimeters (cm) length by 3 cm width by 0.1 cm depth. V65 stated V65 would classify the current coccyx wound as a stage three pressure ulcer. V65 stated V65 was seeing R28 for management of this coccyx wound around a month ago but had stopped seeing R28 because the coccyx wound had healed. V65 stated usually with turning, repositioning, and preventative cares, it would take months for a person to develop a stage three pressure ulcer.R28's Wound Physician Progress Note by V65, dated 5/6/26, documents a pressure ulcer to R28's coccyx was acquired on 3/4/26 and was resolved on 5/6/26. The progress note documented the follow up order to continue to monitor for any further wounds. There were no additional visits by V65 to R28 for wound assessment or treatment.On 7/16/26 at 1:21 PM, V68 LPN stated V68 was R28's nurse today and was aware of the wound to R28's right lower back. V68 stated R28 has had this wound to right lower back for a long time. V68 stated V68 not aware that R28 had a new wound to the coccyx.On 7/16/26 at 2:34 PM, V65 Wound Care NP stated R28's coccyx wound would have been at risk of progressing and worsening if it had not been identified and treated.The facility's Skin Condition Assessment and Monitoring- Pressure and Non-Pressure policy last revised in December 2025 documents the purpose of the policy is to establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented.

Based on observation, interview and record review, the facility failed to safely transfer a resident, investigate a fall to determine root cause, and failed to initiate progressive interventions to prevent further falls for 3 of 3 residents (R2, R5 and R6) reviewed for falls in the sample list of 121. This failure resulted in R2 suffering significant pain during multiple transfers. Findings include: 1. On [DATE] at 1:44 PM, R2 was observed alert and seated upright in a wheelchair with a mechanical lift sling positioned underneath the resident. V39 and V53, Certified Nursing Assistants (CNAs), entered the room and manually transferred R2 from the wheelchair to the bed by placing their bent elbows under R2's arm pits and grasping the waistband of R2's pants to lift the resident onto the bed. R2 did not bear weight on their feet and was completely lifted by V39 and V53. V39 and V53 did not use the mechanical lift, despite the lift sling remaining underneath the resident, and did not utilize a gait belt during the transfer. R2 moaned and grimaced in pain during the transfer. Following completion of the transfer, V39 and V53 apologized to R2 for the pain during the transfer. On [DATE] at 9:05 AM, R2 stated it hurt R2's arm and shoulder when staff transferred R2. R2 stated that more than half the time staff did not use the lift thing and instead transferred R2 with one or two staff members depending on who was available. R2 stated R2 had a previous injury to their right rotator cuff, and that R2 had told staff the transfers hurt R2's rotator cuff, but staff did not listen. On [DATE] at 11:40 AM, V64, Physical Therapy Assistant (PTA), stated R2's functional status fluctuated due to dialysis treatments. V64 stated the preferred transfer method for R2 was a mechanical lift because manual transfers could increase pain and further injure the resident's rotator cuff. V64 further stated that if a manual transfer became necessary, staff should use a gait belt. On [DATE] at 2:33 PM, V39 stated the facility's mechanical lifts were frequently broken or had uncharged batteries, requiring staff to search other units for a functioning lift. On [DATE] at 2:45 PM, V14 Certified Nursing Assistant (CNA) stated the facility had only one functioning mechanical lift. On [DATE] at 9:26 AM, V39 stated that when the mechanical lift was unavailable, staff either delayed resident care or completed manual two-person transfers. Per V39, the staff must either transfer the residents with a two-person transfer or they will have to wait until a mechanical lift is available. On [DATE] at 1:30 PM, R2 stated they had been transferred that morning by one big man and pointed to both shoulders while stating the transfer was painful. On [DATE] at 1:34 PM, V14, CNA, stated the mechanical lift was unavailable this morning when they transferred R2 from her bed to her wheelchair due to the remaining lifts being broken. V14 stated he transferred R2 by themselves. R2's Face Sheet dated [DATE] documents their diagnoses to include End Stage Renal Disease, Weakness, and Right Rotator Cuff Tear. R2's Care Plan documents the focus: R2 is at risk of falls dated [DATE]. R2's Physician Order dated [DATE] documents: Skilled Physical Therapy services including therapeutic exercise, therapeutic activities, gait training, wheelchair management, and mobility interventions. The facility's policy, Transfers – Manual, Gait Belt and Mechanical Lifts, last revised [DATE], states: Mechanical lifting devices shall be used for any resident needing a two person assist, or who cannot be transferred comfortably and/or safely by normal transfer technique. Except during emergency situations or unavoidable circumstances, manual lifting is not permitted . Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. 2. R6's Progress Note dated [DATE] at 10:56 AM, documented by V2, Director of Nursing (DON) documents R6 fell on [DATE] and was found on the floor in their room. The progress note documents R6 had a skin injury to the left side of their head and left elbow. Per the note, R6 was transferred to the emergency room (ER) for further evaluation. No other charting was found regarding the incident. R6's hospital records printed [DATE] documents R6 was admitted to the hospital on [DATE] with the admitting diagnosis of Exacerbation of Chronic Obstructive Pulmonary Disease (COPD). The hospital records included a history and physical dated [DATE] which documented R6 had initially presented to the ER for evaluation of a fall but was admitted due to COPD exacerbation. While evaluated in the ER, R6 had a head computed tomography (CT) which resulted in a superficial scalp contusion on the left without underlying acute displaced calvarial fracture. R6's Minimum Data Set (MDS) dated [DATE] documents R6 was alert and oriented to person, place and time and required staff assistance for transfers and toileting. R6's Care Plan dated [DATE] documents the focus: I am at risk of falls related to gait/balance problems, incontinence, and psychoactive medication. The interventions document R6 was dependent on staff for toileting and required partial to moderate assistance for transfers. On [DATE] at 10:20 AM, V2 stated that a fall investigation was not completed on R6, and the incident was not reported to Illinois Department of Public Health (IDPH) because R6 never returned to the facility. On [DATE] at 12:15 PM V10, Registered Nurse (RN) stated they were told in report that R6 was at the hospital due to tripping over their oxygen tubing. V10 states that R6 fell on the evening shift. On [DATE] at 12:34 PM V24, Certified Nursing Assistant (CNA) stated they were working the hall during the time of R6's fall. V24 stated R6 was prescribed stool softeners and attempted to go to the bathroom, and they tripped over their oxygen tubing and fell. On [DATE] at 9:24 AM V44, CNA, stated R6 was stubborn about calling out for assistance even after being educated many times. V44 stated R6 was trying to transfer themself to the bathroom when they became tangled in their oxygen tubing and tripped. V44 stated they were across the hall when R6 fell, and they ran right in because they heard R6 yell. A death certificate documents that R6 died from COPD and natural causes on [DATE]. 3. R5's progress note dated [DATE] at 2:35 PM documented: Resident was witnessed by another resident that (R5) just fell face first out of chair as if they lost consciousness. Resident was on the ground not saying anything with a big knot on the front of their head. Patient was assessed and vitals were out of range 46/44, respirations 12, pulse 36, O2 85, resident was sent out to (local hospital). R5's progress note dated [DATE] at 10:12 AM documents they returned from the hospital with no new orders and no report of an injury. R5's hospital report dated [DATE] at 12:39 PM documents, CT scan showed large stool burden, prescription for (enema) and MiraLAX sent to patient's pharmacy. Patient was given 1 dose of antibiotics in the emergency department for suspected UTI (Urinary Tract Infection). If urine cultures are positive antibiotics will be sent to patient's pharmacy. Use over the counter medications for headache associated with the fall. Patient will likely be sore over the next few days. Feel free to return to the emergency department if symptoms worsen or any new medical concerns arise. R5's Care Plan, updated [DATE], documents R5 is at risk for falls related to gait/balance problems and incontinence. This care plan does not document a progressive intervention after their fall on [DATE]. On [DATE] at 12:45 PM, V2 stated that there should always be a post-fall intervention placed after each fall occurrence and a fall investigation to find the root cause. A policy named Fall Prevention Program revised on 05/2022 states, .Interventions are changed with each fall, as appropriate.preventative measures. Accident/Incident Reports involving falls will be reviewed by the Interdisciplinary Team to ensure appropriate care and services were provided and determine possible safety interventions. The Director of Nursing or Designee is responsible for monitoring the Fall Prevention Program, including further staff education programs, purchase of additional equipment, or other appropriate environmental alterations. In addition, Director of Nursing is responsible for informing the Administrator of program analysis. A policy named Incident and Accidents-Illinois last revised 5/2022 states The Incident/Accident Report is completed for all unexplained bruises or abrasions, all accidents or incidents where there is injury or the potential to result in injury, allegations or theft and abuse registered by residents, visitors or other, and resident-to-resident altercations. An incident/accident report is to be completed by an RN or LPN, and is to include: A. Date and time of an incident/accident B. Full written statement and possible cause of incident, physical assessment, injuries noted, vital signs, treatment rendered, and notification of appropriate parties.3. The Director of Nursing, Assistant Director of Nursing, or Nursing Supervisor must notify the following if an actual injury occurs: A narrative summary of the incident is to be sent to the Illinois Department of Public Health within five working days.All incident/accident reports are reviewed, signed, and investigated by: The Administrator; and The Director of Nursing or the Assistant Director of Nursing; and The Medical Director (monthly signature on report list). A policy named Transfers-Manual Gait Belt and Mechanical Lifts last revised 8/2023 states 1. Mechanical lifting devices shall be used for any resident needing a two person assist, or who cannot be transferred comfortably and/or safely by normal transfer technique. Except during emergency situations or unavoidable circumstances, manual lifting is not permitted. 3. Mechanical lifts shall be made readily available and accessible to staff 24 hours a day.

Based on interview and record review, the facility failed to provide the services of a Registered Nurse eight consecutive hours per day/seven days per week. This failure has the potential to affect all 121 residents in the sample list of 121 in the facility.Findings include:On 7/21/26 at 12:33 PM, V87 Human Resource Director, provided timecard report for V101 Registered Nurse (RN) and stated, this is the only RN on for 7/4/26 and 7/5/26. V101's timecard report for 7/4/26 shows V101 clocked in at 10:50am and clocked out at 12:59pm for a total of two hours and nine minutes. V101's timecard for 7/5/26 shows V101 clocked in at 10:00 am and clocked out at 11:45am for a total of one hour and forty-five minutes.On 7/21/26 at 12:56 PM, V19 Regional Nurse Consultant stated, I'm going with 100%, no we did not have agency RNs on that weekend (7/4/26 and 7/5/26). We didn't use agency nurse staffing then. We are now due to the staffing stuff but not then.On 7/22/26 at 1:45pm, V19 stated the facility does not have a staffing policy and that they follow state regulations for staffing.On 7/24/26 at 2:42 PM, V16 stated, I just confirmed with V19 that there was no Regional Nurse Consultant here. It was a holiday weekend and they're not going to be here unless it is an emergency situation.The facility's daily census sheet dated 7/13/26 documents that there were 121 residents residing in the facility at that time.

Based on observation, interview and record review the facility failed to provide a clean, sanitary, and homelike environment for the residents. This failure has the potential to affect all 121 residents in a sample of 121 residing in the facility.Findings include:The facility's Daily Census Report dated 7/13/26 documents there are 121 residents residing in the facility.On 7/13/26 at 4:15 AM, a tour of the facility was conducted, and the following was observed:The parking lot of the facility was littered with disposable foam food and drink containers, empty cigarette packs, rubber gloves, and cigarette butts. A blue dumpster was open and had a large accumulation of pieces of disposable foam food and drink containers, paper trash and broken chairs and mattresses outside the container. Upon entering the facility, there was a strong musty odor and the front desk reception area had paper trash scattered on the floor in front of it. The activity area had sweetener packets, a large area of white powdery substance and other food crumb debris beneath the table on the floor and on the windowsills. The 200 hall floors had a sticky surface that made an audible ripping sound with each footstep. There was dark built-up grime along the baseboards and floor. There were brown colored drippings and stains on the bottom half of the walls. There were paper trash, plastic food wrappers and glucose testing strips scattered throughout the hallway on the floor. A dirty incontinence brief and hospital gown could be seen through an open doorway on R45's floor. The facility's elevator floors had built up black grime and food crumb debris in the corners and along the edges, and dried spill streaks on the walls. The third-floor hallway was sticky, and an audible ripping sound could be heard with footsteps. There was a ring shaped brown spill that had dried in the middle of the walkway. Black build-up of grime continues throughout the hallway along the baseboards and the floor. The floor was littered with pieces of paper trash and food crumb debris scattered. On 7/13/2026 at 7:15 AM, R3's room was observed to have a sticky floor with an audible ripping sound with each footstep, paper trash and food debris on the floor. There was opened and half eaten food items in R3's bed with a brown smear on bottom sheet.On 7/13/2026 at 7:33 AM, R33's bed had a large white stain on vinyl cover of mattress, stacked personal items and food items in the corners, sticky floors that had an audible ripping sound with each footstep, trash and food debris scattered on the floor. A strong, musty, body odor smell was noted in room.On 7/13/2026 at 7:33 AM, R34's bed had a puddle of unknown liquid underneath, personal items and open aluminum cans on bedside table. The floor next to R34's bed was sticky and had an audible ripping sound with each footstep.On 7/13/2026 at 7:44 AM, R35's room had a sticky floor with an audible ripping sound with each footstep.On 7/13/2026 at 7:45 AM, R36's floor in front of their bed was sticky with an audible ripping sound with each footstep.On 7/13/26 at 9:00 AM, a tour of the basement was conducted, and the following was observed: a pile of trash in the hallway, multiple empty rooms with trash piles that contained clothes, shoes, empty cardboard boxes and trash. There was a puddle of standing water at end of hallway that was the length and width of the hallway. The outside exit door was propped opened by a black object. There were swarms of flies, dripping water from the overhead pipes and trash and empty boxes sitting in the water. Several walls were missing drywall leaving wooden studs and metal pipes visible.On 7/14/26 at 2:05 PM, V29 Floor Technician was using a scrubber on the floors in front of the elevators on the third floor. The small puddles of bubbly liquid on the floor were dark greyish/brown in color. V29 stated the color is from the mildew inside of the floor scrubbing machine. V29 opened up the top of the floor scrubber and the water inside was black in color.On 7/15/2026 at 9:10 AM, R17's room had open soda cans on floor and cardboard boxes on floor in the closet.On 7/15/2026 at 9:20 AM, Discolored residue was visible on the floor's surface causing shoes to adhere to the floor and a loud audible ripping sound occurred with each step. On 7/15/2026 at 9:45 AM a tour of the dry food pantry on the 400 hall was conducted with V84, Dietary Manager. There were two open food containers observed on bottom shelf, there were orange fish shaped cheese flavored crackers and crumbs on the floor next to the food storage shelves.On 7/16/2026 at 8:58 AM, a tour of the kitchen was conducted, and there were plastic disposable drinking cups, resident dishware, paper trash and food crumbs and dirt debris underneath the ice machine and work station. There was a wire shelf rack storing baking pans and a pot lid that had food crumbs and dust debris on top. There was an open plastic bread bag on a shelf that had a hole where it appeared the plastic melted open. The bread in the bag had different colors of green and white fuzz on the surface. There was a buildup of dust and food debris on the worktable shelves along the edges and on the spice and seasonings shelf.On 7/16/2026 at 1:34 PM, The area under the covered pavilion outside the facility had scattered plastic bags, cigarette butts, cat food, and disposable foam food containers. A strong musty odor of wet cigarette smell noted.On 7/13/2026 at 5:13 AM, V76 floor technician, stated floor techs are responsible for cleaning the floors, and emptying trash out of rooms. V76 stated, The floors are to be cleaned every day if needed, but I will check to see if the floors are really bad. V76 stated he doesn't have enough cleaning supplies for the building. V76 stated the last time V76 cleaned the floors was Thursday July 9th.On 7/13/2026 at 5:36 AM, V76 floor technician stated the facility orders supplies once a month and the supplies don't last the full month, V76 stated the facility has run out of supplies and V76 has had to tell the residents that housekeeping can't provide paper towels and trash bags for their rooms due to no supply.On 7/13/26 at 7:26 AM, V41 CNA stated the facility could be cleaner and housekeeping could do more cleaning.On 7/13/26 at 7:40 AM, V85 housekeeper stated they clean the floors every day and the facility has run out of cleaning supplies. On 7/14/2026 at 2:05 PM, V29 Floor tech, stated the color is from the mildew inside of the floor scrubbing machine. On 7/14/2026 at 4:10 PM, V63 R33's sister, stated R33's room is filthy, the mattress is stained and sunk in the middle, there was pee on the floor, the floor hadn't been mopped. V63 stated, I have to clean her room every time I come. R33 has had breakfast tray left in bedroom till 4:00 pm.On 7/14/2026 at 4:15 pm, V35 Housekeeping Supervisor stated there is a deep cleaning schedule and some housekeeping staff do it and some don't. V35 stated they are aware of one housekeeper working today who doesn't do it.On 7/15/2026 at 9:28 AM, V38 housekeeper stated the facility has run out of supplies and has gone and bought their own supplies to clean the building, V38 did report no supplies to the housekeeping supervisor but it is still a problem.On 7/15/2026 at 9:45 AM, V84 Dietary Manager stated the facility is filthy.On 7/16/2026 at 10:35 AM, V72 Regional Dietary Manager stated the kitchen cleanliness was decent.On 7/21/2026 at 11:57 AM, V35 confirmed housekeeping staff do not document that a room is deep clean, the staff write out their daily duties and scratch off the rooms after cleaning is completed or they send pictures of the room clean.On 7/21/2026 at 3:40 PM, V94 R60's sister stated they bring cleaning supplies to clean R60's room during visits because the room is not adequately cleaned. V94 stated they have used a utility putty knife to scrape residue from the floor and reported the bathrooms are dirty and that they have brought ant traps into the room due to ants. V94 stated they placed a message board above R60's bed requesting housekeeping clean the floors, but the floors were not cleaned. V94 stated they have reported these concerns to nursing staff and administration on multiple occasions.On 7/21/2026 at 10:00 AM, A day shift daily cleaning schedule documents that on 7/5,7/8,7/9 and 7/11 the following tasks were not performed: wash and sanitize can opener, food processor, slicer, mixer, cutting boards, prep tables/countertops, beverage table, coffee urns, pots and pans, clean stovetop/grill, sweep and mop kitchen floor cook area, sweep and mop dish area, clean microwave oven, clean handwashing sink, clean food carts, clean and sanitize pot and pan sink. On 7/21/2026 at 10:10 AM, A day shift daily cleaning schedule documents that on 7/6,7/7 and 7/10 the following tasks were not performed: wash and sanitize mixer, prep tables/countertops, beverage table, coffee urns, pots and pans, sweep and mop dish area, clean microwave oven, clean handwashing sink, clean food carts, clean and sanitize pot and pan sink. On 7/21/2026 at 10:15 AM, A dietary night shift daily cleaning schedule documents that on 7/5,7/6,7/9 and 7/10 the following tasks were not performed: wash and sanitize prep tables/countertops, beverage table, coffee urns, pots and pans, sweep and mop dish area, clean microwave oven, clean handwashing sink, clean food carts, clean and sanitize pot and pan sink. On 7/21/2026 at 10:20 AM, The dietary night shift daily cleaning schedule documents that on 7/7 and 7/8 the following tasks were not performed: wash and sanitize can opener, food processor, slicer, cutting boards, prep tables/countertops, beverage table, coffee urns, pots and pans, clean stovetop/grill, sweep and mop kitchen floor, sweep and mop dish area, clean microwave oven, clean handwashing sink, clean food carts, clean and sanitize pot and pan sink. On 7/21/2026 at 10:25 AM, The dietary night shift daily cleaning schedule documents that on 7/11 the following were not performed: wash and sanitize can opener, food processor, slicer, mixer, cutting boards, clean stovetop/grill, and sweep and mop kitchen floor.On 7/21/2026 at 10:52 AM, A monthly cleaning schedule documents that for the months of January, February, March, April, May and June a solid line is marked through the following tasks: clean refrigerators, clean freezers, clean and sanitize ingredient bins, drain, clean and sanitize ice machine, clean walls/backsplash, clean windows (as needed) and clean ceilings (annually or as needed) garbage cans (all). On 7/21/2026 at 10:52 AM, A monthly cleaning schedule documents that for the month of July the following tasks have not been performed: clean refrigerators, clean freezers, clean and sanitize ingredient bins, drain, clean and sanitize ice machine, clean walls/backsplash, clean windows (as needed) and clean ceilings (annually or as needed) Garbage cans (all). On 7/21/2026 at 10:58 AM, A housekeeper schedule documents a housekeeper was assigned to clean the kitchen on 7/1 and 7/16.On 7/21/2026 at 11:02 AM, a deep cleaning request form documents a deep clean of the kitchen was performed by outside agency on 5/21/2026. Deep clean included: dish room area floors and walls, walls throughout main kitchen and service line, oven inside and outside, stove, backsplash and flat top grill, floor throughout main kitchen, floors where the walk in coolers are located and paper product hall, inside and outside walking coolers (two) inside and outside coolers in main kitchen (three). On 7/21/2026 at 11:58 AM, a housekeeping deep clean schedule of the facility was reviewed with V35 who confirmed housekeeping staff do not document that a room is deep clean, the staff write out their daily duties and scratch off the rooms after cleaning is completed or they send pictures of the room clean.On 7/21/2026 at 12:31 PM, a housekeeper job description was reviewed that documents the essential duties and responsibilities: Ensure that work/cleaning schedules are followed closely as practical. Clean, wash, sanitize and/or polish fixtures, ledges, room heating/cooling units, bathroom fixtures etc. Clean floors including sweeping, dusting, damp/wet mopping, stripping, waxing, buffing, disinfecting etc. Discard waste/trash into proper containers and reline trash receptacle with plastic liner.On 7/21/2026 at 12:39 PM, A policy titled General Sanitation Practices documents the kitchen will be maintained in a clean and sanitary condition. 7. All utensils, pots, pans, etc. will be properly washed, rinsed and sanitized after each use.On 7/21/2026 at 1:02 PM, a policy titled Sanitation of Dining and Food Service Areas documents 5. A cleaning schedule will be posted for all cleaning tasks.

Based on observation, interview and record review the facility failed to implement pest control precautions to prevent pest infestation in the facility. This failure has the potential to affect all 121 residents residing in the facility.Findings includeOn 7/13/26 at 4:15 AM, The facility's Daily Census Report dated 7/13/26 documents there are 121 residents residing in the facility.On 7/13/26 at 4:15 AM, a tour of the facility was conducted, and the following was observed: The parking lot of the facility was littered with disposable foam food and drink containers, empty cigarette packs, rubber gloves, and cigarette butts. A blue dumpster was open and had a large accumulation of pieces of disposable foam food and drink containers, paper trash and broken chairs and mattresses outside the container. Upon entering the facility, there was a strong musty odor and the front desk reception area had paper trash scattered on the floor in front of it. The activity area had sweetener packets, a large area of white powdery substance and other food crumb debris beneath the table on the floor and on the windowsills. The 200 hall floors had a sticky surface that made an audible ripping sound with each footstep. There was dark built-up grime along the baseboards and floor. There were brown colored drippings and stains on the bottom half of the walls. There were paper trash, plastic food wrappers and glucose testing strips scattered throughout the hallway on the floor. A dirty incontinence brief and hospital gown could be seen through an open doorway on R45's floor. There was a black multilegged insect in the two hundred hall nurse's station bathroom. The facility's elevator floors had built up black grime and food crumb debris in the corners and along the edges, and dried spill streaks on the walls. The third-floor hallway was sticky, and an audible ripping sound could be heard with footsteps. There was a ring shaped brown spill that had dried in the middle of the walkway. Black build-up of grime continues throughout the hallway along the baseboards and the floor. The floor was littered with pieces of paper trash and food crumb debris scattered. On 7/13/2026 at 7:33 AM, R34's room was observed to have stacked personal items and open soda cans on bedside table and small flying insects were noted above R34's bed.On 7/13/2026 at 7:44 AM, R35's room had a sticky floor with an audible ripping sound with each footstep. Underneath R35's bed was a line of mouse droppings along the baseboard.On 7/13/2026 at 7:45 AM, R36's had mouse droppings under the bed and along the base boards and underneath the bedside table dresser. In the corner next to the heating and cooling unit bits of torn up paper observed piled in the corner.On 7/13/26 at 9:00 AM, a tour of the basement was conducted, and the following was observed a pile of trash in the hallway, multiple empty rooms with trash piles that contained clothes, shoes, empty cardboard boxes and trash. There was a puddle of standing water at end of hallway that was the length and width of the hallway. The outside exit door was propped opened by a black object. There were swarms of flies, dripping water from the overhead pipes and trash and empty boxes sitting in the water. Several walls were missing drywall leaving visible wooden studs and metal pipes visible. A large puddle of standing water had collected and was the width of the hallway roughly 8 feet in width and 10 feet in length.7/15/2026 at 9:20 AM, R37's room was observed to have a cardboard box on floor in closet, crackers in the original box on bedside dresser, a clean container with a lid with a line of mouse droppings.7/15/2026 at 9:45 AM, A tour of the dry food storage on the fourth floor was conducted with V84 Dietary Manager and the following was observed: two open food containers noted on bottom shelf, fish shaped cheese crackers on the floor next to the storage shelves, mouse droppings on a white wooden shelf attached to wall with dried yellow spot beneath the mouse droppings.7/15/2026 at 12:43 PM, R83's TV had mouse droppings behind it on the dresser.7/16/2026 at 8:30 AM, A blue dumpster with attached black lid was left open.7/16/2026 at 8:58 AM, A kitchen walkthrough was conducted with V84 and the following was observed: 1 dead bug in kitchen doorway, 1 cardboard box dated 12/27 with live insect with long antennae and brown shiny almond shaped exoskeleton and spiny legs noted on the bottom shelf of the worktable.7/16/2026 at 10:35 AM, Pest control service call was observed with V73 Pest Control technician, the following was observed: spraying for roaches along the parameter of the kitchen, checking and rebaiting metal pest control boxes. V73 opened a metal pest control box, and a combination of live and dead roaches were stuck to the glue trap and moving freely within the box. V73 opened a metal pest control box and two dead mice observed stuck to glue trap. V73 uncovered two soup wells on the work table, and one live roach was observed on the rim of the well. V73 opened a metal pest control box, and dead roaches were observed stuck to the glue trap. V73 opened a metal pest control box and eight to ten dead mice in different stages of decay were observed stuck to the glue trap and within the trap. The fourth-floor dry food storage room was treated for pest and the following was observed: the fish shaped cheese flavored crackers remain on the floor and the open food storage containers remain open.V74 Sentinel Pest Control technician opened one of the two metal pest control box in the dry food storage area, and two dead mice were observed stuck to the glue traps inside.On 7/16/2026 at 1:34 PM, a tour of the covered outdoor pavilion area was conducted, and the following was observed: a cardboard box with a pet pillow cushion and a towel draped across the top of the box. There was one bowl of clean water and one bowl full of cat food, with cat food overflowing onto the pavement. One facility door was propped open with grey trash can.On 7/17/2026 at 8:45 AM, A blue dumpster with attached black lid was left open.On 7/13/2026 at 7:15AM, R3 stated they have seen a mouse in their room, R3 stated mouse comes to visit occasionally at least once a week.On 7/13/2026 at 7:20 AM, R31 stated they have seen mice in the facilityOn 7/13/2026 at 7:33 AM, R33 saw a mouse on the windowsill one day ago, R33 told the nurse. R33 is very scared of mice and when R33 saw the mouse she did not feel good.On 7/13/2026 at 7:40 AM, V85 housekeeper saw a mouse last week.On 7/13/2026 at 7:50 AM, V60 Minimum Data Set Nurse, stated she has seen reports of mice, knows pest control came out last week.On 7/13/2026 at 8:10 AM, R110 saw a mouse but it's been awhile.On 7/14/2026 at 4:10 PM, V63 R3's sister stated there are mice in R33's room.On 7/14/2026 at 4:15 Pm V35 housekeeping supervisor pointed out the swarm of flies above R34's bed while V35 was recleaning R34's room. On 7/14/2026 at 4:30 PM V2 Director of Nursing stated they were aware of the mouse problem in the past but hasn't gotten any reports recently.On 7/15/2026 at 9:10 AM, R17 stated, The mice come and go, they disappear for a while. I don't know when they are supposed to clean my room. A mouse ran across my foot, a little baby one.On 7/15/2026 at 9:12 AM, R41stated I always have mice in my room.On 7/15/2026 at 9:12 AM, R42 stated they have seen mice in their room.On 7/15/2026 at 9:20 AM, R37 stated they have mice in their room, R37 is afraid of mice.R37 stated. There was one mouse on my bedside table next to my bed.On 7/15/2026 at 9:28 AM, V38 housekeeper stated they have seen mouse droppings but never saw a live mouse.On 7/15/2026 at 9:45 AM, V84 Dietary Manager stated the facility is filthy, on my first day my focus was the roach infestation, the facility knows about the pest problem, pest control comes weekly.On 7/15/2026 at 12:42 PM, V53 Maintenance Director stated pest control doesn't meet with maintenance department after treatment but does provide recommendations such as keeping resident's food in their rooms in containers and stop feeding the outside stray cats. The dumpster lid should be kept closed and the door to the basement should not be left propped open. There should be no standing water in the basement because it would attract roaches. Pest control was out last week-they have been hitting the kitchen real hard; the facility has been fighting the mice for a while. V53 was not aware of any mice in the kitchen but saw a mouse in the facility. V53 will check the traps but no residents have reported mice to him. V53 stated he checks the traps regularly.On 7/15/2026 at 2:59 PM, V73 Pest Control technician stated the facility had a long standing contract with the facility's previous owners but on 7/15 the contract was updated to reflect the agreement with the new ownership. The agency provides dual service, both interior and exterior pest control. Last time treated the facility was on 7/8/2026 sprayed first floor and second floor for roaches. V53 will get into contact with this agency as needed. V73 confirmed the agency does offer advice to the facility such as keeping snacks and other food items stored in containers, keeping trash off the floor and in bags and containers. V73 confirmed that nesting material would look like bits of shredded paper and indicates they are creating a nest nearby. That would be a clue to lay down more glue traps in that area because mice are creatures of habit. On 7/15/2026 at 4:02 PM, V71 Assistant Dietary Manager stated there was a dead mouse on the glue trap by the dishwasher last night, but the mouse and glue trap wasn't there at the beginning of her shift this morning.On 7/16/2026 at 10:35 AM, V73 stated he communicates with staff as they are his eyes and ears. V84 wasn't aware of the mouse found in kitchen day prior, V71 did not report the mouse to maintenance and V99 Dietary aide saw the dead mouse on the glue trap but did not report it. V73 confirmed the dead bug in kitchen doorway was a roach. V73 had not gotten any communication from facility regarding mouse sightings. V73 stated he was aware of the mice due to state surveyor questioning during phone conversation on 7/15/26. V73 stated it is a constant battle and an ongoing issue that requires team effort with the facility. V73 confirmed that the food debris on pot lid and shelf surfaces would attract pests. V72 Regional Dietary Manager stated the kitchen cleanliness was decent. V74 stated there was lots of mice activity outside based on how much of the bait cube is chewed up. V74 reported that V34 had told him that there were reports of hearing mice in the exterior walls. V73 confirmed loose food in dry food pantry will attract more pests and confirmed mouse droppings on white shelf to be mouse droppings.On 7/16/2026 at 1:34 PM, V69 housekeeper stated the outside door that was propped open leads to the sorting room for trash or laundry. On 7/21/2026 at 12:35 PM, The facility's pest control invoice for the months of April, May, June and July 2026 were reviewed.On 7/21/2026 at 12:39 PM, A policy titled General Sanitation Practices documents the kitchen will be maintained in a clean and sanitary condition. 7. All utensils, pots, pans, etc. will be properly washed, rinsed and sanitized after each use. A. Food service workers will receive training on the following subjects: 13. Avoiding insect and/or pest problems.On 7/22/2026 at 11:41, A policy dated 02/2018 titled Pest Control states the purpose of the policy is to prevent or control insects and rodents from spreading disease. The policy guidelines state 5. Employees are instructed to promptly report all observations of pests to their department heads. 6. Food will be covered and/or refrigerated, as applicable to prevent pest invasion and spoiling. 8. Outside openings shall be protected against the entrance of insects by tight fitting, self-closing doors, closed windows, screening, controlled air currents or other means. 9. The building openings shall be tight-fitting and free of breaks. 10. The facility shall be kept in such condition and cleaning procedures used to prevent the harborage or feeding of insects or rodents. 12. Garbage and trash shall be stored in areas separate from those used for the preparation and storage of food. 13. Garbage and trash shall be promptly removed from the premises in accordance with local and stated waste management guidelines. 17. The dumpster shall be kept clean and maintained in good repair and the lid shall be kept closed.

Based on interview and record review, the facility failed to ensure residents were free from abuse for 3 (R19, R38 and R46) of 4 residents reviewed for abuse in a sample list of 53. Findings include:R19's Medical Diagnosis list dated 5/20/2026 documents R19 has a diagnosis of Hypertension, Anxiety, Depression, and Diabetes. 1. R19's Minimum Data Set (MDS) dated [DATE] documents R19 is cognitively intact. On 7/14/2026 at 9:30 AM, R19 stated R19's roommate had spilled fluids on the floor. R19 stated R19 reported the spill. R19 stated V25, Certified Nursing Assistant, (CNA) refused to clean it, stating with curse words it was not their job. R19 stated V25 was rude. R19 stated V25 yells profanities and uses racial slurs in the hallways and at the nurse's station where it can be heard from R19's room. R19's room is located directly across the hall from the nurse's station. R19 stated V25's conversations with other staff are sexual in nature. R19 stated this upsets R19 and feels this is inappropriate and is abusive to everyone that can hear it. R19's Progress Noted dated 7/14/2026 at 11:00 AM documents R19 made an allegation of abuse from a staff member. R19's Progress Note dated 7/15/2026 at 3:25 PM documents a staff member was placed on leave pending investigation. V25's Corrective Action Form dated 7/17/2026 documents an allegation of abuse was made against V25. After an investigation was conducted, it was determined that the allegation was founded. The facility cited Appendix A #7 of the Collective Bargaining Agreement that states physical or verbal abuse, neglect, or attempting to injure residents or other person results in discharge. Per this Corrective Action Form, V25 was terminated on 7/17/2026. 2. R38's Progress Note dated 1/21/2026 documents R38 has a diagnosis of Dementia, Anxiety, Depression, Hypertension and Hepatic Disorder. R38's MDS dated [DATE] documents R38 as moderately cognitively impaired. On 7/16/2026 at 9:20 AM, R38 stated one of the nurses had yelled at R38 and told R38 they smelled bad. R38 stated this made R38 feel bad and embarrassed. R38 stated there were other people around. On 7/17/2026 at 10:30 AM, V82 (Dietary Aid) stated when V82 was on the elevator, V80 (CNA) and R38 got on at the 2nd floor. V82 stated there was another resident on the elevator. V82 stated V80 told R38 they smelled like shit, and was trifling and nasty. R38 asked V80 to stop yelling at R38 and V80 stated back to R38 well you smell like shit and I ain't fucking yelling. V82 stated they exited the elevator on the 3rd floor. V82 stated V82 reported this encounter to the Administrator immediately. R38's Progress Note dated 6/15/2026 documents R38 made an allegation of abuse from a staff member. R38's Progress Note dated 6/15/2026 documents a staff member was placed on leave pending investigation. V80's Corrective Action Form dated 6/19/2026 documents an allegation of abuse was made against V80. After an investigation was conducted, it was determined that the allegation was founded. The facility cited Appendix A #7 of the Collective Bargaining Agreement that states physical or verbal abuse, neglect, or attempting to injure residents or other person results in discharge. Per this Corrective Action Form, V80 was terminated on 6/19/2026. 3. R46's History and Physical dated 1/7/2026 documents R46 has a diagnosis of Right Hip Fracture, Osteoporosis, Gastro-Esophageal Disease, Hypertension, and Hyperlipidemia. R46's MDS dated [DATE] documents R46 as cognitively intact. On 7/16/2026 at 8:15 AM, R46 stated R46 went out to lunch and when returned to the facility, R46 asked V75, Licensed Practical Nurse (LPN) for pain medicine. R46 stated V75 grabbed R46's arm, yelled an accusation at R46 about being drunk and pulled R46 to R46's room and slammed the door. R46 stated this made R46 feel helpless, humiliated and scared. R46 stated it hurt. R46 stated V7 (CNA) and V25 (CNA) curse and used racial slurs in the hallway where everyone can hear. R46 stated this makes R46 uncomfortable and stated it is inappropriate. R46 states this happens all the time, and it has been reported to other staff members, but no one does anything about it. Reported to V16 (Regional Administrator). On 7/17/2026 at 9:35 AM, V83 (CNA) stated V83 witnessed an incident that involved R46 and V75. V83 stated V75 yelled at R46 about being drunk and refused to give R46 their medications. V83 stated seeing R46 and V75 walking towards R46's room, V75 pushing R46 into the room and slamming the door. V83 stated V75 was aggressive and rude to R46. V83 stated V83 did not report On 7/22/2026 at 11:00 AM, V95 (Receptionist) stated on 4/3/2026, R46 returned to the facility from an outing. R46 was in the dining room and V75 approached R46 yelling and accusing R46 of being drunk. V75 grabbed R46's arm and snatched her up like a child and stood R46 up and yelled in R46's face. V75 forced R46 to her room. V95 stated V95 reported this incident to a nurse. R46's Progress Note dated 4/7/2026 documents R46 made an allegation of abuse from a staff member on 4/3/2026. R46's Progress Note dated 7/15/2026 documents R46 made an allegation of abuse from a staff member. Staff was placed on leave pending an investigation. V75's Corrective Action Plan dated 4/13/2026 documents an allegation of abuse was made against V75. After an investigation was conducted, it was determined that the allegation was founded. The facility cited Appendix A #7 of the Collective Bargaining Agreement that states physical or verbal abuse, neglect, or attempting to injure residents or other person results in discharge. Per this Corrective Action Plan, V75 was terminated 4/13/2026.V7's Corrective Action Plan dated 7/17/2026 documents an allegation of abuse was made against V7. After an investigation was conducted, it was determined that the allegation was founded. The facility cited Appendix A #7 of the Collective Bargaining Agreement that states physical or verbal abuse, neglect, or attempting to injure residents or other person results in discharge. Per this Corrective Action Plan, V7 was terminated 7/17/2026. The facility's Abuse Policy dated March 2026 documents the facility prohibits abuse and mistreatment of residents. The facility's Abuse Policy defines physical abuse as the infliction of injury on a resident that occurs other than by accidental means. The facility Abuse Policy defines verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within hearing distance.

Based on interview and record review, the facility failed to report an allegation of misappropriation of resident property/theft and allegation of physical abuse to the state agency (Illinois Department of Public Health (IDPH) and local police department for two (R1, R8) of seven residents reviewed for abuse in the sample list of 121.Findings include:1. On 7/14/26 at 1:40PM, V1 stated, The Maintenance Director cut the lock off R1's drawers. I wasn't in the room. Then the family started saying a week later that things were missing. They didn't say anything about it that day, but about a week later. I didn't report it because there isn't any proof of anything missing. I started an investigation; I have a soft chart in my office.On 7/14/26 at 2:10pm, V1 stated, They didn't initially complain of missing items. The family initially said it was $30 missing, then the next day it was $500 missing. (R1's) family member said they had the wallet and was missing $30 out of it, then flipped script to $500 missing. Family never said they had given R1 $500. I don't remember if there is a grievance. I did an internal investigation, spoke to billing. I have a soft chart on it.On 7/15/26 at 9:35am, V19, Regional Nurse Consultant, brought in the investigation packet regarding R1's missing wallet and money. The packet contains three written staff statements dated 6/11/26 and a printout of R1's Resident Statement Landscape from 1/2/26 through 6/4/26 with an ending balance of $545.31 printed on 6/11/26. V19 stated, This is the entire thing. There was no documentation of the facility notifying IDPH or local police of the allegation of R1's missing wallet or money.On 7/15/26 at 9:37 am V1 stated, I watched R1's unnamed family walk out of the room with the wallet in their hand. R1's family came back about 5 days later and was saying money was missing. Originally, R1's family stated it was $30 dollars but then it became $500. R1's family had the wallet when they left the building and came back several days later. I started the investigation on the 11th because R1's family didn't say anything was missing until then. I spoke with Social Services about it, but I don't know if we did a grievance. The usual protocol when checking into allegations like this would be to check into it and if they can't get it figured out within an hour, I call it in to IDPH and do an investigation.On 7/15/26 at 11:12 V1 stated, We did not do a grievance about that.On 7/15/26 at 11:33am V44, Certified Nursing Assistant (CNA) stated, I wasn't here the day R1 passed. When R1 passed, R1's family was asking where R1's wallet was. R1's family had all of R1's keys, but some were missing. R1's family kept saying R1 had $500. I don't know which family member it was; I've never seen them before except the night R1 passed and to get R1's stuff. I told the nurse, V10, that R1's family member was saying money was missing. On 7/16/26 at 9:42am V20 Regional Financial Coordinator stated, I haven't heard about this $500 issue until you guys (IDPH) started investigating this. 2. The facility's abuse investigation dated 4/15/26 of R8's abuse investigation packet states, At approximately 0230 on 04/09/2026 the administrator was made aware of a Certified Nursing Assistant (CNA) allegedly making physical contact with the resident involving resident R8.The facility's undated preliminary 24-hour Abuse Investigation Report completed by V16 Regional Director of Operations states, Resident was immediately assessed. V97 CNA was immediately suspended pending investigation. Investigation commenced and POA (Power of Attorney), MD (Medical Doctor), Ombudsman, and Local Police notified. Final report to follow.The facility's final investigation report dated 4/15/26 reveals an incomplete investigation. There is no interview for R8, two separate and different interviews by the same employee V66 CNA, an incomplete and unsigned interview of V105 Licensed Practical Nurse, and there was no police report number or report.On 7/23/26 at 10:05 AM, V16 stated, I called the police department, and they didn't find anything in that date range (4/8/26- 4/15/26). They said they had something on R8, but not for those dates.R8's Face Sheet documents their diagnosis to include Noninfective Gastroenteritis and Colitis, Chronic Obstructive Pulmonary Disease and Gastrostomy Status.R8's Minimum Data Set (MDS) dated [DATE] documents R8 was alert and oriented.R8's Care Plan revised on 5/7/2025 documents R8 is at moderate risk for abuse/neglect as noted from Abuse screening related to current physical health problems. Interventions for this care plan include Law-enforcement and legal support as needed and provide a safe and secure environment. The facility's policy, Abuse Prevention and Reporting-Illinois, last reviewed 03/2026, states, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. External Reporting: When an allegation on abuse, exploitation, neglect, mistreatment or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by phone, fax, email, or portal. Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property has been reported and is being investigated. The facility shall also contact the local law enforcement authorities.

Based on interview and record review, the facility failed to thoroughly investigate an allegation of misappropriation of resident property/theft and allegation of physical abuse for three (R1, R8, R46) of seven residents reviewed for abuse in the sample list of 121. Findings include: 1. On 7/14/26 at 1:40PM, V1 stated, The Maintenance Director cut the lock off R1's drawers. I wasn't in the room. Then the family members started saying a week later that things were missing. They didn't say anything about it that day, but about a week later. I didn't report it because there isn't any proof of anything missing. I started an investigation; I have a soft chart in my office. On 7/14/26 at 2:10pm, V1 stated, They didn't initially complain of missing items. The family member initially said it was $30 missing, then the next day it was $500 missing. (R1's) family member said they had the wallet and was missing $30 out of it, then flipped script to $500 missing. Family never said they had given R1 $500. I don't remember if there is a grievance. I did an internal investigation, spoke to billing. I have a soft chart on it. On 7/15/26 at 9:35am, V19, Regional Nurse Consultant, brought in the investigation packet regarding R1's missing wallet and money. The packet contains three written staff statements dated 6/11/26 and a printout of R1's Resident Statement Landscape from 1/2/26 through 6/4/26 with an ending balance of $545.31 printed on 6/11/26. V19 stated, This is the entire thing. On 7/15/26 at 9:37am V1 stated, I watched her (R1's unnamed family member) walk out of the room with the wallet in their hand. They came back about 5 days later and was saying money was missing. Originally, they stated it was $30 dollars but then it became $500. They had the wallet when they left the building and came back several days later. I started the investigation on the 11th because they (R1s unnamed family member) didn't say anything was missing until then. I spoke with Social Services about it, but I don't know if we did a grievance. The usual protocol when checking into allegations like this would be to check into it and if they can't get it figured out within an hour, I call it in to IDPH and do an investigation. On 7/15/26 at 11:12 V1 stated, We did not do a grievance about that. On 7/15/26 at 11:33am V44, Certified Nursing Assistant (CNA) stated, I wasn't here the day R1 passed. When R1 passed, R1's Family member was asking where R1's wallet was. They had all R1s keys, but some were missing. They kept saying R1 had $500. I don't know which Family Member it was; I've never seen them before except the night R1 passed and to get R1's stuff. I told the nurse, V10, that the family member was saying money was missing. On 7/16/26 at 9:42am V20 Regional Financial Coordinator stated, I haven't heard about this $500 issue until you guys (IDPH) started investigating this. 2. The facility's abuse investigation dated 4/15/26 of R8's abuse investigation packet states, At approximately 0230 on 04/09/2026 the administrator was made aware of a Certified Nursing Assistant (CNA) allegedly making physical contact with the resident involving resident R8. The facility's undated preliminary 24-hour Abuse Investigation Report completed by V16 Regional Director of Operations states, Resident was immediately assessed. V97 CNA was immediately suspended pending investigation. Investigation commenced and POA (Power of Attorney), MD (Medical Doctor), Ombudsman, and Local Police notified. Final report to follow. The facility's final investigation report dated 4/15/26 reveals an incomplete investigation. There is no interview for R8, two separate and different interviews by the same employee V66 CNA, an incomplete and unsigned interview of V105 Licensed Practical Nurse, and there was no police report number or report. On 7/23/26 at 10:05 AM, V16 stated, I called the police department, and they didn't find anything in that date range (4/8/26- 4/15/26). They said they had something on R8, but not for those dates. The facility's policy, Abuse Prevention and Reporting-Illinois, last reviewed 03/2026, states, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This will be done by implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent further occurrences. Internal Investigation: All incidents will be documented, whether or not abuse, neglect, retaliation, exploitation, mistreatment or misappropriation of property occurred, was alleged or suspected. Any incident or allegation involving abuse, neglect, exploitation, retaliation, mistreatment or misappropriation of resident property will result in an investigation. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed along with any pertinent medical records or other documents. The Facility Abuse police dated 3/2026 documents supervisors will monitor the ability of staff to meet the needs of residents, including that assigned staff have knowledge of individual resident care needs. Situations such as inappropriate language, insensitive handling, or impersonal care will be corrected as they occur. The Facility Abuse policy dated 3/2026 documents employees are required to report any incident, allegation or suspicion of potential abuse, neglect, retaliation, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator. 3. R46's History and Physical dated 1/7/2026 documents R46 has a diagnosis of Right Hip Fracture, Osteoporosis, Gastro-Esophageal Disease, Hypertension, and Hyperlipidemia. R46's MDS dated [DATE] documents R46 as cognitively intact. On 7/16/2026 at 8:15 AM, R46 stated R46 went out to lunch on 4/3/2026 and when returned to the facility, R46 asked V75 (Licensed Practical Nurse, LPN) for pain medicine. R46 stated V75 grabbed R46's arm, yelled an accusation at R46 about being drunk, and pulled R46 to R46's room and slammed the door. R46 stated this made R46 feel helpless, humiliated and scared. R46 stated it hurt. On 7/17/2026 at 9:35 AM, V83 (CNA) stated V83 witnessed an incident that involved R46 and V75 (LPN). V83 stated V75 yelled at R46 about being drunk and refused to give R46 their medications. V83 stated V83 saw R46 and V75 walking towards R46's room, V75 pushing R46 into the room and slamming the door. V83 stated V75 was aggressive and rude to R46. V83 stated V83 did not report this incident to anyone at the time it happened. On 7/22/2026 at 11:00 AM, V95 (Receptionist) stated on 4/3/2026, R46 returned to the facility from an outing. R46 was in the dining room and V75 approached R46 yelling and accusing R46 of being drunk. V75 grabbed R46's arm and snatched them up like a child and stood R46 up and yelled in R46's face. V75 forced R46 to their room. V95 stated V95 reported the incident at the time it happened to a nurse but is unable to recall who. The facility abuse investigation report dated 4/6/2026 documents the Administrator was notified of the allegation of abuse on 4/6/2026 at 9:00 AM. On 7/21/2026 at 1:30 PM, V21 (Social Service Director) stated V1 (Administrator) instructed V21 to back date R46's Psychosocial Assessments for 4/3, 4/4, and 4/5. R46's Psychosocial Assessments dated 4/3/2026 has an original date of entry on 4/7/2026 and documents R46 reported a physical abuse allegation against a staff member. R46's Psychosocial assessment dated [DATE] has an original date of entry on 4/7/2026 and documents R46 reported a physical abuse allegation yesterday by a staff member. R46's Psychosocial assessment dated [DATE] has an original date of entry on 4/7/2026 and documents R46 reported an allegation of physical abuse Friday afternoon. R46 is able to recall the incident that occurred. R46's Psychosocial assessment dated [DATE] has an original date of entry on 4/7/2026 and documents R46 reported allegation of physical abuse. The timecard for V75 (LPN) recorded on 4/3/2026 to 4/6/2026 documents V75 worked in the facility on 4/3/2026 from 1:38 PM to 4/4/2026 at 6:21 AM (double shift), on 4/4/2026 from 1:43 PM to 4/5/2026 at 5:06 AM (double shift), and on 4/5/2026 at 1:43 PM to 9:11 PM. V75 continued to work in the facility providing resident care for 3 days before V75 was suspended on 4/6/2026. On 7/21/2026 at 2:04 PM, V1 (Administrator) stated V1 was not aware of the allegation of abuse on 4/3/2026 and was not notified until 4/6/2026. R46's Progress Note dated 4/7/2026 documents R46 made an allegation of abuse from a staff member on 4/3/2026. V75's Corrective Action Plan dated 4/13/2026 documents an allegation of abuse was made against V75. After an investigation was conducted, it was determined that the allegation was founded. The facility cited Appendix A #7 of the Collective Bargaining Agreement that states physical or verbal abuse, neglect, or attempting to injure residents or other person results in discharge. Per this Corrective Action Plan, V75 was terminated 4/13/2026.

Based on interview and record review, the facility failed to follow physician orders for 2 of 2 residents (R2 and R5) reviewed in the sample list of 121 for physician-order implementation. The facility failed to administer R5's intravenous antibiotic at the ordered frequency and failed to follow R2's orders for Midodrine administration and management of a 1,500-milliliter daily fluid restriction. These failures placed R5 at risk for ineffective treatment of an acute infection and placed R2 at risk for medication-related adverse effects and complications associated with improperly managed fluid intake. 1. R2 Review of R2's clinical record showed diagnoses that included end-stage renal disease requiring dialysis, heart failure, essential hypertension, and hypotension. Review of R2's physician orders showed an order for Midodrine HCl 2.5 milligrams by mouth in the morning for hypotension. The order directed staff to give the medication before dialysis and send one tablet with R2 to dialysis on Monday, Wednesday, and Friday. The order further directed staff to hold the medication when R2's systolic blood pressure was greater than 130 mmHg. Review of R2's Medication Administration Record showed Midodrine was administered on 7/11/26 when R2's blood pressure was 168/70 mmHg. R2's systolic blood pressure was 38 mmHg above the physician-ordered hold parameter. Review of R2's Medication Administration Record showed that Midodrine was administered again on 7/14/26 when R2's blood pressure was 140/76 mmHg. R2's systolic blood pressure was 10 mmHg above the physician-ordered hold parameter. Review of R2's Medication Administration Record showed that Midodrine was administered on 7/21/26 when R2's blood pressure was 168/89 mmHg. R2's systolic blood pressure was 38 mmHg above the physician-ordered hold parameter. The facility administered Midodrine to R2 on three occasions when R2's systolic blood pressure exceeded the physician-ordered hold parameter. Review of R2's physician orders showed an order for a no-added-salt diet, regular texture, thin liquids, and a 1,500-milliliter daily fluid restriction, with 1,000 milliliters allotted to dietary and 500 milliliters allotted to nursing. On 7/15/26 at 3:45 PM, V45 stated Certified Nursing Assistants were expected to report residents' fluid intake to the nurses and document intake in the point-of-care tasks. After reviewing R2's documentation, V45 confirmed R2's oral intake was not being monitored or documented and that only output from R2's indwelling urinary catheter was documented. V42 stated that dietary staff did not monitor R2's total fluid intake. V42 stated R2 was alert and oriented and that R2's family visited daily and monitored the fluid restriction. On 7/15/26 at 3:55 PM, V2, Director of Nursing, stated that Certified Nursing Assistants were responsible for reporting and documenting resident intake and output in the point-of-care tasks. V2 stated an alert and oriented resident or the resident's family could monitor a fluid restriction. V2 stated they were not aware of any residents or family members who were independently monitoring residents' total intake and output. On 7/15/26 at 4:02 PM, V71, Assistant Dietary Manager, stated dietary staff used resident meal tickets to identify restrictions. V71 stated water was omitted from a resident's meal tray when the resident had a fluid restriction and the red cups provided on meal trays held eight ounces. On 7/16/26 at 2:40 PM, V70 stated nursing staff did not monitor R2's total oral intake because there was no separate order directing staff to monitor intake. V70 stated the facility monitored only R2's urinary-catheter output and that dietary staff determined the amount of fluid placed on R2's meal trays. V70 stated R2 received morning medications with a four-ounce health shake and no additional water. V70 stated Certified Nursing Assistants were expected to document intake consumed with meals. On 7/21/26 at 12:25 PM, V89, Registered Nurse at R2's dialysis center, stated R2 routinely arrived for dialysis with Midodrine sent by the facility. V89 stated the medication was frequently not administered at dialysis because R2's blood pressure was elevated and did not meet the physician-ordered parameters for administration. On 7/24/26 at 2:22 PM, V112, Medical Doctor, stated the facility was expected to monitor all of R2's oral intake and not only the fluids consumed during meals. V112 stated if the facility did not monitor all oral intake, staff should, at minimum, monitor R2's weight one to two times per week. V112 stated a three-pound weight loss within three days would be concerning for dehydration. V112 stated the facility was not following physician orders by failing to monitor R2's total oral intake and by administering medication when R2's blood pressure was outside the physician-ordered parameters. The facility failed to follow R2's physician orders by administering Midodrine on three occasions when R2's systolic blood pressure exceeded the ordered hold parameter and by failing to measure, monitor, and document R2's total oral intake in accordance with the physician-ordered 1,500-milliliter daily fluid restriction. 2. R5 On 7/23/2026 at 2:00PM, record review of R5's progress note dated 3/22/2026 documents, CNA reported decreased urinary output and R5 was sent to a local hospital for further evaluation. R5 was admitted for acute pyelonephritis and returned to the facility on 3/30/2026 with a new order for ceftazidime 2 grams to be administered every eight hours for seven days and a midline. On 7/23/2026 at 2:10 PM, record review of R5's physician orders documents an order for ceftazidime intravenous solution reconstituted 2 GM (Ceftazidime) Use two grams three times a day related acute pyelonephritis (N10) until 4-6-2026. On 7/23/2026 at 2:13PM, record review of R5's medication administration record documents on 3/31/2026 at 7:39 AM Ceftazidime two gram was given by V92 LPN. On 3/31/2026 at 7: 23 PM Ceftazidime two gram was given by V45 RN. On 3/31/2026 at 11:55 PM Ceftazidime two gram was given by V109 RN. On 4/1/2026 at 7:36 AM Ceftazidime two gram was given by V60 RN. On 4/1/2026 at 2:55 PM Ceftazidime two gram was given by V60 RN. On 4/1/2026 at 10:51 PM Ceftazidime two gram was given by V45 RN. On 4/2/2026 at 7:14 AM Ceftazidime two gram was given by V92 LPN. On 4/2/2026 at 7:48 PM Ceftazidime two gram was given by V45 RN. On 4/3/2026 at 1:08 AM Ceftazidime two gram was given by V5 LPN. On 4/3/2026 at 7:27 AM Ceftazidime two gram was given by V60 RN. On 4/3/2026 at 12:52 PM Ceftazidime two gram was given by V60 RN. On 4/3/2026 at 4:31 PM R5's progress note documents at 1600 CNA reported to writer that this resident had pulled out his SP Cath. vs 120/70 98.4 70 18 98% bs 120. area cleansed no blood noted res combative and striking out at staff he denies pain call placed to POA made aware also Primary made aware report called to ER to give report, and given ER charge [NAME]. On 4/3/2026 at 9:29 PM R5's progress note documents resident returned from MMC at 2100 with SP Cath replaced. No additional orders noted. On 4/4/2026 at 1:48 AM Ceftazidime two gram was given by V5 LPN. On 4/4/2026 at 7:03 AM Ceftazidime two gram was given by V110 LPN. On 4/4/2026 4:18 PM Ceftazidime two gram was give by V5 LPN. On 4/4/2026 at 11:48 PM Ceftazidime two gram was given by V5 LPN. A review of R5's location of administration record documents the medication was administered on 3/31/2026 at 7:23 PM, the medication was ordered to be given at 4:00PM. A review of R5's location of administration record documents the medication was administered on 4/02/2026 at 7:48 PM, the medication was ordered to be given at 4:00PM. A review of R5's location of administration record documents the medication was administered on 4/03/2026 at 12:52 PM, the medication was ordered to be given at 4:00PM. A review of R5's location of administration record documents the medication was administered on 4/05/2026 at 11:34 AM, the medication was ordered to be given at 8:00AM. A review of R5's location of administration record documents the medication was administered on 4/06/2026 at 1:03 PM, the medication was ordered to be given at 4:00PM. On 7/24/26 at 2:22 PM, V112, Medical Doctor, stated that he would expect the facility to follow physician orders as written. The facility's policy titled Medication Administration Policy dated 01/2015 documents II. Medications must be administered in accordance with a physician's order e.g. right resident, right medication, right dosage, right route, right time.

Based on observation, interview and record review the Facility failed to coordinate treatment care of a foot wound for 1 of 3 residents (R4) reviewed for wounds in the sample of 7. This failure resulted in a delay of treatment for R4, causing him to need more of his foot amputated due to the infection and lack of timely scheduling of the surgery.Findings include:R4's Physician Order Sheet (POS) for April 2026 documents a diagnosis of infective myositis, left foot; abscess of tendon sheath, left ankle and foot, other acute osteomyelitis, right ankle and foot; methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere; non-pressure chronic ulcer of other part of right foot with muscle involvement without evidence of necrosis, hereditary and idiopathic neuropathy, chronic obstructive pulmonary disease, unspecified type 2 diabetes mellitus with foot ulcer, acquired absence of right great toe (9/19/2025), abnormal weight loss, hypertension and anemia. R4's POS documents an order for Daptomycin Intravenous solution reconstituted 500 MG (milligrams), use 500 mg intravenously every 24 hours for sustained MRSA (Methicillin-resistant Staphylococcus aureus bacteremia) left foot/left diabetic foot until 4/17/2026, start date for the order was 3/13/2026.R4's Minimum Data Set (MDS) dated [DATE] documents R4 was cognitively intact for decision making of activities of daily living. R4 has no impairment and uses a walker and wheelchair. R4 needs supervision or touching assistance by staff for most ADL's (Activities of daily living).R4's Care Plan documents, Enhanced barrier precautions r/t (related to) chronic wounds/infection dated 3/11/2026; 3/18/2026 I am at risk for skin impairments r/t (related to) diabetes, impaired mobility. I have noted to remove my dressing and to unplug the wound vac and not let staff know that it needs plugged in. I was admitted with the following: stage 3 left plantar foot stage 4 right plantar foot right toes surgical.R4's Physician Order Sheet document R4 was admitted to the facility on [DATE].R4's Wound Notes dated 2/10/2026 documents R4's left plantar foot wound was .80 x 1.00 x 0.10 (L) x width (W) x depth (D); the area was .80 cm2 and the volume was .08 cm3.R4's Wound Note dated 2/26/2026 document R4's left plantar foot wound was getting larger and the measurements were 2.60 x 2.80 x 0.10 (L x W x D); area 7.28, and volume 0.73.R4's Wound Notes dated 3/31/2026 document R4's left plantar foot wound dated 3/31/2026 document the wound was advancing, and the measurement were 4/10 x 3.50 x unknown (L x W x D); area 14.35 cm2, volume is unknown. Exudate is present with serosanguinous, and the bone is now visible with the naked eye.R4's Wound Notes dated 4/7/2026 document R4's left plantar foot wound continues to increase in size and is documented 4.20 x 4.0 x unknown (L x W x D); Area 16.80 cm and volume unknown. The bone is still visible.On 4/7/2026 at 9:55 AM, V1, Administrator stated she was not aware of any issues with scheduling or conflicts for (R4's) surgery. She had not received any phone calls and/or messages related to him needing surgery and was not aware of any delays of treatment.On 4/7/2026 at 10:04 AM, V3, Assistant Director of Nursing (ADON) stated, There was an issue where the doctor needed a signature for surgery for (R4) which we were able to get the next day. I am not aware of any other issues with (R4) needing surgery and I am not aware of any delays, and I did not get any phone calls from the foot doctor.On 4/10/2026 at 4:30 PM, R4's left foot, has a red streak going across his foot from his large, big toe to the middle of his arch. R4 has a large area on the bottom of his foot exposing the bone, there is no drainage or smell. The bone is visible because of the hole. The area was measured by V19, Licensed Practical Nurse and measured .30 centimeters x 6 cm. The area is larger than a fifty-cent piece.On 4/10/2026 at 4:40 PM, V19 stated, (R4) has been having issues with this area on his foot for at least a year. (R4) is having surgery and they are going to amputate part of his toe/foot. I do not remember seeing the bone a year ago. (R4) is easily confused and very forgetful. I am not aware of any issues with (R4) needing scheduled for surgery and any delays. It is a bad wound, and you can see the bone with your eye. We do not have a wound nurse. We have been without one for about a month now. I think they are hiring a new one though.On 4/14/2026 at 11:15 AM, V2, Director of Nursing (DON) stated, I was just out on the floor passing out medications. I just started working here on 1/19/2026 so it has been for about 3 months. I am not aware of any issues with (R4) needing an appointment for surgery and having any issues and/or delays in getting the surgery set up.R4's Progress Notes dated 4/7/2026 at 12:00 AM, Scheduled for surgery on April 14 at (Hospital), likely a first day amputation of right foot by (V16), Podiatrist. Patient has had multiple foot surgeries previously. Post operative plans include partial weight bearing in a shoe for four weeks and dressing to remain until first postoperative appointment.On 4/16/2026 at 4:04 PM, V16, Doctor of Podiatry Medicine (DPM) stated, On 3/24/2026 (R4) was seen at my wound clinic. (R4) has been having issues for a while, and he has had multiple surgeries. I called the DON's number and let her know things are not progressing well and (R4) needs surgery. (R4)'s wound was increasing in size, and the bone is now visible which is never a good thing, and he needed surgery STAT (right away). I faxed the orders over to the facility, but nobody calls me back, nobody schedules (R4's) surgery. I called the facility over six times because (R4's) bone is hanging out and on top of that he has osteomyelitis and he needs surgery to prevent this guy from losing more of his foot or worse yet, him developing sepsis and dying. Nobody is calling me back. Staff from my office were calling as well. I called, I would leave a message, and no staff member ever returned my message. On 3/31/2026 we had everything finalized with insurance and I am trying to get (R4) set up for surgery, so the infection does not spready. Finally, the ADON (Assistant Director of Nursing) calls me, and I am really getting worried for (R4). To me this is neglect. This should have been set up much earlier. They should have seen his bone sticking out and put this as a priority. (R4) was either going to lose more of his foot or potentially get sepsis and die. The facility was not acting and did not seem to care about what would happen to (R4). I realize the (Facility) is busy, but I was really hoping for a better outcome. I did do the surgery on (R4), and I did have to remove more of the foot because the infection had spread. I do believe that if the surgery had been done earlier, I could have saved more of his foot. Again, it puts the resident at risk for more infection and if he gets septic he could easily die. If the surgery had been performed at the end of March, beginning of April, I believe we would have had a better outcome. No staff or management ever told me (R4) was missing his antibiotics, and that is never good, and it just contributes to everything going on with (R4's) foot. (R4) had issues with his foot and he needed surgery and because of the delay we had to amputate more of the foot due to the infection, and I believe he would have a better outcome if the facility had coordinated care and scheduled his surgery earlier and returned my calls. I called and talked to a nurse, and multiple receptionists, there was no Wound Nurse so everything was falling through the cracks because nobody was reaching out to me and nobody was making sure (R4) got his surgery.On 4/17/2026 at 9:57 AM, V22, CNA (Certified Nursing Assistant)/Receptionist stated, I remember several weeks ago I was working the phones, and I got a call from the Podiatrist who was upset because he was trying to schedule a surgery for (R4). The old (DON) told him in the future to talk with her and he was calling, and I would put the calls through, but she was not answering him. He was upset because nobody was returning his calls, and he had left several messages. I remember him telling me if he could not get ahold of the administrator or the DON then he would call Public Health. He said he had called numerous times, and I know I did talk with him three times that day with the phone going back and forth. On 4/21/2026 at 2:54 PM, V3, ADON stated, I found out later after I talked to you, that (R4) was having issues with getting his surgery set up. (V16) called and was irate and upset because he had been calling the DON and she was not returning his calls and (V25, Licensed Practical Nurse)) came and told (V2) she needed to call him. I did not know anything about any delays in surgery for (R4) before that. I don't know if she ever called him or not. Then (V16) calls again and I talked with him and he was mad because (R4's) surgery had not been scheduled and I immediately started working on it. I think this was sometime in April. (V16) was upset because (V2) had not called him back and he was irate and saying this was neglect and abuse and he was going to call Public Health.On 4/21/2026 at 3;24 PM, V25 stated, When someone calls the facility it rings at the receptionist's desk and if nobody picks up then it will ring at the nurses' station. I remember getting a call from (V16) because he wanted to speak with the DON regarding (R4's) surgery and setting something up. He was frustrated because he could not get ahold of (V2). I left a message for (V2) because she was in the afternoon meeting. I knew he wanted to speak with (V2) and I personally followed up with (V2) to make sure she got the message. I don't know anything about (R4) he is not my resident. R4's Progress Notes dated 4/16/2026 at 1:06 PM, He had surgery yesterday on the left foot. He had more amputated due to infection. He has a dressing in place that is CDI. He is in a boot as well. He is to leave the dressing and boot on at all times until FU (Follow Up).R4's Progress Notes dated 2/14/2026 at 11:18 PM, (R4) is an 83 YO (year old) male with PMH (past medical history) of right foot ulcer, neuropathy, amnesia, amputation of the right great toe, COPD (chronic obstructive pulmonary disease), type 2 DM (diabetes mellitus), who was admitted to (Facility) on 9/19/25. On 9/10/2025, he presented to the ER (emergency room) for a scheduled right toe amputation due to OM (osteomyelitis). Patient started on Lisinopril 2.5 mg at bedtime for elevated blood pressure. Initial high reading of 162/60 noted on the 7th, followed by improved readings of 137/62 and 118/56 on subsequent days. Patient denies lightheadedness or dizziness upon standing. No other symptoms such as nausea, vomiting, fevers, or chills were reported. Medication started at lowest dose to help avoid drastic blood pressure changes.R4's Progress Notes dated 3/2/2026 at 12:36 PM, Note Text: Writer went to complete resident scheduled dressing changes and observed bandage to left plantar foot was saturated with blood, wound is odorous. Resident is denying pain to area. Writer observed left toes are discolored, purple, and great toe is swollen, discoloration to entire foot. Right toes have moderate bloody drainage, resident recently d/c (discontinued) from wound vac. Writer received orders to transport resident to ER (emergency room).R4's Hospital Discharge papers documented R4 was in the hospital from [DATE] to 3/13/2026 (eleven days). R4 was admitted for foot infection: Sustained MRSA bacteremia/left foot diabetic foot infection, associated with MRSA, diphtheroid, ABXL Daptomycin 500 mg IV every 24 hours, stop date 4/17/206. Duration six weeks. Blood work weekly.R4's Progress Notes dated 3/30/2026 at 11:14 PM, documents, LTC (Long Term Care) resident. hospitalized on [DATE] for left foot MRSA infection, returned 3/16/26 with on-going IV (intravenous) antibiotics. IDT (Intradisciplinary Tean) met 3/19/206 for weight loss review; care plan updated. He recently lost his wife, likely some of this could also be grief. Next wound clinic follow up appt 4/14/2026; Infectious Disease follow-up 3/31/2026. He denies chest pain or shortness of breath. 30 minutes total spent face to face, reviewing medical chart, medications, lab result and discussing POC (Plan of Care) with nursing staff.R4's Progress Notes dated 4/10/2026 at 12:02 PM, Patient is scheduled to have a surgical procedure 4/14/2026.On 4/17/2026 at 10:25 AM, V23, Wound Nurse LPN, I have been here for two days. (V26) was the wound nurse before me. She never consulted with me regarding any patient care or treatments. When the doctor makes rounds, I do measurements and follow up with the doctors. I am not familiar with (R4), again I just started. (V26) was not here when I started.On 4/17/2027 at 10:33 AM, V24, LPN, I have worked here for over a year. I have a lot of history with wound treatment when we lost our Wound nurse (V26), they would have me fill in. When it was doctor day, I would make rounds and do measurements but for the most part I was also working on the floor as an LPN. Because of my history with wounds, I was trying to help out. I would do measurements on Mondays and make rounds on Wednesday. I was just helping. We were without a wound nurse for about a month. She left in March. I am vaguely familiar with (R4). I remember after he came back from the hospital I could see the bone in his foot. R4's area started out as a small area on (R4's) foot and I do not know when or how, but he went out to the hospital and when I did his treatment, I pulled the dressing off and I could see the bone and slough. He came back from the hospital and had orders and was seeing the wound clinic. I do not know anything about any doctor wanting to schedule, or any delays for his surgery.R4's Medication Administrator Record (MAR) for March, 2026 documents, Left foot. Do not remove Restrada graft-in wound base. Cleanse area with NS (Saline Solution), pat dry. Apply wet to dry. Apply ADB. Wrap with Keflex PM when wound vac is not available as needed for left foot wound. (Start date 3/13/2026). R4's MAR from 3/13/2026 to 3/31/2026 does not document this treatment was completed.R4's MAR for April 2026 documents, R4 did not receive Daptomycin Intravenous solution reconstituted 500 MG (milligrams), use 500 mg intravenously every 24 hours for sustained MRSA bacteremia left foot/left diabetic foot. R4 did not receive the daptomycin on 4/8/2026, 4/9/2026 and 4/12/2026.R4's MAR for April of 2026 also documents Daptomycin Intravenous solution was not administrated per physician orders at 1:30 PM and was not given every 24 hours. The following dates the medication was not given per physician order. On 4/1/2026 the medication was given at 7:35 AM. On 4/2/2026 the medication was documented as being given at 3:37PM. On 4/3/2026 the medication was documented as being given at 7:28 AM. On 4/4/2026 the medication was documented as being given 5:00 PM. On 4/5/2026 the medication was documented as being given at 4:00 PM. (Total of five days the Physician Orders were not followed).R4's MAR for April 2026 documents Hibiclens External Solution 4% (chlorhexidine Gluconate) apply to body topically two times a day for surgery. (start date 4/82/2026) Saturday 4/10/2026 the AM dose was not documented as being given.R4's April 2026 MAR documents Assess PICC/Midline (peripherally inserted central catheter) for complications (redness, warmth, tenderness or swelling) every shift for PICC line. (Start date) 3/13/2026. R4's MAR documents this was not completed on 4/4/2026 and 4/12/2026.R4's MAR for April 2026 document, Fax over lab results one time a day until 4/17/2026. R4's MAR documents were not completed on 4/8/2026 and 4/12/2026 and 4/14/2026.On 4/14/2026 at 11:15 AM, V2 stated, I was just out on the floor passing out medications. I just started working here on 1/19/2026 so it has been for about 3 months. I am not aware of any issues with IV's not being given. I will look into why (R4) has holes on 4/8/2026; 4/9/2026 and 4/12/2026. I am not sure why. I would expect the medication to be given within two hours of the order. (R4's) order is for 1:30 PM so it should have been given in that two-hour window. If there are holes and the MAR is blank, then it would not be charted and if it is not charted, then it was not done. We have four Registered Nurses (RN) and two are full time for the census of 118 residents, including myself and the ADON. I would expect all medications to be given and charted as being given. We are doing the best we can but honestly, it is not enough at times. I am not aware of any issues with (R4) needing an appointment for surgery and having any issues.On 4/14/2026 at 12:30 AM, V3, ADON (Assistant Director of Nursing) stated there are holes in (R4's) MAR and if it was not charted then it was not done. Basic nursing 101. If there is no record of care documented, then it was not done.On 4/15/2026 at 9:03 AM, V17, Medical Director stated, I would expect all physician orders to be followed and for no resident to miss any doses. (R4) has a long history of having vascular issues and has multi factors and has had vascular issues and it is a chronic condition.V16's Wound Notes for R4 dated 3/31/2026, document, Unfortunately clinical symptoms are worsening with regards left foot. He now has exposed bone including sesamoid and 1st metatarsal plantarly. I did debride the wound on the plantar aspect of the left foot with tissue [NAME], removing tendon, sesamoid, necrotic tissue from the wound base. See post debridement wound measurements. Continue with saline wet-to-dry dressing to the wound daily. Right foot wound is completely healed, recommend (foam dressing) hours to that area. Discussed clinical findings worsening. I am not sure he understands this. He is going to need repeat debridement of the left foot wound to include left 1st ray amputation. We will attempt to communicate with his family with regards to need for surgical intervention. Wound care orders forwarded on to the nursing home. (R4) is an [AGE] year-old male seen for follow-up after hospitalization for sustained MRSA bacteremia, left foot diabetic foot infection associated with myositis and tenosynovitis. Patient reports currently residing at (facility). Since leaving the hospital, he reports he has been feeling fine overall. He remains on IV (intravenous) daptomycin for a foot infection, administered through a line in his chest. Weekly laboratory monitoring is intended while he is on antibiotics, but it is unclear whether the facility has been consistently obtaining these labs. The wound continues to be managed, and wound care frequency at the facility appears to be less than ordered, with the patient indicating it is being done every other day, despite being ordered by podiatry as saline wet-to-dry dressing changes for twice daily. Patient is unsure when he follows up with podiatry.On 4/21/2026 at 4:00 PM, V27, Registered Nurse for the Podiatry Clinic stated, We started the process of attempting to schedule the surgery for (R4) on 3/24/2026. We were able to get insurance approval on 3/31/2026 and then is when the staff, including the Physician, were making multiple calls to the Facility to try and schedule (R4's) surgery. We attempted to call the facility on 3/31/2026, 4/1/206, 4/2/206, 4/3/226, 4/6/2026 and were finally able to get ahold of the ADON on 4/6/2026. So, it was a week of us attempting to get (R4) scheduled, but then we could not do the surgery until 4/14/2025 so there was a delay of another week.On 4/22/2026 at 9:20 AM, V1 stated there was no policy on Wound Care and they expect Physician Orders to be followed.The Physician-Family Notification- Change of Condition Policy last updated on 12/2025 documents, To ensure the medical care problems are communicated to the attending physician or authority designee and family/responsible part in a timely, efficient and effective manner. The Facility will inform the resident, consult with the resident's physician or authorized designee such as Nurse Practitioner, and if known the resident's legal representative or an interested family member when there is 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.The Medication Administrator Policy dated 8/2026 documents, Documentation of medication administration is recorded on the Medication Administration Record (MAR.) or Treatment Record and includes the date, time, and initials of the licensed nurse or CMA who administered the medication. 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 interviews, observations, and record review, the facility failed to maintain resident safety, to document resident fall risk assessments before and after falls occur, and to follow interventions in place to prevent falls for 3 of 4 residents (R1, R3, R12) reviewed for resident safety in the sample of 13.The findings include: 1. R1's admission Record, dated 11/25/25, documents R1 was admitted to the facility on [DATE] with diagnosis of Encephalopathy, Type 2 Diabetes Mellitus (DM), uropathy, disorder of kidney/ureter, morbid obesity, malnutrition, benign prostatic hyperplasia (BPH), Urinary Tract Infections (UTI), major depressive disorder, anemia, atrial fibrillation (A-Fib), hypertension (HTN), legal blindness, adult failure to thrive, anxiety disorder, hallucinations, and schizoaffective disorder.R1's Care Plan, dated 11/17/25, documents R1 is at risk for falls related to impaired mobility due to morbid obesity. Interventions: 1/7/25: Bolsters added to bed as he is visually impaired so that he can know when he is close to the edge of the bed, 12/10/22: non-skid socks, 7/31/22: Educate to seek assistance with transfers/utilize the call light, 7/30/24: offered a body pillow to assist with positioning in bed, 7/29/22: non-skid strips beside bed, 8/17/22: Utilize appropriate Bari shower chair. R1's Minimum Data Set (MDS), dated [DATE], documents R1 has a moderate cognitive impairment and is dependent on staff for all Activities of Daily Living (ADLs) and transfers. R1 has a urine catheter in place and is always incontinent of bowel. On 11/24/25 at 10:20 AM, R1 seen lying in bed with air mattress and bolsters on mattress, small side rails up, bed appears to be in a high position, R1's call light was clipped to itself and hanging down the wall and not within reach of R1, who is blind and not able to see where the call light is placed. There is no body pillow seen in R1's room, no non-skid strips seen on his floor by the side of his bed, and his call light was out of reach. On 11/25/25 at 11:00 AM, R1 was seen lying in bed with an air mattress and bolsters on the side of the mattress, small side rails up on each side with the bed appearing to be in a mid-position. R1's call light was clipped to itself and hanging down the wall and not within reach of R1, who is blind and not able to see where the call light is placed. When asked how R1 gets help when needed, R1 stated, I just start yelling and they will eventually come, sometimes it may take a while, but they do come. When asked if he has had staff offer or give him a body pillow, R1 stated, A body pillow, no one has ever given me a body pillow and I'm not even sure what that is. On 11/25/25 at 11:45 AM, V1, Administrator, stated, (R1) has only had one fall that I can see and that was in June 2025. There is no fall risk assessment dated [DATE]. There are no updated interventions documented in R1's Care Plan after his fall on 6/1/25. R1's Comprehensive Incident Fall Assessment, dated 11/5/24, documents R1 was a High Fall Risk. There is no other fall risk assessment documented after 11/5/24 and before 1/7/25. This was completed after R1 experienced a fall on 11/5/25. There was no fall interventions placed in R1's Care Plan after this fall.R1's Comprehensive Incident Fall Assessment, dated 1/7/25, documents R1 as being a High Fall Risk. This was completed after R1 experienced a fall on 1/7/25. R1's Incident Note, dated 1/7/25 at 10:55 AM, documents, Resident sustained a fall on 1/7/25 8:30 AM. The incident occurred in the resident's room. Resident is alert and disoriented per usual baseline. No changes in range of motion from normal baseline. Physician notified on: 1/7/25 8:30 AM. Resident denies pain. No new skin concern or change in skin condition noted.R1's Nursing Note, dated 1/7/25 at 7:04 PM, documents, Staff informed the writer that the res (resident) was sliding out of the bed and almost on the floor. The writer assessed the res, no injuries noted, VS (vital signs) WNL (within normal limit), pain 2 on a faces scale. The writer called 911 per PCP (primary care provider). EMS (Emergency Medical Services) and SFD (local fire department) arrived and assisted res onto the stretcher. Res sent out to ER (Emergency Room) for eval/ treatment. Administrator, DON (Director of Nursing), and POA (Power of Attorney) aware.R1's IDT (interdisciplinary team) Note, dated 1/8/25 at 3:57 PM, documents, Attendees present: IDT. Summary of IDT meeting: resident having agitation and screaming and slid himself to the floor before staff could intervene. Intervention: Bolsters added to resident's bed as he is visually impaired so that he can know when he is close to the edge of the bed.The facility's fall investigation, dated 1/7/25, documents, in part When the writer entered the room, the res was sitting on the floor with his legs bent against the wall and holding onto the bed rail. Resident unable to give description.R1's Nursing Note, dated 6/1/25 at 7:21 PM, documents, Aide found res on floor, v/s (vital signs) taken, ambulance called, DON & MD (Medical Doctor) aware. Res transferred to (local hospital) via ambulance.R1's IDT Note, dated 6/2/25 at 2:58 PM, documents, Late Entry: Attendees present: IDT. Summary of IDT meeting: Per staff resident threw himself on the floor onto his fall mat. Intervention: resident sent to ED (Emergency Department) to have urine checked, as this is the behavior he exhibits with UTI.The facility's fall investigation, dated 6/1/25, documents in part, Incident description: Aide went into res room and found on floor. Resident unable to give description. Mental Status: Disoriented, but WNL for this resident.There was no Fall Assessment or new interventions put in place completed after R1's fall on 6/1/25. R1's Call Light was consistently out of R1's reach and awareness of the location due to his blindness. R1's only option was to yell out loud when he needed assistance.2. R3's admission Record, dated 11/25/25, documents R3 was admitted to the facility on [DATE] and discharged on 11/7/25 with diagnosis of Congestive Heart Failure (CHF), A-Fib, falls, dementia, dysphagia, occlusion/stenosis of carotid artery, arteriosclerotic heart disease (ASHD), muscle wasting and atrophy, anemia, major depressive disorder, esophageal obstruction, HTN, polyosteoarthritis, and hyperlipidemia. R3's Care Plan, dated 10/23/25, documents R3 is at risk for falls. Interventions: Anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, 10/26/25: Ensure that the resident is wearing appropriate footwear, 10/25/25: Moved to a room across from the nurse's station for maximum monitoring, reminder signs added in room to remind her to call for staff assistance. It continues R3's Care Plan, dated 10/23/25, documents R3 has an ADL self-care performance deficit. Interventions: Side rails: up per order for safety during care provision, to assist with bed mobility, repositioning.R3's MDS, dated [DATE], documents R3 has a moderate cognitive impairment and requires substantial/maximal assistance for ADLs and is dependent on staff for toileting. R3 is frequently incontinent of urine and occasionally incontinent of bowel.R3's Skilled Charting Note, dated 10/25/25 at 1:59 AM, documents in part, Narrative: Mental Status: Resident is in an unrousable/coma/persistent vegetative state. Resident is alert. Oriented to: Person Short term memory impairment, Impaired decision-making ability, Confusion. GU: Incontinent of urine. Toileting hygiene: Substantial/maximal assistance. Sit to lying: Substantial/maximal assistance. Lying to sitting on side of bed: Substantial/maximal assistance. Sit to stand; Substantial/maximal assistance. Chair/bed-to-chair transfer: Substantial/maximal assistance. Toilet transfer Substantial/maximal assistance.R3's admission Assessment: Falls, dated 10/23/25 at 3:15 PM, documents R3 is at risk for falls. There is no Fall Risk Assessment documented.R3's admission Assessment: Side Rails, dated 10/23/25 at 3:15 PM, documents, Benefits of bed rail use: Increased bed mobility, side rails indicated to promote mobility and independence. Intervention: SIDE RAILS: Up per order for safety during care provision, to assist with bed mobility, repositioning.R3's Incident Note, dated 10/25/25 at 8:59 AM, documents, Late Entry: Note Text: Resident sustained a fall on 10/25/2025 7:30 AM. The incident occurred in the Resident room. Resident is alert and disoriented per usual baseline. No changes in range of motion from normal baseline. Physician notified on: 10/25/2025 9:00 AM. Date/time family/responsible party notified: 10/25/2025 8:00 AM. Resident denies pain. No new skin concern or change in skin condition noted.R3's Incident Note, dated 10/25/25 at 11:15 PM, documents, Late Entry: Note Text: Resident sustained a fall on 10/25/2025 11:15 PM. The incident occurred in the resident's bathroom. Resident is alert and disoriented per usual baseline. No changes in range of motion from normal baseline. Physician notified on: 10/25/25 11:20 PM. Date/time family/responsible party notified: 10/25/25 11:15 PM. Resident denies pain. No new skin concern or change in skin condition noted. Care plan reviewed.R3's Comprehensive Incident Fall Assessment, dated 10/25/25 at 11:15 PM, documents R3 experienced an unwitnessed fall, observed by staff on the bathroom floor, resident unable to state what had happened. Actions taken - resident assessed in place and assisted back to bed with staff x 2 and mechanical lift. New Intervention: resident to be placed in a high traffic area when she is noted to be restless. R3's Nursing Note, dated 10/26/25 at 00:02 AM, documents, CNA reported to writer resident is on the floor. Writer entered room resident could be seen laying on back in restroom facing the entrance way. The lights were off in room. Resident states she was attempting to use the restroom. resident has pulled out (urinary catheter) with bulb intact. Vitals obtained, head to toe assessment, no injuries to note at this time. Resident denies hitting head, resident denies pain, writer offered Tylenol. Completed neuros initiated, MD - no new orders, continue to monitor, leave the (urinary catheter) out monitor urine output. notified, left message for POA to call back no answer.R3's IDT Note, dated 10/27/25 at 2:24 PM, documents, Late Entry: Attendees present: IDT Summary of IDT meeting: Per resident interview I was trying to go to the bathroom Intervention: Resident moved to a room across from the nurse's station for maximum monitoring.R3's IDT Note, dated 10/27/25 at 3:24 PM, documents, Late Entry: Attendees present: IDT Summary of IDT meeting: Resident unable to state what happened. Per staff interviews the resident was attempting to self-transfer. Intervention: Reminder signs added in resident's room to remind her to call for staff assistance.R3's Nurse Practitioner (NP) consultation note, dated 10/27/25 at 1:52 AM, documents in part: Date of Service: 10/27/25. CC: (chief complaint) Muscle atrophy and deconditioning secondary to age related debility and recent hospitalization. (R3) is a [AGE] year-old female with PMH (past medical history) significant for dementia. She arrived via EMS from her assisted-living facility after two falls and generalized weakness with right knee pain and was admitted . Interval History: Patient seen and examined. She is in bed with HOB (head of bed) elevated at time of examination. Reports right knee pain. She reportedly fell out of bed twice on 10/25/25. Psych: Normal mood. Normal affect. Patient responds appropriately to examiner. Judgment and insight appear impaired.There was no Fall Risk Assessment completed upon admission, other than the initial admission nursing assessment. There are no further fall risk assessments completed after each fall. 3. On 11/25/2025 at 10:15 AM, R12 was sitting up to his wheelchair, wheelchair was at the foot of his bed, and he was staring out the window. R12's call light was no within reach if he needed to call for assistance. R12 stated that he has had a couple of falls at the facility, and he knows better to ask for help and use his call light.R2's MDS, dated [DATE], documented that his cognition was intact.R2's Physicians order sheet, dated November 2025, documented diagnoses of Type 2 Diabetes Mellitus without complications, Epilepsy and Anxiety Disorder.R2's Care Plan, dated 5/20/2024, documented, Be sure call light is within reach and encourage me to use it for assistance as needed.R2's Medical Chart did not document any Fall Risk Assessment prior to R2's falls on 10/27/2025 and 11/9/2025.On 11/26/25 at 2:10 PM, V14, LPN, stated, Anytime there is a resident fall, I go into (electronic medical record) and go under 'Risk Management' and answer all the questions it has. Once you answer all of the questions, it determines what steps we take next. I follow it step by step. I complete a fall and incident report and will put what new intervention that I put in place. I would complete the fall risk assessment after each fall. Once completed the Risk Management will automatically trigger certain forms and follow-ups that will need to be done for the next few days. I know that the call lights are supposed to be within the resident's reach, however, sometimes they unclip it or it falls on the floor.On 11/26/25 at 2:00 PM, V1, Administrator, stated, I expect all staff to follow a resident's fall interventions in order to keep them safe. I expect the nurses to complete a fall risk assessment upon admission, quarterly, and after any fall the resident has. I expect all staff to keep the resident's call light in reach and to verbalize the placement of that call light to visually impaired residents.The facility's Fall Prevention Program Policy, dated 5/2025, documents in part 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. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Guidelines: Use and implementation of professional standards of practice. Care Plan incorporates: Identification of all risk/issue, addresses each fall, interventions are changed with each fall, as appropriate, and preventive measures. Standards: A Fall Risk Assessment will be performed by a licensed nurse at the time of admission. The assessment tool will incorporate current clinical practice guidelines. A Fall Risk Assessment will be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident. Safety interventions will be implemented for each resident identified at risk. Fall/Safety interventions may include but are not limited to: At the time of admission and in accordance with the plan of care the resident will be oriented to use the nurse call device. The nurse call device will be placed within the resident's reach at all times. The location of the placement will be verbalized for those residents with visual deficits.

Based on interview and record review, the facility failed to implement, and document fall interventions for 1 (R7) of 3 residents who was newly admitted to the facility with hospital documentation of multiple vertebral fractures from a previous fall prior to being admitted to the facility of 3 residents reviewed for falls. This failure resulted in an alert resident (R7) falling twice at the facility and being transferred to the emergency room where she received IV fluids and narcotic pain medication. She sustained 2 skin tears from falls and was transferred to the emergency room due to post fall lethargy. Findings include:R7's Undated Face Sheet documents she was initially admitted to the facility on [DATE] with diagnoses including compression fractures of second and fourth lumbar vertebra, burst fractures of T11-T12 vertebra, falls, low back pain, abnormalities of gait and mobility, muscle wasting and atrophy and lack of coordination.R7's Hospital Discharge Plan, dated 9/30/2025 documents she was in the hospital because: falls and weakness. R7's Baseline Care Plan, dated 9/30/2025 documents safety risks: resident does have a history of falls and has fell within the last month prior to admission, has had a fall within last 2-6 months prior to admission. Focus: the resident is at risk for falls r/t (related to) history of falls. No goal or interventions to prevent falls was documented on R7's baseline care plan. R7's admission Assessment, dated 9/30/2025 documents R7 was at risk for fall r/t history of falls, but no goal or interventions were documented. Staff documented resident has a history of 1-2 falls in the past 3 months. R7's Nurse's Note, dated 9/30/2025 at 9:28 PM documents patient arrived at facility via wheelchair with facility's transportation. Patient wanted to get in bed body brace was removed when placed in bed. patient has T3, T5, T6, T10 & L1 fracture. Patient educated on how to properly use call light when needing assistance. Patient A&0 x3. Will continue to monitor patientR7's Nursing Note, dated 10/5/2025 at 5:05 AM documents heard someone yell for help and then a crash as was going down hall to find who had yelled. R7 was only in depend lying on floor across the room from the bed in front of the TV and the bedside table was on its side between her and the bed. Currently VS returning to baseline, family notified by voice mail. Order obtained for treatment of skin tear.R7's Unwitnessed Fall Report, dated 10/5/2025 at 4:35 AM documents resident stated, I was going to the bathroom. Skin tear to left elbow, no other injuries noted. Assisted to toilet. Staff documented resident was alert and ambulatory with assistance. No intervention documented on fall report to prevent future falls. R7's Nursing Note, dated 10/6/2025 at 12:39 AM documents CNA answered call light to find resident on floor next to bed. She came for me (R7) for help. Assessed in place to find skin tear on right elbow this time. Cleansed and dressed. Lifted into bed. Resident was not as alert as normal. Called MD (physician) and got order to send to ED (emergency department.) Called for transport, notified family and administrator. Resident sent to local emergency room via ambulance.R7's Unwitnessed Fall Report, dated 10/6/2025 at 12:00 AM documents CNA came to get me reporting the resident had fallen again. Resident on floor up against bedframe. Resident stated, I don't know, I don't know why I'm doing this. Resident assessed in place, cleansed and dressed skin tear, lifted to bed, discussed with MD. Skin tear: right elbow. Resident lethargic post fall. Wheelchair bound. Staff documented resident was taken to hospital. No intervention documented on fall report to prevent future falls. R7's Nursing Note, dated 10/6/2025 at 8:25 AM documents Resident returned from ED visit. Dx of Hypokalemia. IV fluids 500 ml (milliliters) administered at ED. R7's Hospital Discharge Paperwork, dated 10/6/2025 documents R7 received IV fluids and a narcotic pain medication, hydrocodone/acetaminophen. R7's Electronic Medical Record (EMR) dated 10/5/2025 and 10/6/2025 no documentation fall interventions or precautions to prevent falls were implemented upon admission to the facility on 9/30/2025 or after these two falls.On 10/10/2025 at 10:35 AM V2, Director of Nurse (DON) stated when residents are initially admitted to the facility, they don't really know the resident other than what the hospital medical discharge paperwork documents. V2 stated if a resident had a history of falls, and the facility staff were aware of that there should be interventions documented on the resident's baseline care plan and admission assessment. All residents have low bed and are orientated to their call light to ask for assistance from staff when needed. V2 stated staff ensure residents always have proper footwear on, their call light within reach and are orientated to the facility. The Facility's Fall Prevention Program, revised 5/2022 purpose: to assure the safety of the residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Guidelines: The Fall Prevention Program includes the following components: methods to identify risk factors, methods to identify residents at risk, educate resident and to fall prevention program at the time of admission, throughout residents stay and when changes occur, assessment time frame, use and implementation of professional standards of practice, immediate change in interventions that were successful, notifications of physician, communication with direct care staff members, documentation requirements, adherence to manufacturer's recommendation in use of alarm and medical devices and special care equipment. Care plan incorporates: identification of all risk/issue, addresses each fall, interventions are changed with each fall, as appropriate, preventative measures. Periodic quality assurance audit activities of records relating to falls that exhibit adherence to facility policies and implementation of the plan of care. Standards: A Fall Risk Assessment will be performed by a licensed nurse at the time of admission. The assessment tool will incorporate current clinical practice guidelines. The admitting nurse as assigned CNA are responsible for initiating safety precautions at time of admission. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. Accident/Incident Reports involving falls will be reviewed by the Interdisciplinary Team to ensure appropriate care and services were provided and determine possible safety interventions. The Director of Nursing or designee is responsible for monitoring the Fall Prevention Program, including further staff education programs, purchase of additional equipment, or other appropriate environmental altercations. In addition, Director of Nursing is responsible for information the Administrator of program analysis. Fall/safety interventions may include but are not limited to: monitor gait, balance and fatigue with ambulation if applicable, foot wear will be monitored to ensure the resident has proper fitting shoes and/or footwear is non-skid, the resident will be reminded as needed to call for assistance before attempting to ambulate, residents at risk of falling will be assisted with toileting needs as identified during the assessment process and as addressed on the plan of care, nursing personnel will be informed of residents who are at risk of falling, the fall risk interventions will be identified on the care plan, dim lighting may be left on in resident's room at night, call lights will be answered promptly, residents will be observed approximately every two hours to ensure the resident is safely positioned in the bed or a chair and provide care as assigned in accordance with the plan of care, the residents personal possessions will be maintained within reach when possible, these items include tissues, water, drinking glass and phone.

Based on interview and record review, the facility failed to ensure competency of the Professional Nursing staff for 1 of 6 (R5) reviewed for Professional Standards in the sample of 50. This failure has the potential to affect all 128 Residents residing in the facility.The immediate jeopardy began on 9/10/25, when V6, Registered Nurse (RN), failed to appropriately respond to an emergent medical event, when R5 displayed symptoms of medical distress and presented with a blood glucose level of 33. V6 failed to follow physician's order of administering Baqsimi (Glucagon) for low blood sugar, and instead disassembled prefilled Epinephrine and Narcan cartridges, combining pieces of both medication cartridges, and administered Epinephrine injection nasally. On 9/16/25 at 2:15 PM, V1, Administrator, and V2, Director of Nursing (DON), were notified of the Immediate Jeopardy. The surveyor confirmed by interview, observation, and record review, the Immediate Jeopardy was removed on 9/17/25, but noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The Findings Include: R5's admission Record, dated 9/11/25, documents R5 was admitted to the facility on [DATE] with diagnosis of: Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), Hypoxemia, Type 2 Diabetes Mellitus (DM), End Stage Renal Disease (ESRD), Dependent on Dialysis, Hypertension (HTN), anxiety disorder, and schizoaffective disorder.R5's Care Plan, dated 4/1/25, documents R5 has Diabetes Mellitus and Diabetic Neuropathy. Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness, Monitor/document/report PRN any s/sx (signs/symptoms) of hypoglycemia: Sweating, tremor, increased heart rate (Tachycardia), pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait, Monitor/document/report PRN (as needed) any s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing, acetone breath (smells fruity), stupor, or coma.R5's Minimum Data Set (MDS), dated [DATE], documents R5 is cognitively intact and is dependent on staff for most ADLs. R5's Physician Order, dated 7/23/25, documents, Baqsimi one pack nasal powder 3 MG (milligram)/dose (Glucagon) 1 pump in nostril as needed for low blood sugar. May repeat in 15-minutes.R5's Medication Administration Record (MAR)-Treatment Administration Record (TAR), dated September 2025, does not document Baqsimi One Pack Nasal Powder 3 MG/Dose (Glucagon) was given to R5. There is no documentation of R5 receiving Narcan or Epinephrine (Epi).R5's SBAR (situation, background, assessment, and recommendation) Note, dated 9/10/25 at 8:08 AM, documents in part, Situation: The Change in Condition (CIC)/s reported on this CIC Evaluation are/were: Altered mental status. At the time of evaluation resident/patient vital signs, weight and blood sugar were:- Blood Pressure: BP 120/70 - 9/10/25 at 8:09 AM,- Pulse: P 70 - 9/10/25 at 8:09 AM, Pulse Type: Regular- RR (respiratory rate): R 18 - 9/10/25- Temp: T 97 - 9/10/25 - Pulse Oximetry: O2 97.0 % - 9/10/25 Method: Oxygen via Nasal Cannula- Blood Glucose: BS 49.0 - 9/10/25 at 7:50 AM.Relevant medical history is: COPD Diabetes. Code Status: Full Code. Resident/Patient is on: Hypoglycemic medication(s)/Insulin. Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were:- Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse)- Neurological Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse)Nursing observations, evaluation, and recommendations are:Primary Care Provider Feedback: Primary Care Provider responded with the following feedback:A. Recommendations: send for eval.On 9/11/25 at 11:05 AM, V6, Registered Nurse (RN), stated, I went in to see (R5) yesterday morning to check his blood sugar and he was lethargic, would only respond by opening his eyes when his name was called. His blood sugar was 49 at that time so I gave him some Ensure to drink, then got him some Glucagon spray from the E-Kit (Emergency Kit) and gave that to him. I then rechecked (R5's) blood sugar and it had dropped and was now reading 33. I called 911 to transport (R5) to the hospital. I do not recall giving (R5) anything else, including any injections. (V27, Licensed Practical Nurse (LPN) was the other nurse helping me with (R5).On 9/11/25 at 11:55 AM, V27, LPN, stated, (V6) asked me to come help her with (R5) and that she needed the E-Kit. I went and got the E-Kit and handed her a long tube-looking thing and a nasal spray. I saw her take out the long tube looking thing, then put the top from the nasal spray on the long tube thing and she gave it to (R5) in his nose. I did not give any drugs. If that was an Epi Pen, then yes, I handed it to her and that was my fault. I did an incident report, reported it to the NP (Nurse Practitioner) and the DON (Director of Nursing).On 9/11/25 at 12:00 PM, V26, NP, stated, I was just getting to the facility when EMS was taking (R5) out. (R5) had his eyes open when he left here. V27 then came and told me that (V6) gave (R5) Epi by accident. I do not see how they could have given the Epi with a Glucagon Nasal Spray cap on it. (R5) probably did not even get it, which is why his blood sugar never went up for them. It was a med error and a mistake.On 9/11/25 at 1:41 PM, V28, Emergency Medical Technician Paramedic (EMTP), stated, When we arrived at the facility, we had a male unresponsive with a blood sugar of 42. We started an IV (intravenous catheter) and administered D10. When we were moving him from his bed to our stretcher, we found an Epi Pen with a Narcan nasal spray cap on top of it. When I asked the nurse about it, she said she gave him Glucagon. I had two other firefighters look at it and they both verified that it was an Epi Pen. Again, the nurse stated that she knew she gave Glucagon. We put the resident on the stretcher and left the facility and took him to the ER (emergency room). Upon our arrival to the ER, the resident was slightly more alert to verbal stimuli, and his glucose was up to 136. I told the ER and my EMS director about the Epi Pen, and they were going to report it.R5's Emergency Medical Service (EMS) Report, dated 9/10/25, documents in part: Arrived on scene, made entry into the facility and into pt (patient) room to find male pt lying in bed unresponsive. Nurse states pt is diabetic and his blood sugar was low. Nurse states she gave pt internasal glucagon and placed him on a non-rebreather mask with 15 LPM (liters per minute) of O2 (oxygen). No staff is bedside with pt upon arrival. ALS (advanced life support) had arrived first on scene. Obtained blood glucose level via finger prick method. Value of 42. Started 18g (gauge) angiocath in pt left hand and flushed with saline before locking and securing with Tegaderm. Pt skin is warm and clammy at this time. Started 250 ML (milliliter) bag of D10% (glucose solution) using macro drip tubing. While D10 is infusing, pt is moved to the stretcher from his bed using bed sheet and assistance from FD (fire department). While moving pt, an Epi Auto Injector pen is found in pt. bed. Placed on top was the nasal piece used for internasal Narcan. When staff nurse was asked why the Epi pen was in the bed, she stated that it was Glucagon, and she had administered it in an attempt to raise pt glucose level. Pen was handed to FD for confirmation. FD also confirmed that pen is an Epi pen and not Glucagon. Nurse continues to argue that it is Glucagon, and it must have been placed in the wrong spot, and she did not confirm before administration.On 9/11/25 at 9:50 AM, V24, Master Social Work (MSW)/Licensed Social Worker (LSW), stated, I was working yesterday when (R5) arrived in the ER. The EMS guys gave us an Epi Pen that had a Narcan Cap from a intranasal administration unit on top of it and was told that the nurse at the facility gave this to (R5). The EMS told the ER staff that (R5) was unresponsive upon their arrival to the facility, they gave some D10 solution to raise his glucose and upon arrival to the ER, (R5) was awake, alert but still groggy. (R5) was admitted to the ICU for observation.On 9/11/25 at 12:05 PM, V6, RN, stated, I have to tell you what happened. I lied to you earlier. (V27) handed me the Epi Pen and Glucagon Nasal Spray and I did not even look at them to see what they were. I put the cap on the pen and tried to give it to (R5). Honestly, I don't even know if he got any of it. So much was going on at that time and the next thing I know, EMS was here and took over. I did give the EMS guys the Epi Pen and Nasal Spray. I'm not that familiar with these types of drugs. This was my first med error, and I feel horrible, especially about lying about it.On 9/11/25 at 2:40 PM, V2, DON, stated, There are tackle boxes with emergency medications in it, including Epi Pens, Narcan, and Baqsimi Nasal Powder. The nurses would grab this for emergency situations.On 9/15/25 at 10:25 AM, V3, LPN, stated, If I found a resident who was unresponsive, I would check their blood sugar, look for orders, and grab the medication that you put up their nose. I can't think of the name of it right now, but if I see it, I will know what it is. It is kept in the tackle box E-Kit. I would not give Epi because it is not an allergic reaction, nor would I give Narcan because it is not an overdose.On 9/15/25 at 10:30 AM, V11, LPN, stated, If I found one of my residents unresponsive, I would check their vital signs and blood sugar. If the blood sugar is low and they are not able to take something by mouth, I would go to the E-Kit and get the Glucagon nasal spray and administer it to them to get their blood sugar up. I would not give Epi for something like this because it is not an allergic reaction.On 9/15/25 at 10:50 AM, V2, DON, brought in an Epi Pen and a Narcan Nasal Spray and attempted to demonstrate how V6 was administering R5's medication. V2 stated, I doubt that he got any of the medication the way she put this together. I feel this is simply incompetent nursing.On 9/15/25 at 2:13 PM, V29, Physician/Medical Director, stated, I was only notified of (R5's) hypoglycemic episode and that he was sent to the hospital. No one mentioned to me that he was not given his glucose and was given something else. I have standing orders for Glucagon to be given and that should have been given. When told of V6 giving R5 an Epi Pen with the Narcan top and spraying up R5's nose, V29 stated, Oh my God, that is unbelievable. I have never heard of such a thing. This could have been detrimental to (R5) and could have been fatal to him. He didn't get his Glucagon that was ordered, and his glucose could have continued to drop. This is truly unbelievable; the lack of competency could have subsequently determined (R5's) outcome, which could have been death in this case. I would expect the Nurse to administer medications as per my orders, and per appropriate route.On 9/11/25 at 2:10 PM, V2, DON, stated, I would expect the nurses to use the five rights of medication administration and to follow physician orders.V2's Investigation, dated 9/11/25, documents, Nursing Description: Nurse called into room and found resident's blood sugar to be 39. Blood sugar was retaken and decreased to 33. Nurse then went to medication room to obtain Glucagon nasal spray and Narcan nasal spray was given in error. Immediate action taken: NP was made aware of the Epi spray being given. VS-120/70, 70, 18, 97.0. Nursing stayed with resident and 911 called to transport resident to ER via stretcher. Resident was alert leaving the unit. V2 stated she is not finished with the investigation and will be in-servicing the nurses.The Facility's Registered Nurse Job Description, dated 10/2024, documents in part The Registered Nurse is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is always maintained. Essential Duties and Responsibilities: Prepare and Administer medications as ordered by the physician. Qualifications: Must be able to make independent decisions when circumstances warrant such action. Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities.According to the NIH - National Library of Medicine; SCOPE OF PRACTICE - Nursing Fundamentals - NCBI Bookshelf at https://www.ncbi.nlm.nih.gov/books/NBK610819. The Scope of Practice refers to services a trained health professional is deemed competent to perform and permitted to undertake according to the terms of their professional nursing license. Nursing scope of practice provides a legal framework and structured guidance for activities that practical nurses and registered nurses can perform based on their nursing license. Nurses must also follow standards when providing nursing care. Standards are set by several organizations, including your state's Nurse Practice Act, the American Nurses Association (ANA), agency policies and procedures, and federal regulators. These standards help guide nursing actions with the intent that safe, competent care is provided to the public. Nursing Process: The nursing process is a critical thinking model based on a systematic approach to client-centered care. Nurses use the nursing process to perform clinical reasoning and make clinical judgments when providing client care. The nursing process is based on the Standards of Professional Nursing Practice established by the American Nurses Association (ANA). These standards are authoritative statements of the actions and behaviors that all registered nurses (RNs), regardless of role, population, specialty, and setting, are expected to perform competently. Education: The registered nurse seeks knowledge and competence that reflects current nursing practice and promotes futuristic thinking. Quality of Practice: The registered nurse contributes to quality nursing practice. Resource Stewardship: The registered nurse utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, financially responsible, and judiciously used.The Immediate Jeopardy that began on 9/10/25 was removed on 9/17/25 when the facility took the following actions to remove the Immediacy:1. All nurses were educated on the use of Emergency Medications by V2, DON, on 9/17/25.2. Any nurses that are not available in person have been contacted via phone. If not reachable, will be educated prior to taking shift by DON or designee.3. 9/15/25 V2, DON, V30, LPN, and V31, RN, ADON reviewed the incident.4. 100% Nursing staff has been educated on the signs and symptoms of hypoglycemia and hyper glycemia by V2, DON, and R31, RN, ADON on 9/17/25.5. Any nurses that are not available in person have been contacted via phone. If not reachable, will be educated prior to taking shift by DON or designee.6. On 9/10/25 NP was notified of the change in condition and MD notified of the resident being hypoglycemia and being sent to ER.7. V6 and V27 educated on ensuring right medication and dose prior to medication administration by V2, DON, on 9/17/25. 8. The monthly refresher will begin on 9/23/25 at our all-staff meeting.9. All nursing staff educated on the 5R's of medication administration by V2, DON, on 9/17/25.10. V6 and V27 were educated and completed competent in medication administration on Narcan, Epinephrine, and Baqsiumi on 9/17/25.11. 100% of nursing staff was educated on medication administration on 9/17/25.12. DON or Designees will audit medication administration 2 times a week for 3 months. This began on 9/17/25.13. DON or Designee will audit 3 residents 2 times weekly to ensure blood sugar are within normal limit per MD orders for 3 months this began on 9/17/25.14. DON or designee will perform an audit to ensure all emergency was handled correctly. This started on 9/17/25. This will be ongoing for 3 months and reviewed in our QA meeting.15. The emergency kits and the cart will be audit weekly to ensure educational material is in place. This started on 9/17/25. This will be on going for 3 month and review in our QA meeting. This will be monitor by ADON or designee.16. ADHOC QA completed with IDT regarding Policy and procedure on 9/15/25.17. QA to review policy and procedure as part of Quality Assurance Process; next QA meeting.18. This will be on going for 3 months.

Based on interview, observation, and record review, the facility failed to provide a resident in a crisis condition the correct medication for 1 of 6 residents (R5) reviewed for medication errors in the sample of 50. This failure resulted in the R5 not receiving his Glucagon when needed resulting in his blood sugar dropping to a critical low and being transferred to the hospital and subsequently admitted to the Intensive Care Unit (ICU).The Immediate Jeopardy began on 9/10/25, when V6, Registered Nurse (RN), failed to appropriately respond to an emergent medical event, when R5 displayed symptoms of medical distress and presented with a blood glucose level of 33. V6 failed to follow physician's order of administering Baqsimi (Glucagon) for low blood sugar, and instead disassembled prefilled Epinephrine and Narcan cartridges, combining pieces of both medication cartridges, and administered Epinephrine injection nasally. On 9/16/25 at 2:15 PM, V1, Administrator, and V2, Director of Nursing (DON), were notified of the Immediate Jeopardy. The surveyor confirmed by interview, observation, and record review, the Immediate Jeopardy was removed on 9/17/25, but noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The Findings Include:R5's admission Record, dated 9/11/25, documents R5 was admitted to the facility on [DATE] with diagnosis of: Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), Hypoxemia, Type 2 Diabetes Mellitus (DM), End Stage Renal Disease (ESRD), Dependent on Dialysis, Hypertension (HTN), anxiety disorder, and schizoaffective disorder.R5's Care Plan, dated 4/1/25, documents R5 has Diabetes Mellitus and Diabetic Neuropathy. Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness, Monitor/document/report PRN any s/sx (signs/symptoms) of hypoglycemia: Sweating, tremor, increased heart rate (Tachycardia), pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait, Monitor/document/report PRN (as needed) any s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing, acetone breath (smells fruity), stupor, or coma.R5's Minimum Data Set (MDS), dated [DATE], documents R5 is cognitively intact and is dependent on staff for most Activities of Daily Living (ADLs). R5's Physician Order, dated 7/23/25, documents Baqsimi one pack nasal powder 3 MG (milligram)/dose (Glucagon) 1 pump in nostril as needed for low blood sugar. May repeat in 15-minutes.R5's Medication Administration Record (MAR)-Treatment Administration Record (TAR), dated September 2025, does not document that Baqsimi One Pack Nasal Powder 3 MG/Dose (Glucagon) was given to R5. There is no documentation of R5 receiving Narcan or Epinephrine (Epi).R5's SBAR (situation, background, assessment, and recommendation) Note, dated 9/10/25 at 8:08 AM, documents in part, Situation: The Change in Condition (CIC)/s reported on this CIC Evaluation are/were: Altered mental status. At the time of evaluation resident/patient vital signs and blood sugar were:- Blood Pressure: BP 120/70 - 9/10/25 at 8:09 AM,- Pulse: P 70 - 9/10/25 at 8:09 AM, Pulse Type: Regular- RR (respiratory rate): R 18 - 9/10/25- Temp: T 97 - 9/10/25 - Pulse Oximetry: O2 97.0 % - 9/10/25 Method: Oxygen via Nasal Cannula- Blood Glucose: BS 49.0 - 9/10/25 at 7:50 AM.Relevant medical history is: COPD Diabetes. Code Status: Full Code. Resident/Patient is on: Hypoglycemic medication(s)/Insulin. Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were:- Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse)- Neurological Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse)Nursing observations, evaluation, and recommendations are:Primary Care Provider Feedback: Primary Care Provider responded with the following feedback:A. Recommendations: send for eval.On 9/11/25 at 11:05 AM, V6, Registered Nurse (RN), stated, I went in to see (R5) yesterday morning to check his blood sugar and he was lethargic, would only respond by opening his eyes when his name was called. His blood sugar was 49 at that time so I gave him some Ensure to drink, then got him some Glucagon spray from the E-Kit (Emergency Kit) and gave that to him. I then rechecked (R5's) blood sugar and it had dropped and was now reading 33. I called 911 to transport (R5) to the hospital. I do not recall giving (R5) anything else, including any injections. (V27, Licensed Practical Nurse (LPN) was the other nurse helping me with (R5).On 9/11/25 at 11:55 AM, V27, LPN, stated, (V6) asked me to come help her with (R5) and that she needed the E-Kit. I went and got the E-Kit and handed her a long tube-looking thing and a nasal spray. I saw her take out the long tube looking thing, then put the top from the nasal spray on the long tube thing and she gave it to (R5) in his nose. I did not give any drugs. If that was an Epi Pen, then yes, I handed it to her and that was my fault. I did an incident report, reported it to the NP (Nurse Practitioner) and the DON (Director of Nursing).On 9/11/25 at 1:41 PM, V28, Emergency Medical Technician Paramedic (EMTP), stated, When we arrived at the facility, we had a male unresponsive with a blood sugar of 42. We started an IV (intravenous catheter) and administered D10. When we were moving him from his bed to our stretcher, we found an Epi Pen with a Narcan nasal spray cap on top of it. When I asked the nurse about it, she said she gave him Glucagon. I had two other firefighters look at it and they both verified that it was an Epi Pen. Again, the nurse stated that she knew she gave Glucagon. We put the resident on the stretcher and left the facility and took him to the ER (emergency room). Upon our arrival to the ER, the resident was slightly more alert to verbal stimuli, and his glucose was up to 136. I told the ER and my EMS director about the Epi Pen, and they were going to report it.R5's Emergency Medical Service (EMS) Report, dated 9/10/25, documents in part: Arrived on scene, made entry into the facility and into pt (patient) room to find male pt lying in bed unresponsive. Nurse states pt is diabetic and his blood sugar was low. Nurse states she gave pt internasal glucagon and placed him on a non-rebreather mask with 15 LPM (liters per minute) of O2 (oxygen). No staff is bedside with pt upon arrival. ALS (advanced life support) had arrived first on scene. Obtained blood glucose level via finger prick method. Value of 42. Started 18g (gauge) angiocath in pt left hand and flushed with saline before locking and securing with Tegaderm. Pt skin is warm and clammy at this time. Started 250 ML (milliliter) bag of D10% (glucose solution) using macro drip tubing. While D10 is infusing, pt is moved to the stretcher from his bed using bed sheet and assistance from FD (fire department). While moving pt, an Epi Auto Injector pen is found in pt. bed. Placed on top was the nasal piece used for internasal Narcan. When staff nurse was asked why the Epi pen was in the bed, she stated that it was Glucagon, and she had administered it in an attempt to raise pt glucose level. Pen was handed to FD for confirmation. FD also confirmed that pen is an Epi pen and not Glucagon. Nurse continues to argue that it is Glucagon, and it must have been placed in the wrong spot, and she did not confirm before administration.On 9/11/25 at 9:50 AM, V24, Master Social Work (MSW)/Licensed Social Worker (LSW), stated I was working yesterday when (R5) arrived in the ER. The EMS guys gave us an Epi Pen that had a Narcan Cap from a intranasal administration unit on top of it and was told that the nurse at the facility gave this to (R5). The EMS told the ER staff that (R5) was unresponsive upon their arrival to the facility, they gave some D10 solution to raise his glucose and upon arrival to the ER, (R5) was awake, alert but still groggy. (R5) was admitted to the ICU for observation.On 9/11/25 at 12:05 PM, V6, RN, stated, I have to tell you what happened. I lied to you earlier. (V27) handed me the Epi Pen and Glucagon Nasal Spray and I did not even look at them to see what they were. I put the cap on the pen and tried to give it to (R5). Honestly, I don't even know if he got any of it. So much was going on at that time and the next thing I know, EMS was here and took over. I did give the EMS guys the Epi Pen and Nasal Spray. I'm not that familiar with these types of drugs. This was my first med error, and I feel horrible, especially about lying about it.On 9/11/25 at 2:40 PM, V2, DON, stated, There are tackle boxes with emergency medications in it, including Epi Pens, Narcan, and Baqsimi Nasal Powder. The nurses would grab this for emergency situations.On 9/15/25 at 10:25 AM, V3, LPN, stated, If I found a resident who was unresponsive, I would check their blood sugar, look for orders, and grab the medication that you put up their nose. I can't think of the name of it right now, but if I see it, I will know what it is. It is kept in the tackle box E-Kit. I would not give Epi because it is not an allergic reaction, nor would I give Narcan because it is not an overdose.On 9/15/25 at 10:30 AM, V11, LPN, stated If I found one of my residents unresponsive, I would check their vital signs and blood sugar. If the blood sugar is low and they are not able to take something by mouth, I would go to the E-Kit and get the Glucagon nasal spray and administer it to them to get their blood sugar up. I would not give Epi for something like this because it is not an allergic reaction.On 9/11/25 at 2:10 PM, V2 stated I would expect the nurses to use the five rights of medication administration and follow the physician orders.On 9/15/25 at 10:50 AM, V2 brought in an Epi Pen and a Narcan Nasal Spray and attempted to demonstrate how V6 was administering R5's medication. V2 stated I doubt that he got any of the medication the way she put this together. I feel this is simply incompetent nursing.V2's Investigation, dated 9/11/25, documents Nursing Description: Nurse called into room and found resident's blood sugar to be 39. Blood sugar was retaken and decreased to 33. Nurse then went to medication room to obtain Glucagon nasal spray and Narcan nasal spray was given in error. Immediate action taken: NP was made aware of the Epi spray being given. VS-120/70, 70, 18, 97.0. Nursing stayed with resident and 911 called to transport resident to ER via stretcher. Resident was alert leaving the unit. V2 stated she is not finished with the investigation and will be in-servicing the nurses.On 9/15/25 at 2:13 PM, V29, Physician/Medical Director, stated I was only notified of (R5's) hypoglycemic episode and that he was sent to the hospital. No one mentioned to me that he was not given his glucose and was given something else. I have standing orders for Glucagon to be given and that should have been given. When told of V6 giving R5 an Epi Pen with the Narcan top and spraying up R5's nose, V29 stated Oh my God, that is unbelievable. I have never heard of such a thing. This could have been detrimental to (R5) and could have been fatal to him. He didn't get his Glucagon that was ordered, and his glucose could have continued to drop. This is truly unbelievable; the lack of competency could have subsequently determined (R5's) outcome, which could have been death in this case. I would expect the Nurse to administer medications as per my orders, and per appropriate route.According to the NIH - National Library of Medicine; Nursing Rights of Medication Administration - StatPearls - NCBI Bookshelf at https://www.ncbi.nlm.nih.gov/books/NBK560654/. Nursing Rights of Medication Administration: Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration. It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. The five traditional rights in the traditional sequence include: Right Patient, Right Drug, Right Route, Right Time, and Right Dose.According to the NIH - National Library of Medicine; SCOPE OF PRACTICE - Nursing Fundamentals - NCBI Bookshelf at https://www.ncbi.nlm.nih.gov/books/NBK610819. The Scope of Practice refers to services a trained health professional is deemed competent to perform and permitted to undertake according to the terms of their professional nursing license. Nursing scope of practice provides a legal framework and structured guidance for activities that practical nurses and registered nurses can perform based on their nursing license. Nurses must also follow standards when providing nursing care. Standards are set by several organizations, including your state's Nurse Practice Act, the American Nurses Association (ANA), agency policies and procedures, and federal regulators. These standards help guide nursing actions with the intent that safe, competent care is provided to the public. Nursing Process: The nursing process is a critical thinking model based on a systematic approach to client-centered care. Nurses use the nursing process to perform clinical reasoning and make clinical judgments when providing client care. The nursing process is based on the Standards of Professional Nursing Practice established by the American Nurses Association (ANA). These standards are authoritative statements of the actions and behaviors that all registered nurses (RNs), regardless of role, population, specialty, and setting, are expected to perform competently. Education: The registered nurse seeks knowledge and competence that reflects current nursing practice and promotes futuristic thinking. Quality of Practice: The registered nurse contributes to quality nursing practice. Resource Stewardship: The registered nurse utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, financially responsible, and judiciously used.According to the NIH - National Library of Medicine; Nursing Rights of Medication Administration - Stat Pearls - NCBI Bookshelf at https://www.ncbi.nlm.nih.gov/book/NBK/560654/ documents in part Nursing Rights of Medication Administration. Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration. It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. The five traditional rights in the traditional sequence include: Right Patient, Right Drug, Right Route, Right Time, and Right Dose. The Facility's Medication Administration Policy, dated 10/2024, documents in part Administration of Medications: Medications must be administered in accordance with a Physician's order, e.g., the Right Medication, Right Dosage, Right Route, and Right Time. The Immediate Jeopardy that began on 9/10/25 was removed on 9/17/25 when the facility took the following actions to remove the Immediacy: 1. All nurses were educated on the use of Emergency Medications by V2, DON, on 9/11/25.2. Any nurses that are not available in person have been contacted via phone. If not reachable, will be educated prior to taking shift by DON or designee.3. 9/15/2025, V2, DON, V30, LPN, and V31, RN, ADON reviewed the incident.4. 100% Nursing staff has been educated on the signs and symptoms of hypoglycemia and hyper glycemia by V2, DON, and V31, RN, ADON on 9/15/25.5. Any nurses that are not available in person have been contacted via phone. If not reachable, will be educated prior to taking shift by DON or designee.6. On 09/10/ 2025 NP was notified of the change in condition and MD notified of the resident being hypoglycemia and being sent to ER.7. V6 and V27 educated on ensuring right medication and dose prior to medication administration by V2, DON, on 9/15/25. 8. All nursing staff educated on the 5R's of medication administration by V2, DON, on 9/15/25.9. V6 and V27 were educated and completed competent in medication administration on Narcan, Epinephrine, and Baqsimi on 9/15/25.10. 100% of nursing staff was educated on medication administration on 9/15/25.11. DON or Designees will audit medication administration 2 times a week for 3 months. This began on 9/15/25.12. DON or Designee will audit 3 residents 2 times weekly to ensure blood sugar are within normal limit per MD orders for 3 months this began on 9/15/25.13. The emergency kits and the cart will be audit weekly to ensure educational material is in place. This started on 09/15/25. This will be on going for 3 month and review in our QA meeting. This will be monitor by ADON or designee.14. ADHOC QA completed with IDT regarding Policy and procedure on 9/15/25.15. QA to review policy and procedure as part of Quality Assurance Process; next QA meeting.16. This will be on going for 3 months.

Based on interview, observation, and record review, the facility failed to dispose of an expired Tuberculin vial and to safely secure medications in a medication cart while sitting in the hallway and available for all residents and visitors to get into. Reviewed for medication labeling and storage in the sample of 50. This failure has the potential to affect all residents living in the facility.The Findings Include: 1. On [DATE] at 10:18 AM, the Medication Cart on the end of the 200-hall was observed sitting in the hallway unlocked with no staff member around it. V7, Certified Nursing Assistant (CNA), stated, The Nurse had to go to central supply to get something and should be back soon. On [DATE] at 10:25 AM, V6, Registered Nurse (RN), came back to the cart and stated, The cart is broken, and we are waiting for the pharmacy to come fix it. We are unable to lock it and if we did, we can't get it back open. The drawers on the right side are locked, and we are not able to open those drawers, if needed, we have to go get the med from stock or emergency supply. On [DATE] at 10:30 AM, V8, Regional Nurse Consultant was notified of broken and unlocked medication cart sitting in the hall. V8 stated, I was not aware of that, and we can't have a cart left in the hallway unlocked. I will get this taken care of immediately. On [DATE] at 9:55 AM, R12 stated, The med cart has been broken since last Friday ([DATE]) because the nurse tried to get it open to give him his medications and she couldn't get it open. On [DATE] at 9:57 AM, V12, CNA, stated, (R12) would probably know because he keeps up with what goes on around here. R12's Minimum Data Set (MDS), dated [DATE], documents R12 is cognitively intact. On [DATE] at 11:00 AM, the med cart on the 4th floor was seen unlocked in the hall with no staff around. On [DATE] at 11:12 AM, the med cart on the 3rd floor was seen sitting in the hall unlocked with no staff around. On [DATE] at 2:10 PM, V2, DON, stated I would expect the nurses to use the five rights of medication administration. I would expect the nurses to keep the medication carts locked at all times when walking away from the cart. 2. On [DATE] at 10:46 AM, the 300-hall medication room was checked. In the medication refrigerator, there was an opened multidose bottle of Tuberculin protein derivative Diluted/Aplisol 5TU/0.1 milliliters, 5ML/50 test that was opened on [DATE]. On [DATE] at 10:35 AM, V4, LPN, stated that on the 4th floor, they do not keep the tuberculin testing serum on their floor and that she gets it from either 2nd or 3rd floor medication room. On [DATE] at 10: 55 AM, the 200-hall medication room was checked and there was not a bottle of Tuberculosis testing serum in the refrigerator. On [DATE] at 11:00 AM V2, Director of Nurses, stated that they have a bottle of tuberculosis test in the 3rd floor medication room that they have been using if there wasn't any in the 200-hall medication room. On [DATE] at 3:15 PM, V1, Administrator stated the bottle of Tuberculin, dated [DATE], should have been thrown away a long time ago. The Facility's Medication Storage Policy, dated 4/2025, documents To ensure proper storage, labeling and expiration dates of medications, biologicals, syringes and needles. 3. General Storage Procedures: 2. Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. 5. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. The Long-Term Care Facility Application for Medicare and Medicaid (CMS 671), dated [DATE], documents there were 128 residents residing in the facility.

The facility failed to use hair nets while in the kitchen, to provide paper towels for hand hygiene, to label food items stored in the refrigerator, and to dispose of expired food items. This has the potential to affect all residents in the facility.The Findings Include:1. On 9/7/25 at 8:50 AM, while doing the initial kitchen tour, V18, Dietary Aide, and V19, Dietary Prep, were seen with no hair net on and upon surveyor entrance, both were seen going and getting a hairnet and putting one on.2. There were no paper towels available for handwashing at the handwashing sink.3. A large piece of ham was seen in the refrigerator wrapped in plastic wrap and undated.4. A large pan of sliced tomatoes was seen in the refrigerator covered in plastic wrap and undated.5. A pan of mixed vegetables was seen in the refrigerator covered in plastic wrap and undated.6. On the fourth-floor dry food storage room, there were three packages of hot dog buns that expired on 9/4/25.On 9/7/25 at 9:00 AM, V20, Cook, stated The items in the fridge should have been dated, especially since they are prepped and ready to eat items. The delivery guy usually rotates the bread when delivered, so I'm not sure why we have expired buns.On 9/11/25 at 2:15 PM, V21, Dietary Manager, stated I would expect the dietary staff to wear hair nets while in the kitchen, label all food items that are opened and/or prepped and placed in the refrigerator, and to dispose of any food items that are expired.The Facility's Food & Supplies: Storage Policy, dated 1/2024, documents in part Food and supply storage areas shall be maintained in a clean, safe and sanitary manner. 4. Prepared foods stored in the refrigerator until service will be covered, labeled, and dated with an expiration date. 6. All foods will be covered, labeled, and dated. If there is no expiration date on the package or container, a use-by-date must be written on the product.The Long-Term Care Facility Application for Medicare and Medicaid (CMS 671), dated 9/7/25, documents there were 128 residents residing in the facility.

Based on observation, interview and record review the facility failed to implement enhance barrier precautions and change gloves when soiled for 5 of 32 residents (R1, R4, R12, R40 and R121) reviewed for infection control in the sample of 50.Findings include: 1. On 09/09/2025 at 12:11PM V9 wound nurse and V16 Certified Nursing Assistant (CNA) entered R1's room. V16, CNA did not sanitize hands, don gloves, or gown prior to entering R1's room. Sign on wall beside R1's door documents enhanced barrier precautions. While standing at R1's bedside V16 sanitized hands and donned gloves. V16, CNA did not don a gown. V16 with gloved hands assisted V9 to roll R1 towards V16 for V9, wound nurse to do wound care to R1. Enhanced Barrier Precautions sign documents Stop, everyone must clean their hands, including before entering and when leaving room. Providers and staff must also: wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting. Device care or use: wound care: any skin opening requiring a dressing, central line, urinary catheter, feeding tube tracheostomy. R1's Physician Orders (PO) dated 6/17/2025 documents enhanced barrier precautions. 2. R12's admission Record, dated 9/11/25, documents R12 was admitted to the facility on [DATE] with diagnosis of Furuncle of groin, abscess of groin, infection following a procedure/surgical site, open wound to right lower leg, and Type 2 Diabetes Mellitus. On 9/9/25 at 9:25 AM, V11, Licensed Practical Nurse (LPN), was observed doing wound care on R12. V11 removed the old dressing on R12's right medial calf which was dated 9/7/25 and was not changed prior day (9/8/25). R12 pulled his pants down and assisted V11 to provide wound care to his scrotum/penis area. V11 cleansed R12's wound with Normal Saline (NS) to 4X4 gauzes, then used the same gloves to get a sterile Q-Tip and applied meta-honey to the wound site. V11 doffed her Personal Protective Equipment (PPE) when R12 mentioned that his lateral calf has been oozing for about a week now. V11 examined R12's lateral calf and there was a small open area noted with slight ooze. V11 donned PPE, cleansed the wound with NS and 4X4 gauzes, then used the same gloves and got a sterile Q-Tip and applied meta-honey to the open areas, and then applied a dressing. V11 failed to change gloves when going from soiled, cleaning the wound, to applying meta-honey and then a dressing. 3. R121's admission Record, dated 9/11/25, documents R121 was admitted to the facility on [DATE] with diagnosis of Cerebral Palsy, Paraplegia, and malnutrition. On 9/9/25 at 12:15 PM, V14, CNA, and V15, CNA, was observed providing peri-care on R121. V14 brought in supplies and placed on bedside table. An Enhanced Barrier Precaution (EBP) sign was on the door with PPE hanging on the door. V14 had water running in the sink when V15 called V14 to the door and told V14 that he had to don PPE first, then they both walked in with PPE on. V15 held R121 while V14 provided peri-care and catheter care on R121. During the care, V14 had gloves on which he wiped R121's buttocks and anal area after cleaning feces off once, changed gloves, then wiped R121's buttocks and anal area off again and then using the same soiled gloves, used the remote to the bed and raised the bed slightly, then continued to provide care to R121 including drying, putting clean brief down, and adjusted R121 in bed and covered R121 up with his sheet all with the same soiled gloves on. On 9/11/25 at 2:10 PM, V2, DON, stated I would expect all staff to use appropriate hand hygiene and glove changes during resident care. 4. On 09/07/2025 at 10:02 AM V3, Licensed Practical Nurse (LPN) entered R4's room to give a 125 milliliter (ml) water flush. V3 turned off the feeding pump, disconnected the tubing from the G-tube and gave R4 a 125 ml water flush through the G-tube. V3 failed to wear a gown. R4's Physician Order, dated 8/8/25, documents, ENHANCED BARRIER PRECAUTIONS D/T (due to) RISK FACTORS OF: FOLEY CATHETER, G-TUBE & WOUNDS. R4's admission Record, print date of 9/10/25, documents, R4 was admitted on [DATE] and has diagnosis of gastrostomy status. On 9/11/25 at 11:54 AM, V3, Licensed Practical Nurse (LPN), was questioned why she did not wear a gown while caring for R4, V3 stated, I am new here and I have never seen anyone wear a gown. 5. On 9/8/25 at 11:35 AM V9, LPN/Wound Nurse entered R40's room to change his left heel pressure ulcer and change his right upper leg dressings. V9 was wearing gloves, but no gown. V9 opened the door and went back to the wound cart to get a marker, V9 returned and removed the old dressing. V9 change gloves with hand hygiene in-between. V9 cleansed the pressure ulcer, change the right glove only with no hand hygiene in between, applied the Medihoney, and foam dressing. R40's Physician Order, dated 9/2/25, documents, ENHANCED BARRIER PRECAUTIONS D/T RISK FACTORS OF: WX'S (wounds). R40's admission Record, print date of 9/10/25, documents R40 was admitted on [DATE] and has a diagnosis of Emphysema. On 9/11/25 at 12:17 PM, V2, Director of Nurses, stated gowns should be worn with dressing changes and G-tube. V9 told me she didn't wear a gown. The policy Enhanced Barrier Precautions, dated3/25, documents, 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. Personal Protective Equipment: gown and gloves. EBP may be considered and implemented for: Wounds and / or indwelling medical devices. 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, Wound Care. The policy hand Hygiene / handwashing, dated 5/25, documents, Examples of When to Perform Hand Hygiene. Before glove placement. After glove removal. The policy Glove Use – Nursing, dated 10/24, documents, 3. Gloves used for contact shall be removed and discarded after contact with each person, fluid item, or surface.

Based on Interview, Observation, and Record Review, the facility failed to identify and treat a resident's wounds for 1 of 6 residents (R12) reviewed for wound care in the sample of 50.The Findings Include:R12's admission Record, dated 9/11/25, documents R12 was admitted to the facility on [DATE] with diagnosis of Furuncle of groin, Abscess of groin, Infection following a procedure/surgical site, Open wound to right lower leg, Type 2 Diabetes Mellitus (DM), Chronic Kidney Disease (CKD), Atherosclerotic Heart Disease (ASHD), Congestive Heart Failure (CHF), and Hypertension (HTN).R12's Care Plan, dated 7/29/25, documents R12 has a potential for impairment to skin integrity related to decreased mobility. Interventions: Assess/record changes in skin status, follow facility protocols for treatment of injury, pressure relieving/reducing cushion to protect the skin while up in chair, pressure relieving/reducing mattress to protect the skin while in bed, use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. It continues 8/14/25: R12 has a surgical incision/ wound. Site: right lateral calf and right medial calf. Interventions: Keep incision site clean/dry, monitor site for signs/symptoms of infection, treatment as ordered. It continues 11/14/24: R12 is on Enhanced barrier precautions related to chronic wounds. It continues 8/14/25: R12 has an unstageable pressure ulcer to left heel. R12 has abrasion to right toes. 9/19/24: R12 no longer wants the facility wound nurse to follow his wounds. R12 feels that she cleans them too hard, and he wants the floor nurses to perform his treatments. Interventions: Administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing, measure length, width and depth where possible, assess and document status of wound perimeter, wound bed and healing progress, report improvements and declines to the Medical Doctor (MD), follow facility policies/protocols for the prevention/treatment of skin breakdown, monitor dressing during cares to ensure it is intact and adhering, report lose dressing to nurse, weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate.R12's Minimum Data Set (MDS), dated [DATE], documents R12 is cognitively intact and requires supervision/touching assistance for all Activities of Daily Living (ADLs). R12's Physician Order (PO), dated 8/29/25, documents Cleanse open areas to scrotum with NS (normal saline)/house wound cleanser, pat dry, apply medi-honey to open areas only daily and PRN (as needed), every day shift and as needed.R12's PO, dated 8/22/25, documents Skin prep area to right inner heel daily and PRN, every day shift and as needed.R12's PO, dated 5/15/25, documents Weekly Skin Assessment. Every night shift every Mon (Monday) notify MD (medical doctor) if new impairment and complete other skin condition UDA (user defined assessment).R12's PO, dated 9/9/25, documents Cleanse area to right lateral calf with wound cleanser, pat dry, apply medi-honey to wound bed and cover with bordered gauze daily and PRN, every day shift for wound care and as needed for wound care.R12's PO, dated 9/9/25, documents Cleanse right medial leg with wound cleanser, pat dry, apply medi-honey to bed and cover with bordered gauze daily and PRN, every day shift for wound care and as needed for wound care.R12's Skin Condition Report, dated 9/20/24, documents R12 had a new skin concern, pinprick open area, scrotum on left side, pinprick area of bleeding no redness around it and does not appear to be ingrown hair, new orders: foam dressing to cover daily and PRN. There is no other skin condition report completed until 9/9/25.R12's Skin Condition Report, dated 9/9/25, documents R12 has a new skin concern, Excoriation/Denuded Skin, open areas caused by edema, right lower leg (front) Medial 14.2x2.0x0.1, right lower leg (front) Lateral 1.1x0.3x0.1, no ss (signs/symptoms) of infection. Wound bed pink, scant serosanguinous exudate, cleanse daily apply medi-honey and bordered gauze.R12's Monthly Charting document (assessment), dated 8/22/25, does not document anything for R12's skin conditions.R12's Monthly Charting document (assessment), dated 7/22/25, documents No new changes to skin integrity noted.On 9/7/25 at 9:52 AM, R12 stated he does not wear pants due to edema to his scrotum and right leg. R12 has an old undated dressing to his right leg with the gauze wrap falling to his ankle and old xeroform packing stuck to the open sites to his medial calf. The dressing appeared to be very heavily soiled, brown in color with oozing from wound. R12 stated they haven't changed his dressing in a while and doesn't remember last time it was changed. R12 stated they are supposed to change it every day. On 9/8/25 at 10:05 AM, R12 observed lying in bed with a new dressing to his right medial calf and now dated 9/7/25. On 9/9/25 at 9:25 AM, V11, Licensed Practical Nurse (LPN), was advised that R12 needed wound care done. V11 stated she was not aware of R12's dressing to his right leg. V2, Director of Nursing (DON), was standing at the med cart reviewing R12's orders and stated that she did not see any orders for wound care or dressing changes to R12's Right Lower Extremity (RLE). V11 removed the old dressing from R12's right medial calf which was dated 9/7/25 and was not changed yesterday (9/8/25). V11 used NS to a 4X4 gauze and wiped R12's right medial calf wound which measured at 14.2 CM (centimeters) long X 2 CM wide X 0 CM deep. R12 pulled his pants down and assisted V11 to provide wound care to his scrotum/penis area. V11 cleansed R12 scrotum/penis area with NS on 4X4 gauzes, then used the same gloves to get a sterile Q-Tip to apply medi-honey to site. V11 doffed her PPE when R12 mentioned his lateral calf has been oozing for about a week now, V11 examined R12's lateral calf and there was a small open area noted with slight ooze and measured at 1.1 CM long X 0.3 CM wide X 0 CM deep. V11 wiped the wound with NS on 4X4 gauzes, then used the same gloves and got a sterile Q-Tip to apply medi-honey to the open area and then applied a dressing. V11 stated she was not aware of either of R12's wounds to his right leg and will have to let the doctor know. V11 failed to change gloves when going from soiled areas, cleaning the wounds, to applying meta-honey and then a dressing. On 9/9/25 at 2:25 PM, V9, LPN/Wound Nurse, stated I was off for the past week and was not made aware of (R12's) wounds to his right calf. I did educate the nurses that if they find a new wound during skin assessments, they are to put something (a wound care order) in place temporarily, then notify me so I can assess the wound and determine if the appropriate wound care orders were in place. I would notify the physician and discuss the wound and care needed. I did not know about (R12's) wounds until today. Those are new wounds for (R12) because he did not have them the last time I took care of him. I don't know how long he has had them or who found them. The DON (Director of Nursing) told me about (R12's) wounds and that there were no orders in place to take care of them.On 9/15/25 at 9:35 AM, V2 stated I would expect the nurses and/or CNAs to report any new wounds or skin conditions to the wound nurse in order to obtain physician orders for treatment.The Facility's Skin Condition Assessment and Monitoring - Pressure and Non-Pressure, dated 4/2025, documents in part Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented. Guidelines: Pressure and other ulcers (diabetic, arterial, venous) will be assessed and measured at least weekly by licensed nurse and documented in the resident's clinical record. Non-pressure skin conditions (bruises/contusions, abrasions, lacerations, rashes, skin tears, surgical wounds, etc.) will be assessed for healing progress and signs of complications or infection weekly. A skin condition assessment and pressure ulcer risk assessment (Braden) will be completed at the time of admission/readmission. The pressure ulcer risk assessment will be updated quarterly and as necessary. Residents identified will have a weekly skin assessment by a licensed nurse. A wound assessment will be initiated and documented in the resident chart when pressure and/or other non-pressure skin conditions are identified by licensed nurse. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. 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. At the earliest sign of a pressure injury or other skin problem, the resident, legal representative, and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes.

Based on interview, observation, and record review, the facility failed to prevent and assess a pressure ulcer for 1 of 7 residents (R10) reviewed for pressure ulcers in the sample of 50. Findings include: R10's admission record, print date of 9/11/25, documents R10 was admitted on [DATE] and has diagnoses of Multiple Sclerosis and Traumatic Brain Injury. R10's Minimum Data Set, dated [DATE], documents R10 is moderately cognitively impaired, requires partial to moderate assistance with dressing, toileting, bed mobility, and transfers. R10's Braden Observation, dated 6/6/25, documents R10 is at moderate risk for pressure ulcers. R10's Nursing Note, dated 7/17/25, documents, Writer obtained consent from resident for res (resident) to be seen and treated by (wound clinic). Services are to begin 7/24/25. R10's, undated, Wound Summary documents R10 has a Facility Acquired Pressure ulcer on the coccyx that was identified on 7/16/25. R10's, undated, Wound Summary documents on 7/21/25 R10's coccyx pressure ulcer was partial thickness of slough white fibrinous tissue with scant serosanguineous drainage measuring 2.5 cm (centimeters) in length x 3 cm wide. R10's, undated, Wound Summary documents on 7/28/25 R10's coccyx pressure ulcer was unstageable with 30% slough white fibrinous tissue and 70% necrotic soft tissue measuring 3.4 cm in length and 2 cm wide. R10's Electronic Medical Record fails to document a coccyx pressure ulcer assessment on 7/16/25 or 7/17/25. R10's July 2025 Treatment Administration Record, documents Cleanse area to coccyx with normal saline/house wound cleanser, pat dry, apply calcium alginate cut to size and cover with mepilex daily and PRN (as needed) every day shift -Start Date of 07/17/2025 0600.R10's Nursing Note, dated 9/4/25, documents, Wound culture obtained on coccyx wound this AM while rounding with wound MD. Wound has slough and foul odor noted. On 9/9/25 at 1:12 PM, V9 Licensed Practical Nurse/ Wound Nurse, removed R10's coccyx dressing. The dressing had serous drainage on it. The wound had a foul odor. The wound bed was cleansed with normal saline. The wound bed is brown with white slough. The peri wound is bright red. The pressure ulcer measures 3.7 cm in length, 2.6 cm wide, and 1.9 cm deep. On 9/8/25 at 2:30 PM, V2, Director of Nurses, stated that there was not an initial assessment of R10's coccyx pressure ulcer and there should have been one done when it was found. On 9/9/25 at 1:10 PM, R10 stated that his buttocks hurt, and he does not know when he got the pressure ulcer. On 9/9/25 at 1:17 PM, V9 stated that the wound culture was rejected by the laboratory because the specimen was not collected on the labs swab. The lab never notified the facility that the culture wasn't accepted. We were just waiting for the results because it takes a while for a culture. R10 is being sent to the hospital so they can culture it. V9 stated R10 had C.Diff (chloridoids difficile colitis), and he became weaker with the C Diff and being weaker he got the pressure ulcer and then it just grew. The Skin Condition Assessment & Monitoring - Pressure and Non - Pressure, dated 04/2025, documents, A wound assessment will be initiated and documented in the resident chart when pressure and / or other non-pressure skin conditions are identified by licensed nurse. It continues, The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes.

Based on interview, observation, and record review, the facility failed to check for placement or residual of a Gastrostomy tube (G-tube) for 1 of 2 residents (R4) reviewed for G-tubes in the sample of 50. Findings include: On 09/07/2025 at 10:02 AM V3, Licensed Practical Nurse entered R4's room to give a 125 milliliter (ml) water flush. V3 turned off the feeding pump, disconnected the tubing from the G-tube and gave R4 a 125 ml water flush through the G-tube. V3 failed to check for residual.R4's admission Record, print date of 9/10/25, documents, R4 was admitted on [DATE] and has diagnosis of gastrostomy status.R4's Physician Order, dated 8/16/24, documents, Enteral Feed Order every shift Enteral - Check Tube Placement before feeding, Flush and Meds (medications).On 9/11/25 at 11:54 AM, V3, Licensed Practical Nurse (LPN), was questioned why she did not check for residual before giving the water flush. V3 stated, I checked for residual, then left the room, and then came back to give the water.On 9/11/25 at 12:17 PM, V2, Director of Nurses, stated the residual should have been checked before giving the water flush.The policy Medication Administration - gastrostomy or Nasogastric Tube, dated 8/202, document, Check tube for proper placement: Gastrostomy Tube: Aspirate to visually verify stomach contents.

Based on interview and record review the facility failed to timely treat a urinary tract infection (UTI) for 1 of 3 residents (R3) reviewed for catheter care in the sample of 7. This failure resulted in R3 having a delay in treatment for a urinary tract infection and being admitted to the intensive care unit for septic shock. Findings include: R3's Care Plan, dated 1/9/2024, documents, I have Indwelling Catheter due to Obstructive Uropathy. Monitor/record/report to MD for s/sx (signs and symptoms) UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. R3's Minimum Data Set, dated dated [DATE], documents R3 was cognitively intact. R3 requires assistance from staff for activities of daily living (ADLs). R3's Physician Progress Note, dated 3/27/2024, written by V8, Urologist, documents, Chief Complaint Patient presents in office today for a cystoscopy with catheter in place. Subjective The patient is a [AGE] year-old man who was hospitalized in December because of a right femoral head fracture/fragmentation and subluxation of the medial aspect of the femoral head. The patient was unable to void, and his bladder has been managed with a Foley catheter since. Imaging has not revealed evidence of hydronephrosis. His creatinine on January 17, 2024, was 1.4 mg/dT. The patient has failed voiding trials. He is here for a cystoscopic exam. CYSTOSCOPY PROCEDURE: The patient was brought to the procedure room and placed on the table in the supine position. The penis and scrotum were prepped and draped in sterile fashion. The [NAME] flexible cystoscope was passed into the urethra and advanced to the bladder. The prostatic urethral mucosa had a normal appearance. There was no obstructing benign prostatic hyperplasia, and the bladder neck was widely patent. The bladder was loaded with debris and the cystoscopic exam was suboptimal. I was able to visualize had a normal appearance. Foley catheterization. The patient needs better care at his facility. We will submit an order to irrigate the bladder weekly and as needed thereafter. He will need to have monthly catheter exchanges. The patient is very disabled and looks as if he has failure to thrive. Cystoscopy showed wide open prostatic urethra and bladder neck. Bladder was FULL of debris and catheter tubing was very dirty. He needs better care. Please send an order to change the catheter bag and to irrigate the bladder through the Foley weekly and as needed. R3's Nurse's Note, dated 4/5/2024 at 8:53 PM, documents, Health Status Note Text: Res (Resident) said his catheter hurts. Dark, cloudy, yellow urine noted. Afebrile. Wife (V7) present and aware. Writer will notify MD (doctor) at this time. R3's Nurse's Note, dated 4/5/2024 9:01 PM, documents, Health Status Note Text: (V6, R3's Physician) is aware of dark, cloudy, yellow urine and gave orders: UA (urinalysis), CBC (complete blood count), CMP (Comprehensive Metabolic Panel). R3 is aware and said he will tell his wife. Documentation from V8's Urology Office regarding communication to the facility documents 04/10/24 01:22pm, Patient has UTI. Bactrim DS Q (every)12 hrs. (hours) x 7 days. Change catheter in 5 days. 4/10/2024 at 2:58 PM Left message to return call back to office. R3's Nurse's Note, dated 4/12/2024 at 12:11PM, documents, Nurses Note Narrative: This nurse placed a call to AHA (lab) and inquired on the final results from UA was completed on 4/7/24. Associate told this nurse they were awaiting a call back from staff to see if we wanted them to complete the work up on the urine. This nurse told them absolutely and we were under the impression it was already being done due to the partial saying C+S (culture and sensitivity) to follow. Final results should be available tomorrow 4/13/24 and will need to be faxed to (V8, physician) office at (office number). R3's Urinalysis Lab Results, dated 4/13/2024, documents the specimen was collected on 4/7/2024 at 5:00 AM, Lab received 4/8/2024 at 7:20 PM and reported to the facility on [DATE]. The Report documented R3 had a urinary tract infection. Documentation from V8's Urology Office regarding communication to the facility documents, 4/16/2024 at 10:07 AM Left message to return call back to office. 4/17/2024 at 11:37 AM Left message to return call back to office, 3rd attempt. 4/18/2024 at 11:16 AM (Facility) on the line to speak with the nurse. He is a resident there. They are calling about UA results. Documentation continued 4/18/2024 at 7:13 PM Patient has UTI. Bactrim-DS Q12'hrs x 10 days., Change Foley catheter in 5 days. 4/19/2023 at 8:43 AM nurse has been made aware. Medication sent to pharmacy. R3's Nurse's Note, dated 4/19/2024 9:30 AM, documents, Order Note Text: The order you have entered Bactrim DS Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth every 12 hours for bacterial infection for 10 Days Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction The system has identified a possible drug interaction with the following orders: Losartan Potassium Oral Tablet 25 MG Give 25 mg by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Severity: Moderate Interaction: Coadministration of angiotensin II receptor antagonists and trimethoprim may increase the risk of hyperkalemia especially in the elderly. R3's Physician Order Sheet, not dated, documents 4/19/2024 Bactrim DS Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth every 12 hours for bacterial infection for 10 Days. R3'S Medication Record (MAR), dated April 2024, documents R3 received the 1st dose of Bactrim on 4/19/2024 at 8PM. R3's Progress Note, dated 4/20/24 at 12:39 AM, documents INFECTION TYPE: Type or Infection: Urinary Tract infection urine. The Note documents TREATMENT/ ORDERS: (R3) is receiving Bactrim DS Tablet 800-160 MG,1 tablet by mouth every 12 Hours. changed foley. R3's Change in Condition Evaluation, dated 4/23/2024, documents R3 was experiencing a change in condition. R3's had abnormal vital signs, decrease food intake/inability to eat, urinary incontinence new or worsening, BP (blood pressure)114/62, P (pulse) 62, R (respirations) 16, T (temperature) 98.7, O2 Sat RA (room air) 94% obtained on 4/23/2024 at 11:14 AM. R3 had increase confusion, general weakness and need more assistance with ADLs, decline in ability to dress, eat and transfer. R3 had decreased urine output, poor urine flow with foley changed several times, frequent urinary issues. Pain to back, musculoskeletal, persistent back pain not responding to existing or progressive orders with no new abnormal neurological signs. Progressive or more frequent pain. R3's (Local Hospital) emergency room (ER) Notes, dated 4/23/2024, documents, Pt (Patient) arrives via EMS (Emergency Medical Service) from (facility) with reports of abnormal lab results of hgb (hemoglobin) of 7.7 drawn on 4/8/24. Pt also complains of lower abdominal pain. Pt has foley catheter in place. Hx (history) of UTI's. Pt BP found to be 80's/40's for EMS (Emergency Medical Services). Pt Aox4. Patient is a [AGE] year-old male with past medical history of CAD (Coronary Artery Disease) status post CABG (Coronary Artery Bypass Graft) and PCI (percutaneous coronary intervention), pacemaker implantation for second-degree AV block, CKD (chronic kidney disease) stage III baseline of 1.6, A-fib previously on Xarelto held for GI bleeding, thalassemia, COPD not on home oxygen, chronic Foley presented to the ER with suprapubic pain, weakness and decreased oral intake, found to have AKI (acute kidney injury), oliguric, likely prerenal/ATN (acute tubular necrosis) with metabolic acidosis, severe anemia with hemoglobin of 5 without any active signs of bleeding, lactic acidosis, elevated lipase with CT (computed tomography) scan showing acute Interstitial pancreatitis, hypoglycemia, sepsis secondary urinary tract infection versus pneumonia, received 2 L (Liters) of IV (intravenous) fluid along with 2 units of blood In the ER following which was started on pressers and ICU (Intensive Care Unit) was consulted. R3's Nurse's Notes, dated 4/23/2024 11:29 PM, documents, Narrative: resident admitted to (Local Hospital) in cardiac ICU (intensive care) with dx (diagnosis) septic shock. On 5/1/2024 at 12:54 PM V4, Licensed Practical Nurse, LPN, stated since admission R3 has been in poor health. V4 stated R3 had multiple physicians. V4 stated R3 was receiving cancer treatments and had urinary issues. V4 stated R3 had a catheter and frequent urinary tract infections (UTI). V4 stated R3 was seeing V8, Urologist, for his urinary problems. V4 stated she works 3 to 4 days a week. V4 stated she is not sure when the urinalysis results came back. V4 stated when she got the results, she faxed them to V8's office. V4 stated she was off for a couple of days after. V4 stated when she noticed there hadn't been a response, she called V8's office and left a message with the receptionist needing an order for R3's UTI. V4 stated she did not speak with V8 or his nurse. V4 stated it is difficult to speak to and has never spoken directly to V8 or his nurse. V4 stated she has only spoken to the receptionist. V4 stated R3's urine always fluctuates. V4 stated sometimes it's clear and sometimes it dark. V4 stated R3 doesn't drink well and only takes sips. V4 stated R3 always have pain. V4 stated R3 is more worried about the bone pain. V4 stated she sent R3 out to the hospital on the 23rd. V4 stated R3 was pale, weak, talking in a whisper. V4 stated she has sent R3 to the hospital in the past and this is how he gets. V4 stated R3 was different than his normal. On 4/2/2025 AT 8:24 AM V8, Urologist, stated he is seeing R3. V8 stated he saw R3 on 3/27/2024 and performed a cystoscopy. V8 stated at time he felt R3 was poorly cared for and R3's bladder was loaded with debris. V8 stated at time he ordered Bactrim, monthly catheter change, irrigation for 5 days and as needed after. V8 stated he did receive the urinalysis results but not the culture. V8 stated from 4/10/2024 to 4/19/2024 his office made several attempts to contact the facility without success to give order for antibiotic therapy, catheter irrigations and catheter change at the next doctor's visit. V8 stated after several attempts over several days he reached out to the nurse practitioner. V8 stated he was informed on 4/23/2024 R3 had started antibiotic on the 19th and had a catheter change at the facility. V8 stated R3 having a delay in antibiotic therapy, the change in catheter prior to 5 days of therapy caused R3's current septic condition. V8 stated the purpose in the catheter being changed in his office was so the antibiotic had time to treat, and the irrigations would flush the debris out. V8 stated this reduce and prevents the risk for the infection to become systemic. V8 stated he feels when the catheter was changed, prior to treatment, this caused the infection to become systemic. On 5/6/2024 at 1:50 PM V11, CNA, stated she provides care to R3. V11 stated she is normally assigned to R3. V11 stated R3 had a catheter. V11 stated there were only small amounts in bag. V11 stated R3 would take small sips of drinks. V11 stated she encouraged R3 to eat and drink more but he would not. V11 stated V7 was here visiting every day. V11 stated V7 was nice and did not complain to her about anything with R3. V11 stated both R3 and V7 were very nice. On 5/6/2024 at 1:56 PM V3, Assistant Director of Nursing, stated she was aware of R3 having the urinalysis. V3 stated she noticed there were no results posted as 4/12/2024. V3 stated she contacted the lab to find out if they faxed the results. V3 stated she was informed the lab and had spoken with a nurse at the facility and was awaiting a return call for ok for culture. V3 stated at time she gave the ok for the culture. V3 stated she did not receive the culture results. V3 stated she left for vacation on the following day. On 5/8/2024 at 3:20 PM V12, Client Service from Laboratory, stated R3's urinalysis was faxed to the facility on [DATE]. V12 stated the facility also has access to the Emed lab website and can retrieve the results from there as well. On 5/16/2024 at 9:30 AM V3 stated a urinalysis takes 24 hours to return. V3 stated if there is a culture the culture can take up to 48 hours. V3 stated it is the nurse who is assigned responsibility to follow through with this process and checking for results. V3 stated once the resident receives the antibiotic the nurses document an infection note. On 5/16/2024 V1, Administrator, stated the only Change in Condition policy was Physician-Family Notification- Change in Condition policy. V1 stated she looked, and this was the only one. The facility's Physician-Family Notification- Change in Condition policy, dated 11-13-18, documents Purpose: To ensure 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 resident; 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: (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the 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); Life-threatening conditions are such things as a heart attack or stroke. Clinical complications are such things as development of a stage II pressure sore, onset or recurrent periods of delirium, recurrent urinary tract infection, or onset of depression. (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); A need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or commence a new form of treatment to deal with a problem (e.g., the use of any medical procedure, or therapy has not been used on resident before). (D) A decision to transfer or discharge the resident from the facility.

Based on interview, observation and record review, the facility failed to identify, treat, monitor and provide pressure reducing interventions for 3 of 3 residents (R1, R2, R3) reviewed for pressure ulcers in the sample of 11. This failure resulted in R2 and R3 sustaining unstageable necrotic pressure ulcers while in the facility. Findings include: 1. R3 Admission Record, print date of 1/10/24, documents R3 was admitted on [DATE] and has diagnoses of Dementia, fracture of right femur, coronary artery disease and Type 2 Diabetes Mellitus. R3's Minimum Data Set (MDS), dated [DATE], documents R3 is severely cognitively impaired, requires substantial maximum assistance from staff for bed mobility and transfers and is at risk for pressure ulcers. R3's Admission Assessment, dated 10/26/23, documents R3's does not have any pressure ulcers. R3's Braden Assessment, dated 10/26/23, documents R3 is at high risk for pressure ulcers. R3's Alert Note, dated 11/10/23 at 2:43 PM, documents, New skin condition will evaluate. This Alert Note fails to document what the new skin condition is. R3's Wound Summary Report, print date of 1/10/24, documents a Deep Tissue Pressure Injury on R3's left heel was identified on 11/11/23, measurements were taken on 11/14/23 of 7.00 cm x 6.0 cm x unknown depth. R3's Wound Summary Report, print date of 1/10/24, documents a Deep Tissue Pressure Injury on R3's left heel measurements on 12/27/23 and 1/3/24 were measured at 3.0 cm x 2.5 cm x unknown depth. R3's Specialized Wound Doctor Wound Evaluation and Summary Report, dated 12/26/23, documents, Unstageable (Due to Necrosis) of the Left Heel Full Thickness. Etiology Pressure. Wound Size (L (length) x W (width) x D (depth): 3.2 x 2.5 x not measurable cm (centimeters). Thick adherent black necrotic tissue (eschar) 100%. Dressing Treatment Plan: Betadine once daily. Recommendations: Pressure Off- Loading Boot, Off Load wound. R3's Specialized Wound Doctor Wound Evaluation and Summary Report, dated 1/8/24, documents, Unstageable (Due to Necrosis) of the Left Heel Full Thickness. Etiology Pressure. Wound Size (L (length) x W (width) x D (depth): 3.5 x 2.5 x not measurable cm (centimeters). Thick adherent black necrotic tissue (eschar) 100%. Dressing Treatment Plan: Betadine once daily. Recommendations: Pressure Off- Loading Boot, Off Load wound. R3's December 2023, Treatment Administration Record (TAR), documents, Skin prep to left heel and apply heal protector. every day shift for wound care - Start Date 11/11/2023 0600 -D/C Date 12/13/2023 1419. R3's December 2023, TAR, documents, Cleanse left heel wound with wound cleaner, pat dry, apply xeroform, cover with Abd (abdominal) pad and kerlix. every day shift for Wound Care - Start date 12/14/2023 0600 - D/C Date 12/26/2023 1243. R3's December 2023, TAR, documents, Apply Betadine to left heel and offload area with protective boot. every day shift for Wound Care -Start Date 12/27/2023 0600 -D/C Date 12/27/2023 0956. R3's December 2023 and January 2024 Physician Order and TAR's fails to document a treatment order, or a treatment being done for R3's left heel between 12/27/23 and 1/9/24. R3's January 2024, TAR, documents, cleanse l (left) heel with wound cleanser, bad dry, paint with Betadine, cover with Abd, wrap in kerlix daily and prn (as needed) for wound care -Start Date 01/09/2024 1015. R3's Care Plan, dated 11/11/23, documents, I have a pressure ulcer to left heel. Intervention: Administer treatments as ordered and monitor for effectiveness - Skin prep to left heel and apply heal protector every day shift. At times I am noncompliant with allowing staff to administer wound treatment as ordered. Education provided on importance of compliance to keep wound clean and dry to promote wound healing and increased risk for possible wound infection, if I continue to refuse my choice will be honored. Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD (Medical Doctor). Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. On 1/9/24 at 11:49 AM, R3 was sitting in his room in his wheelchair. R3 was wearing house slippers. The heels of the house slippers have been folded forward and his heels are resting on. R3's left heel dressing observed to be a dry dressing. On 1/10/24 at 11:30 AM, R3 was sitting in his wheelchair watching TV. R3 was wearing tennis shoes on both feet. On 1/9/24 at 11:55 AM, V3, Certified Nurses Aide (CNA), stated R3 was working with therapy earlier and is why he has slippers on instead of his pressure relieving boot. On 1/9/24 at 12:48 PM, V6, Licensed Practical Nurse, (LPN), stated, I did his dressing already this morning. I did Betadine and a dry dressing. The area is totally necrotic. On 1/10/24 at 1:30 PM, V1, Administrator, stated, On 12/27/23, the old wound nurse entered orders for R3's heel of Apply Betadine to left heel and offload area with protective boot every day for Wound Care but then instead of implementing the order she accidentally hit resolved and the order was discontinued. On 1/10/24 at 1:55 PM, V10, stated the dressing order was just changed yesterday to have a foam dressing or an Abd (abdominal) pad and then wrap with Kerlix. On 1/11/23 at 11:05 AM, V1, Administrator, stated R3's heel pressure ulcer should have noticed and treated before 11/11/23 since it got to the size of 7 cm x 6 cm. 2. R2's Admission Record, print date of 1/10/24, documents R2 was admitted on [DATE] and has diagnoses of Periprosthetic fracture around internal prosthetic right knee joint, infection and inflammation reaction due to internal fixation device, Dementia. R2's MDS, dated [DATE], documents R2 is severely cognitively impaired, dependent on staff for bed mobility and transfers, frequently incontinent of bladder. R2's Braden Observation, dated 1/9/23, documents R2 is a moderate risk for pressure ulcers. R2's Care Plan, dated 10/17/23, documents, I have the potential for impairment to skin integrity r/t (related to) impaired mobility, incontinence. Intervention: Follow facility protocols for treatment of injury. R2's Nurses Note, dated 1/9/24, documents, during routine wound vac change this nurse noted an open area to l (this should be right) foot small toe approx. 1.0 x 1.5 bed is necrotic in color with moderate serosanguinous drainage. No odor noted. This nurse cleansed and dressed and notified NP (Nurse Practitioner) and obtained new orders. On 1/10/24 at 2:55 PM, review of R2's Wound Summary Report fails to document the right foot 4th and 5th toes, lateral middle of foot and bottom of right foot necrotic pressure ulcers. On 1/10/24 at 3:00 PM, R2's Physician Orders, dated January 2024, failed to document treatment for the right foot 4th toe, lateral middle of foot and bottom of right foot necrotic pressure ulcers. On 1/17/24 at 12:49 PM, R2's Physician Orders, dated January 2024, failed to document treatment for the right foot 4th toe, lateral middle of foot and bottom of right foot necrotic pressure ulcers. R2's Wound Summary Report, dated 1/17/24, documents a facility acquired pressure ulcer was identified on 1/17/24. The tissue is necrotic and firm. The pressure ulcer measures 12.50 x 4.00 x Unknown. On 1/9/24 at 3:30 PM, R2's right leg and foot was observed during a wound vac dressing change. R2's 5th toe (pinky toe) appeared necrotic with a black hard appearance and the peri-wound was red. The top of the 4th toe appeared to be necrotic, in between the 4th and 5th toe was necrotic and red, the middle of the outside foot had a necrotic area was the approximate size of a quarter, and under the necrotic area went to sole of the foot. V2 cleansed the 5th toe and in between the 5th and 4th toe with normal saline. The gauze had slight bloody drainage to it after cleansing. V2 (Director of Nurses) then applied a calcium alginate strip in between the 4th and 5th toes, sprayed the outside of the 5th toe with Betadine and covered the areas with a dry dressing. V2 failed to treat the middle lateral pressure ulcer of the R2's foot or the sole of R2's foot. On 1/9/24 at 3:30 PM, V2, Director of Nurses and V14, Licensed Practical Nurse (LPN), entered the room to change R2's wound vac dressing. V2 completed the wound vac dressing change. V2 was questioned if she had a treatment for the lateral (outside) of R2's foot and toes. V2 stated she has not done R2's treatment in a long time and she was unsure if there were orders for treatment to the pressure ulcers, but she would treat them. On 1/17/24 at 11:30 AM, R2's room was entered with V2. V2 observed the 4th and 5th toes, lateral middle of the foot and bottom of right foot pressure ulcers. R2 also had 2 new necrotic pressure ulcer areas on the side of the heel and up towards the toes on the side of the foot. On 1/10/23 at 11:45 PM, V10, Registered Nurse (RN) / Wound Nurse, stated she saw R2's toes and lateral right foot this morning for the first time. V10 stated the areas are pressure ulcers, and the areas are all necrotic. V10 stated R2 would benefit from some type of pressure relieving device for the right foot. On 1/10/23 at 1:35 PM, V2, stated, R2's lateral foot pressure ulcer and toes did not just happen. Yesterday (1/9/24) was the first time I have seen her in a long time, from reviewing her records, the necrotic areas had not been documented on. I did not measure them yet. I have put in an order for a treatment to it. I have also ordered a pressure relieving boot for her. On 1/16/24 at 11:50 AM, V15, Assistant Director of Nurses, ADON, stated, After the wound nurse left, I did wound assessments in wound rounds. I stopped doing last Friday. Some residents I would treat some I would not. I did change her (R2's) dressing once or twice. I never noticed her necrotic toes. On 1/17/24 at 12:05 PM, V2 stated she sent R2 to the hospital because she can no longer wait for (V17, Doctor) to call her back. V2 stated, She needs somebody to look at leg and foot. V2 stated the new areas were not there yesterday when she looked at her foot. V2 stated R2's 4th toe, lateral middle foot and bottom of the foot should have been noticed before 1/9/24 and should have assessments done and treatments ordered. On 1/17/24 at 1:30 PM, V18, Nurse Practitioner, stated, I think R2's wounds are pressure wounds because she lays with the outside of her foot on the bed because of the exposed hardware in her leg. She does have pain and is why she lays that way. 3. R1's Admission Record, print date of 10/10/24, documents R1 was admitted on [DATE] and has diagnoses of Osteomyelitis of vertebra, sacral and sacrococcygeal region and Adult Failure to Thrive. R1's MDS, dated [DATE], documents R1 is cognitively intact, requires substantial / maximal assistance from staff for toileting hygiene, dependent on staff for bed mobility and transfers and R1 is always incontinent of bowel and bladder. R1's Care Plan, dated 6/1/23, documents, I have a pressure ulcer to my sacrum, right outer ankle and to right heel, I have skin impairment to my right posterior thigh and left upper back d/t (due to) progression of disease process, immobility, incontinence and fragile skin. Interventions: Encourage and assist with offloading pressure from BLE (Bilateral Lower Extremity) with the use of heel boots or pillows while in bed as allowed and tolerated. R1's Physician Order, dated 11/23/23, documents, Air Loss Mattress, bilateral heel protectors, and cushion to w/c (wheelchair). R1's Wound Summary Report documents on 1/4/23, R3's right heal measurements were 3.0 cm x 3.50 cm x 0.2 cm. On 1/9/24 at 11:52 AM, R1 is lying in bed on his back. His bilateral heel protectors are in the chair in the room. On 1/9/24 at 1:46 PM, R1 was uncovered by V3 CNA for incontinent care. R1's bilateral heels were directly on a pillow. V3 stated, After care we will put his boots on. The Pressure Ulcer Prevention policy, dated 1/18/18, documents, Inspect the skin several times daily during bathing, hygiene, and repositioning measures. Turn dependent resident approximately every 2 hours or as needed and position resident with pillow or pads protecting bony prominences as indicated. Use positioning devices or pillows, rolled blankets, etc. to reduce pressure and friction / shearing from heels, toes, and malleoli as indicated. The Pressure Injury and Skin Condition Assessment, dated 1/17/18, documents, 1. A skin condition assessment and pressure ulcer risk assessment will be completed at the time of admission / readmission. 2. Residents identified will have weekly skin assessments by a licensed nurse. 3. A wound assessment will be initiated and documented in the resident chart when pressure and / or other ulcers are identified by licensed nurse. 4. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. It continues, 7. At the earliest sign of a pressure injury or other skin problem, the resident, legal representative, and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes. It continues, 11. A wound assessment for each identified open area will be completed and will include: a. site location. b. size (length x width x depth). c. Stage of pressure ulcer. d. odor. e. drainage. f. Description. g. Date and initials of the individual performing the assessment. It continues, The licensed nurse is responsible for notifying the attending physician, Director of Nursing and legal representative of any suspected wound infection.

Based on interview, observation and record review, the facility failed to monitor and supervise a resident with severe cognitive impairment for 1 of 1 resident (R4) reviewed for supervision in the sample of 5. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 7/31/23 when the facility failed to identify that R4 was missing, last seen at around 11:00AM and discovered entrapped on the elevator at 10:30 PM. This Past Noncompliance occurred from 7/31/23 to 8/1/23. On 8/22/23 at 3:03 PM, the V1, Administrator, V2, Director of Nursing (DON) and V22, [NAME] President of Operations, were notified of the Immediate Jeopardy. Findings include: R4's Minimum Data Set, dated dated [DATE], documented R4 had severally impaired mental cognition, however, R4 recalls long term memory and not short-term memory but is able to speak and answer simple questions. R4's Admission Record, dated 8/10/23, documented R4 had diagnoses of dementia, psychotic disturbance, mood disturbance, anxiety, heart disease and major depressive disorder. R4's Care Plan, dated 6/20/23, documented, R4 requires assistance with transfers due to being unaware of safety issues and a fall risk with an intervention of a 1-person assistance with transfers, including locomotion on and off the unit. R4's Care Plan documents R4 is incontinent of bowel and bladder, physical addiction to nicotine/smoking and a fall risk due to a medical condition of Dementia with the use of a medication to treat moderate to severe dementia of the Alzheimer type. R4's Facility documentation, untitled and dated 7/31/23, documents, On 7/31/23, the facility called a code pink at 20:30 PM, (8:30 PM) after not being able to locate a resident when completing a facility check. Staff verify that the resident was not out on pass. The Administrator was notified and instructed the nurse in charge to notify the police. Resident was in the facility in the small elevator. Fire department, (elevator service company) and Emergency Medical Transport called to the facility. Resident was removed from the elevator at approximately 11:00 PM. Resident refused to go to the hospital, therefore the facility nurse assisted and resident was given food and assisted to his room. R4's July 2023 Medication Administration Report (MAR) documented the following medications were not given to R4 on 7/31/23 during the 8:00 PM medication administration: Hydralazine HCl, 10 milligrams (mg) for hypertension with blood pressure not taken; Namenda, 5 mg, for dementia, psychotic disturbance, mood disturbance and anxiety; Lisinopril, 20 mgs, 1 tablet for hypertension; Tamsulosin HCl, 0.4 mg one capsule for benign prostatic hyperplasia. Tamsulosin capsule 0.4 milligram (mg) for benign prostatic hyperplasia. The MAR documented R4 should have vital signs every Monday on the evening shift, and these were not documented as completed. The MAR documented R4 should receive health shake, magic up, ensure or fortified pudding with meals at 5:00 PM and this was not documented as given. On 8/10/23 at 3:00 PM, V3, Licensed Practical Nurse (LPN), stated R4 is a smoker and will come and go. V3 stated R4 propels himself in his wheelchair, is a smoker and knows when its smoking time. V3 stated R4 answers short questions and has short term memory recall. V3 stated she worked the day of 7/31/23, 2:00PM -10:00 PM. V3 stated R4 has a blood pressure reading scheduled at around 7:30 PM. V3 stated R4 was not found in his room and there was an un-eaten supper tray at his bedside table. V3 stated a search was conducted down stairs where R4 likes to hang out, he was not found. V3 stated, at that point she notified V1, Administrator, that R4 was not to be found in the facility. V3 stated a whole outside ground and building search was performed. The emergency department, fire department, police and Elevator service were all notified and were present in the facility at approximately 9:30 PM. V3 stated at around 10:00 PM, R4 was found located in the elevator, but not retrieved from the elevator until 11:00 PM, by the Elevator Service Company. V3 stated she remained in the building until around 10:30 PM. On 8/10/23 at 2:30 PM, V1, Administrator, stated R4 was assessed after the incident. V1 stated R4 refused to go to the hospital and R4's physician was notified on 8/1/23. V2 stated labs were obtained as ordered for 8/1/23 and within normal limits. V1 stated she was at the small elevator door on the 2nd floor. V1 stated R4 did respond after V1 knocked on the elevator door at around 10:00 PM. V1 stated the emergency department stayed at the 2nd floor elevator door and she went down to the basement with the elevator maintenance personnel, where the mechanical issues were addressed. V1 stated they opened the small elevator door and released R4 from the elevator. On 8/10/23 at 3:15 PM, V5, Certified Nurse Aide, CNA, stated R4 takes all four scheduled smoke breaks, as R4 is aware of the smoking scheduled times. V5 stated she worked the day of the incident on 7/31/23 from 2:00 PM to 10:00 PM; however, she had the first half of the hall and R4 resides at the back end of the hall. V5 stated she saw R4 propel himself in his wheelchair and down the elevator but she did not follow-up to check on R4's whereabouts. The facility's entitled form, Smoking Times, undated, documented the following smoke times: 9:15 AM, 11:00 AM, 3:00 PM and 6:00 PM. On 8/14/23 at 9:40 AM, V8, Activity Aide, stated R4 requires supervision. V8 stated the activity staff go to his room and assist R4 from the 3rd floor down to 2nd floor for smoking times and activities. V8 stated R4 enjoys doing activity's; however, R4 will come down the elevator unassisted by himself. V8 stated she worked the day of 7/31/23. V8 stated R4 was assisted down at 9:30 AM smoke break. V8 stated after the smoke break the activity department serves morning coffee which R4 enjoys. V8 stated R4 arrived on the 2nd floor for 2nd smoke break at around 11:00 AM but that is the last she saw R4. V8 stated she worked until 5:00PM. V8 stated at 3:30 PM, during 3rd scheduled smoke break she realized R4 did not come down to smoke. V8 stated she did not go look for R4. On 8/14/23 at 10:04 AM, R3 stated that R3 does not smoke; however, he walks a lot down the hall and uses the elevator from the 3rd floor to the 2nd floor. R3 stated R4 uses a wheelchair, as he tries to propel himself, but it's hard for him. R3 stated he has assisted R4 to the elevator by pushing him in his wheelchair many times, and seen other residents assist him as well. On 8/14/23 at 10:15 AM, R5 stated R4 smokes along with him. R5 stated R4 can get himself in his wheelchair and take himself down to the 2nd floor for smoke breaks. R5 stated he heard about the incident with R4 and was wondering why R4 never returned to his room for a long time. R5 stated R4 can get in his wheelchair by himself, but he rolls along in his wheelchair slow, so other residents have help to push R4 to the elevator. On 8/14/23, at 2:00 PM, V9, CNA stated she was assigned to care for R4. V9 stated R4 is known to get up on his own into his wheelchair and take himself to the elevator as he likes to be downstairs. V9 stated at scheduled smoking times and activities the activity aide or the CNA retrieves R4 and assist him downstairs. V9 stated the last scheduled smoke break is at 6:30 PM. V9 stated, I should have checked on (R4), but did not check on him or his whereabouts and should have. V9 stated supper is delivered and served on the 3rd floor around 5:30-5:45PM. V9 stated about 8:00 PM, is when V9 was informed by V11, Licensed Practical Nurse to do a search inside and outside of the facility building for R4 with V10, CNA. V9 stated, she took the 3rd floor and V10 took the 2nd floor and R4 was not found. V9 stated V3 had notified V1, then the fire department, police department and elevator inspector service had all arrived at the facility. On 8/15/23 at 11:56 AM, V2, Director of Nursing, DON stated R4 should be supervised and checked on every 2-3 hours. On 8/15/23 at 2:00 PM, V1 stated she did not have a policy for resident requiring supervision/monitoring and she is aware R4's scheduled medication for 8:00P was not marked as given on the Medication Administration Record. V 1 stated, she couldn't find documentation that physician was informed of the medications R4 did not receive. On 8/21/23 at 2:57 PM, V28, R4's physician, stated he recalls receiving a call on 7/31/23 that R4 was trapped in an elevator but stated he was not informed R4 missed his scheduled 8:00 PM medication. V28 stated if informed he would asked the nurse the status of R4's vital signs (blood pressure/heart rate) and if vital signs were his normal range limit, would have given telephone orders to resume his normal medication the following day at scheduled time of 8:00 AM. On 8/23/23, at 9:10 AM, V16, Elevator Company Maintenance, stated he was called out to this facility due to a trapped resident (R4) and informed he is to continue weekly monitoring of the elevator functioning. V16 stated he was called out on 7/31/23 around 11:00 PM. V16 stated he went to the basement to check the coding issue of the elevator, went back upstairs, and opened the elevator door to the small elevator, and R4 was sitting in a wheelchair. V16 stated R4 was happy to see V16. V16 stated if the elevator by chance, has too many buttons pushed at one time, can shut off the memory to the elevator and shut it down. In this case V16 was unsure what happened but was present when the small elevator door was opened and R4 was sitting in a wheelchair and retrieved by the emergency department. The Immediate Jeopardy began on 7/31/23 when staff were unaware R4 was missing and located/entrapped in a non-functioning elevator and was removed on 8/1/23. Prior to the survey date, the facility took the following actions to remove the immediately and correct the noncompliance: 1)Immediate actions taken for those residents identified: Resident R4: Resident has been assessed for Psychosocial needs related to incident with no negative outcome noted. Resident's skin was assessed with no negative outcome noted. Resident remains at baseline. The facility will continue to provide needed care and services. Psychosocial Assessment was completed 08/01/2023 by V25, Social Service Director. Skin assessment was completed 07/31/2023 by V26 RN. Physical Assessment was completed 08/01/2023 by Nurse Practitioner. 2) Measures put into place/ System changes: All Staff have been educated on the definition of Supervision. If any staff are unable to be contacted, they will be taken off the schedule until education can be provided. Completed 08/01/2023 by Director of Nursing, Dietary Manager, Minimum Data Set/Care Plan (MDS/CP) Coordinator, Human Resource (HR) Director, and Administrator. All Staff have been educated on the following: Anytime a resident is not available for meals, smoke breaks, or medications, staff will immediately locate the resident. Completed 08/01/2023 by Administrator, Director of Nursing, Dietary Manager, MDS/CP Coordinator, HR Director. Two-hour resident checks have been implemented. Initiated 08/01/2023 and ongoing. Direct Care Staff Daily Elevator checks have been implemented. Maintenance Director, Dietary Manager, Social Service Director, Director of Nursing, Completed Daily Residents have been educated/reviewed with/on the Steps to use the Elevator Social Service Director 08/01/2023. Elevator was evaluated and repaired 7/31/2023. The Facility will contract with (Elevator company) to maintain a Weekly Check for Safety for 3 months then Monthly for 3 months then quarterly ongoing. 3) How the corrective actions will be monitored: Administrator/Designee will complete five random Resident Safety Checks a week for 12 weeks to ensure Supervision of residents. The results of these checks will be reviewed in Quality Assurance Meeting monthly x6 months or until an average of 90% compliance or greater is achieved x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. Date of compliance: 08/01/2023 On 8/23 and 8/24/23, the surveyor verified Past Noncompliance by the following: Reviewed staff in-service sign in sheets for Supervision with signature verification of completion; Interviews were conducted with V12, RN, V15, Transport Driver, V16, Elevator Repair Service, V17, Dietary Aide, V18, Activity Director, V20, CNA, V21, Maintenance Director, V24, Activity Aide, and V25, Social Service; Daily Elevator Checks were reviewed for dates of 8/1/23 through 8/23/23; R2, R3, R5, R6, R7, R8, R9 were all interviewed regarding if they received in-service to use the elevator and what to do if the elevator malfunctions with no issues noted; Elevator annual inspection of 3/21/23 and 7/31/23 were reviewed and weekly checks for safety were reviewed which were provided by the Outside Elevator maintenance; R4 was observed with staff providing supervision to smoking, activities and while on elevator; Review of documentation, entitled, Out facility, In facility, review dated from 8/1/23 through 8/21/23 of every resident room, documents residents were assured to be in the facility from the 2nd and 3rd floors, every 2 hours, starting at 6:00AM to 4:00AM following days; Quality Assurance Meeting documentation was reviewed for 8/1/23.

Based on interview and record review, the facility failed to prevent significant medication errors in 1 of 6 residents (R2), reviewed for medications in the sample of 7. This failure resulted in R2 not receiving a medication that subsequently led to admittance to the hospital. Findings include: On 10/6/22 at 9:40 AM, R2, stated, she takes [MEDICATION(S)], ([MEDICATION(S)]), 4 times per day, before meals and at bedtime. R2 stated, when she first went on the [MEDICATION(S)], she wasn't getting it at the proper times and she ended up in the hospital twice with a gastrointestinal, (GI), bleed but, she isn't sure if it was caused by that. R2 stated, she has had 3 scopes and several units of blood between the 2 hospitalization s but, they figured out I had 3 bleeding ulcers that was causing the problems and they are healed now, but the doctor says I will always have to take the [MEDICATION(S)] and iron. R2's Face Sheet, undated, documents R2 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Minimum Data Set (MDS), dated [DATE], documents R2 is cognitively intact. R2's Care Plan, dated 12/30/21, documents R2 has [CONDITION(S)] and to give medications as ordered. R2's Hospital After Visit Summary, dated 6/29/22, documents R2 was admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Progress Note, dated 7/11/22 at 4:29 PM by V11, Nurse Practitioner, documents R2 is being seen today for complaints of diarrhea. She reports that she has consistently had diarrhea right after her meals since Friday. She denies seeing any blood in her stools. She denies abdominal pain. She was recently hospitalized for GI bleed and discharged on [MEDICATION(S)] and [MEDICATION(S)]. She is to have a follow up with GI in 3 months. She was started on Maalox as needed on Friday and had labs drawn today. In looking at (R2's) medication profile, it appears the [MEDICATION(S)] was never started. She was to get this 4 times per day with meals and at bedtime. She is tired and fatigued. Color is pale. She denies fever, chills, body aches, nausea, or vomiting. Later in afternoon, a critical H/H (Hemoglobin/Hematocrit) was called to facility. Her hemoglobin was 5.9 and hematocrit 20.7. (R2) will need to be transferred to hospital for possible blood transfusion and further work-up. R2's MAR, dated 7/1/22 - 7/31/22, documents a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Progress Note, dated 7/12/22 at 7:28 AM, by V12, LPN, document Writer called (hospital) this morning to get update on resident from yesterday's transfer for critical lab values. Resident is admitted to ICU (Intensive Care Unit) at this time for GI bleed. R2's MAR, dated 7/1/22 - 7/31/22, goes on to document a subsequent order following R2's readmission to the hospital on 7/11/22, dated 7/18/22, for [MEDICATION(S)] 1 gram by mouth 4 times daily for gastric distress. On 10/6/22 at 10:35 AM, V4, Licensed Practical Nurse (LPN), stated R2 came back from the hospital with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/7/22 at 9:05 AM, V10, R2's Physician, stated R2 not getting the [MEDICATION(S)] as ordered from 6/29/22 through 7/11/22, could have contributed to her subsequent hospital readmission on 7/11/22 for the GI bleed. V10 stated [MEDICATION(S)] is like a chalk and gets in between the mucosa of the GI tract and decreases the acid production. V10 stated [MEDICATION(S)] is normally given for 4-6 weeks to aid in healing gastric ulcers. V10 stated any order should be followed and if not taken for that time frame, could have delayed the time for healing. V10 stated if the ulcer is not healed within the 4-6 weeks, he would follow up with an endoscopy to ensure there is not something else going on. On 10/7/22 at 10:05 AM, V1, Administrator, states she would expect the nurses to follow physician orders. The Medication Administration Oral policy, undated, documents the purpose is to safely administer medications as prescribed.

Based on interview and record review, the facility failed to ensure residents are not sexually abused for one of one resident (R2) reviewed for sexual abuse in the sample of 5. This failure resulted in R2 engaging in an ongoing sexual relationship that included sexual intercourse with a facility employee, V4 (Housekeeper). This failure resulted an Immediate Jeopardy when V4, Facility Employee, began having sex with R2. R2 is vulnerable for exploitation and abuse related to her [DIAGNOSES REDACTED]. Due to R2's vulnerability for exploitation related to these diagnoses, this failure increased her likelihood for risk of psychosocial harm and potential future abuse. The IJ was identified to have begun on March 31, 2020 when V4, Facility Employee/Housekeeper, began having sex with R2. The IJ was identified on 12/16/20 at 3:06 PM and presented to V1, Administrator, V2, Director of Nursing and V7, Infection Preventions. On 12/18/20, the surveyor confirmed through observations, record review and interview that the Immediate Jeopardy was removed on 12/17/20, but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Finding includes: On 11/25/2020 at 1:12 AM, R2 Nurse's Note documented Resident (R2) was upset, stated she was asked to leave the facility by one of the house keepers to have sexual intercourse, she was very upset that she would be in trouble, informed her that (V1, Administrator) was informed by the 2p-10p nurse and that she is not in trouble, redirected her and informed her that everything would be ok and to get some rest. Resident verbalized understanding and went to her room, nurse checked on her 30 min later and she was sleeping. On 11/25/20 at 9:30 AM, V1 documented an interview with R2. The interview documented R2 informed V1 that she was having an ongoing sexual relationship with V4, Housekeeper that included sexual intercourse since March, 2020. On 11/25/20 at 10:15 AM, V1 documented in investigation notes, the local police were notified of the allegation. Investigation notes documented, at 10:30 AM, R2 was interviewed via telephone by the police. On 11/25/20 at 12:17 PM, V6, Nurse Practitioner, documented in nurse's notes, R2 stated She has been having a sexual relationship with an employee of the facility. She tells me that this relationship has been going on since March 2020. She tells me that she would go to his office and have sexual intercourse with him. However, she is now wanting the relationship to stop. She is very upset and worried that he will get in trouble. The facility obtained social media screen shots from R2's mobile phone of messages between R2 and V4. Screen shot of message between R2 and V4 dated 9/12/20 at 1:36 PM, documented Love you much more, when u want me to come down. The response from V4 was documented as, How about tomorrow. R2 responded, I'll try. On 09/12/20 at 2:31 PM, V4 documented, Hey sexy. On 09/27/20 at 2:34 PM, the social media pictures documented V4 stated I love you win (sic) you sick (sic) d***. R2's response was documented as I know bae, I love it when you put it in. I wish you were here in my room to give me some. V4 then documented the response as I love you. R2's response was documented as I love you more. On 12/10/19, a County Court Order documented R2 was an alleged disabled adult and appointed V19, R2's Grandfather, as her legal guardian. The physician's orders [REDACTED]. R2's Minimum Data Set (MDS), dated [DATE], documented R2 was cognitively intact and required limited assist of one staff for all Activities of Daily Living (ADL's). R2's Care Plan, revision date 04/28/20, documented R2 was I am sexually active or have been sexually active during my tenure in the facility. Interventions include: Counsel resident concerning safe sex practices (e.g. [MEDICAL CONDITION] .), issues of consensual sexual contact ., educate resident that condoms are available at the nurse's station and social services office and provide information about birth control and contraception. Also, it documented R2 was identified as being at risk for abuse/neglect related to history of abuse and 11/25/20 alleged sexual relations between herself and an employee. On 11/01/19, the Abuse/Neglect Screening documented R2 was a high risk for the likelihood potential future problems/symptoms related mistreatment. On 11/25/20, the Abuse/Neglect Screening documented R2 was a high risk and under the comments section: High risk of problems/symptom's related to mistreatment due to intellectual disabilities, Serious Mental Illness (SMI) and history of being abused in the past. On 12/08/20 at 9:30 AM, V1, Administrator stated R2 was alert and oriented and makes her needs known. V1 stated R2 had a history of [REDACTED]. V1 stated R2 had a history of [REDACTED]. V1 stated that V4 was in violation of the standard of conduct expected by the facility. On 12/08/20 at 10:30 AM, V3, Regional Director of Operations stated R2 was alert and oriented and could make her needs known. V3 stated R2 was sexually active and had a history of [REDACTED]. V3 stated she did not believe R2 and V4 used any type of safe sex practices. V3 stated that V4 was in violation of the standard of conduct expected by the facility. On 12/08/20 at 12:50 PM, R2 stated she had an ongoing sexual relationship with V4, Housekeeper that included intercourse since March, 2020. R2 stated she kept the relationship a secret because she knew it would get V4 in trouble. R2 stated they had unprotected sex and knew she should have used condoms. R2 stated she told staff about the relationship only because she wanted to stop it and V4 wanted to continue to see her. She further stated she felt nervous about V4 returning to work and wanting to see her. On 12/09/20 at 9:45 AM, V19, R2's Guardian stated he believed R2 makes poor choices in regards to having sex and therefore must be monitored. V19 stated he became her guardian because she was having sexual encounters for money and because of those poor choices R2 contracted [MEDICAL CONDITION]. The policy titled, Compliance Program Employee Guide, dated 12/19/18 documented III. Employee Conduct: Rules of Conduct: As members of the team responsible for providing quality care and services to our residents, the Facility expects that each employees' conduct and performance will conform with the highest standards of professionalism and ethical practice; the requirements of his or her job; published and common-sense health and safety rules; and applicable federal, state, and local laws, rules and regulations. It continues 5. Engaging in words or actions that violate the residents' legally protected rights. (Note: This includes, but is not limited to, threatening, intimidating, or abusing residents in any way - physically, mentally, verbally, sexually, etc.). The policy titled, Abuse Prevention Policy, dated 12/19/18 documented, The abuse, neglect, or other mistreatment of [REDACTED]. Also, under, Abuse policy: It is the policy of (facility) that each resident will be free from 'abuse'. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion. This prohibition applies to (facility) staff, other residents, staff, volunteers, families and friends. No abuse of any type will be tolerated, and residents and staff will be monitored for protection. (Facility) will strive to educate staff and other applicable individuals in techniques to protect all parties. The Immediate Jeopardy that began on 3/31/20 was removed on 12/18/20 when the facility took the following actions to remove the Immediacy: 1. On 11/25/20, V4, Facility Employee/Housekeeper, resigned from the facility. 2. All interviewable residents were interviewed to ensure they are not experiencing sexual abuse/abuse. Any affirmative answers will be reported and investigation initiated. Completed by Social Service Designees and Administrator on 12/16/20. 3. All residents will have abuse/neglect risk screening completed. All high risk residents will have care plan and interventions updated. Completed by MDS Coordinator and Social Service Designee on 12/17/20. 4. All Abuse policies and procedures were reviewed by compliance department. Completed by Vice President of Compliance on 12/17/20. 5. All staff were in-serviced/trained on how to recognize sexual abuse and the facility's abuse protocol to prevent it from happening to residents. This includes indicates of abuse. All staff will be re-educated prior to next scheduled shift. Completed by Administrator, Director of Nurses and Assistant Director of Nurses on 12/17/20.

A. Based on observation, interview and record review, the facility failed to develop and implement progressive interventions to prevent falls for 3 of 10 residents (R20, R59, R192) reviewed for falls in the sample of 69. This failure resulted in R59 falling and sustaining a laceration to her head requiring emergency room services and sutures. This failure resulted in R192 falling and sustaining a laceration to his left forehead, requiring emergency room services and treatment. Findings include: 1. On 09/24/20 at 10:15 AM, R59 had 3 band aids to her right upper forehead, a dark shadow noted on band aids, a large hematoma noted around band aids. R59 stated that she fell a few weeks ago and she just had the staples taken out. R59's Care Plan, dated 06/02/2020, documents R59 is at risk for falls related to [MEDICAL CONDITION], incontinence and history of falls. The Interventions documented Grippy socks on at all times. R59's Care Plan, dated 07/14/2020, documents, Alarm to bed and chair to alert staff of unassisted transfers. R59's Minimum Data Set (MDS), dated [DATE], documents she has severe cognitive impairment and requires assistance with one staff person for transfers. The MDS documents she is not steady and only able to stabilize with staff assistance with moving on and off toilet and surface to surface transfer (transfer between bed and chair or wheelchair.) R59's Fall Report, dated 09/12/2020, documents that R59 fell on [DATE] and it was unwitnessed. R59's Fall Interdisciplinary Team Note, dated 9/12/2020, documents, Summary of the fall: (R59) continues on hospice. (R59) was found on floor in room lying beside the bed. She (R59) was bleeding from the forehead. (R59) denied any other pain (range of motion) (within normal limits). (R59) was assisted to bed with assist (of 2 staff). (Nurse Practitioner) notified via phone order received to send to (emergency room ). Ambulance was called to transfer resident to (emergency room ) at (local hospital) for possible sutures. Large skin tear noted to right forehead. Pressure applied to wound after skin approximated. Bleeding slowed but didn't stop completely before ambulance arrived. (R59) remained alert and oriented with no loss of consciousness noted. Notified (Director of Nurses) and on call about the fall. Notified (Power of attorney) via phone call. Root cause of fall: Alarm was in the wheelchair and was not put in (R59's) bed while she was lying down. Intervention and care plan updated: Educated staff on proper placement of alarm. R59's Health Status Note, dated 09/14/2020 at 2:30 PM, documented, (R59) noted to be sitting on the floor next to her bed by maintenance after opening the door for inspection. (R59) fully dressed with cotton socks on. No c/o (complaint of) pain or discomfort. Call light in reach, but not in use. Alert with confusion. Able to make needs known. Wheelchair in reach with brakes unlocked. No injuries noted to head with sutures, and staples present from previous fall. Received 4 abrasions total with wound nurse assessing (and) measuring. Two to spine (and) two to (right) shin. Able to bear weight bilaterally with unsteady gait (and) assist of two. On 10/14/20 at 10:45 AM, R59 was lying in her bed. There was no bed alarm noted on the bed and the alarm was in her wheelchair (w/c) and not sounding. On 10/15/20 at 10:00 AM, R59 was sitting up to wheelchair propelling self around her room. R59 was wearing cotton socks without shoes on. On 10/15/20 at 10:07 AM, V67, Licensed Practical Nurse (LPN), stated, (R59) should have the wheelchair alarm and bed alarm on at all times and that she should have on appropriate footwear too. On 10/20/2020 at 11:20 AM, V4, Assistant Director of Nurses (ADON), stated that each manager takes turns and does Angel rounds to check residents to see if they have their appropriate equipment in place, if it is operational and that the resident has their fall precautions in place. 2. R20's Physicians Order summary sheet , dated 10/14/2020, documents she has [DIAGNOSES REDACTED]. R20's MDS, dated [DATE], documents she has moderately impaired cognition. The MDS documents she requires assistance of two staff persons for transfers and toilet use. The MDS documents she has limitations in range of motion in both lower extremities and is not steady, only able to stabilize with staff assistance when moving on and off toilet and surface to surface transfers (transfer between bed and chair or wheelchair). R20's Care Plan, initiation date of 1/23/20 documents she is at risk for fall/injury from weakness and tiredness related to [MEDICAL CONDITIONS], dementia and [MEDICAL CONDITION]. R20's Care Plan Intervention, dated 12/9/15 documents continue to encourage me to wear gripper socks and continue to remind me to request assistance with transfers. R20's Care Plan Interventions, dated 1/7/16 documented Offer frequent toileting upon rising, before meals and at bedtime. The last interventions implement on this care plan were dated 4/12/18. On 09/23/20 at 12:40 PM, R20's room door was closed and she was yelling Help me, help me! At 12:43 PM, R20's room door was opened by R20. R20 was on the floor in the bathroom, with bilateral knees bent up underneath her. R20 had cotton socks on her feet and wheelchair was in front of her. V30, Certified Nurse Assistant (CNA) was alerted and came into room stated to resident, You can get up. V30 didn't place gait belt on R20 but called out for V31, CNA. Both entered R20's room and closed the door. When V30 and V31 exited the room, R20 was lying in her bed. No nurse was present to assess R20 prior to V30 and V31 getting R20 up off of the floor. V30 stated She falls all the time and it's care planned. On 09/23/2020 at 1:10PM, V30, CNA made V32, LPN, aware of R20 being on the floor. At that time, V32, LPN stated, She sits on the floor and it is care planned. R20's Progress notes, dated 09/23/2020 at 1:12 PM, V32, LPN documented, Informed per CNA (resident) on floor per her norm (has been care planned) (resident) with no noted injuries no noted mental status changes (continues) to transfer self (wheelchair) to toilet/bed color fair skin (warm dry) no (signs/symptoms) distress. (Director of Nurses) aware (Minimum Data Set nurse) aware. R20's Care Plan was reviewed and did not address any interventions regarding R20 putting herself on her floor and how staff should address this. R20's Fall risk assessment, dated 09/23/2020, documents that R20 was at risk for falls. R20's Care Plan was not revised until 10/1/20 with progressive interventions to prevent her from future falls. The Intervention documented It is care planned that she crawls on the floor. Move resident directly closer to desk for better visual of the resident. On 09/30/20 at 11:50 AM V1, Administrator, stated, A nurse should have assessed her and a fall incident report should have been made out for the 09/23/2020 incident and if the resident is on the floor and it is unwitnessed then an incident report should have been filled out but if staff sees her put herself on the floor then they can just chart it. V1, Administrator, continued, (R20) does not have any incident reports for falls from 03/2020 until 09/30/2020. 3. R192's Care Plan, dated 8/28/2020, documents I am at risk for fall/injury R/T (related to):[MEDICAL CONDITION](stroke) with left sided [MEDICAL CONDITION], DM (Diabetes Mellitus),[MEDICAL CONDITION](Hypertension), incontinence and Hx (History) of falls. R192's Care Plan Intervention, dated 9/11/18, documents Dycem (anti-slip pad) placed in wheelchair. R192's Care Plan Interventions with initiation date of 1/8/18 documents Provide appropriate footwear. Keep personal items within reach. R192's MDS, dated [DATE], documents he has severe cognitive impairment. The MDS documents he requires extensive physical assist of 2 person for transfers. The MDS documents he is not steady and is only able to stabilize with assistance. The MDS documents he has range of motion impairment on one side of upper and lower extremities. R192's General Progress note, dated 7/2/2020, V34, Nurse Practitioner, documented, in part, For the last 2 weeks, resident has been seen leaning to the right side while sitting in his wheelchair. His hips slide forward which puts him at risk for falling out of his wheelchair. R192's Fall Initial Occurrence Progress Note, dated 9/18/2020, documents R192 had an unwitnessed fall in his room at 7:45 AM. The Occurrence note documented CNA (Certified Nursing Assistant) entered resident's room to assist him to bed and found him on the floor face down and onto the left side. The Note documented R192 stated I was getting my shoes. The Progress Note documented R192 had a 4-centimeter laceration to his left forehead. The Note documented R192 was sent to the ER for evaluation. On 10/20/2020 at 3:14 PM V46, LPN, stated The CNA went in to get him ready for supper. Resident was on the floor face down on his side. He said he was reaching for his shoes. He had a laceration to his head. Sent him out to the hospital. The managers put the interventions in place. We don't. We would just watch him more frequently. He did not have a dycem in his chair. On 10/21/2020 at 2:36 PM V45, CNA, stated, The resident asked to stay up later. I came back to him and he was on the floor. He slid out of the chair. The chair was not turned over. He had 1 shoe on and one shoe off. He was bleeding from his head. He was sent to hospital. He did not have dycem in his wheelchair. R192's Fall Report, dated 9/18/20, documented R192 had an unwitnessed fall. This report had no information if R192 fell from his wheelchair or bed. The Report did not document any fall intervention other than his call light was in reach prior to him falling. The Report did not document if R192 had Dycem in his wheelchair or appropriate footwear in place at the time the fall occurred. The Report did not document if R192's personal items (i.e. shoes) were within reach at the time of the fall. The Report did not document any progressive interventions to prevent R192 from future falls or injuries. R192's Care Plan was not revised after he fell on [DATE] with progressive interventions to prevent him from future falls. On 9/23/2020 at 11:00 AM R192 sitting in his wheelchair. R192 was leaning to his right side with buttocks towards edge of the wheelchair seat. R192 feet were on the floor. There was no cushion or nonskid surface/pad in place and no tilting to the back of the wheelchair. On 10/5/2020 at 1:00 PM R192 was sitting in wheelchair. R192 was leaning to right side and buttocks to the edge of the chair. There was no cushion or nonskid surface/pad in place in his wheelchair. R192's back to wheelchair had not been modified. On 10/8/2020 at 10:10 AM V19, CNA, stated He leans in the chair all the time. That's how he sits. He doesn't keep his legs on the foot pedals. We try but he gets tired. He slides forward in his wheelchair. We can't keep them on there (foot pedals). Sometimes he gets a burst of energy but usually he is so tired from [MEDICAL TREATMENT] it wears him out. On 10/8/2020 at 1:10 PM V13, Occupational Therapist, stated, I do not communicate with the nursing staff. It is the nursing staff that are to let us know of any changes. Positioning is difficult. V13 stated they did not make recommendations to nursing staff regarding R192. V13 stated When assisting with positioning we can get him up right in his wheelchair, but he is dependent on the staff to position correctly. He gets tired from [MEDICAL TREATMENT] and doesn't keep his feet on the foot pedal. If the foot pedal, dycem and cushion is in place, this will help with his seating and keep him from falling out. On 10/27/2020 at 10:50 AM V2, Director of Nursing (DON), stated, If (R192) would have had his interventions in place it would have prevented the fall from happening. On 10/27/2020 at 11:25 AM , when asked if R192's fall on 9/18/20 could have been prevented if R192's fall prevention interventions were in place V71, Medical Director, stated I would be guessing. But I would expect that the interventions were in place. The Facility's Fall Prevention Program, dated 11/21/2017, documents Purpose: To assure 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. 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. The Facility's policy documents Residents at risk of falling will be assisted with toileting needs as identified during the assessment process and as addressed on the plan of care. It continues, Foot wear will be monitored to ensure the resident has proper fitting shoes and /or footwear is non-skid. B. Based on observation, interview and record review, the facility failed to assess and implement interventions to provide safe smoking for one of three residents (R9) reviewed for supervision/smoking in the sample of 69. Finding includes: On 10/08/2020 at 10:06 AM, R9 was observed outside smoking without a smoking apron on. V24, Activity Aide, aide was supervising the smoking. R9 was observed to have difficulty holding his cigarette steady in his right hand and dropped ashes on his pants. R9's Admission Record, print date 9/30/2020, documents R9 was admitted [DATE] with [DIAGNOSES REDACTED]. R9's Minimum Data Set (MDS), dated [DATE], documents that R9 is cognitively intact and uses tobacco. R9's Care Plan, dated 6/3/2019, documents, Focus: I am a smoker. Interventions: Instruct about smoking risks and hazards and about smoking cessation aids that are available. Resident will keep smoking materials in a secured location. Resident will participate in smoking assessments as needed. R9's Smoking Safety Risk Assessment, dated 9/15/20, documents, Level of supervision: Requires assistance and supervision with smoking. Comments: Resident needs assistance with smoking, will evaluate a need for a smoking apron. The facility provided document (R9) Smoking Assessment, dated September/October 2020, given to survey team on 10/6/2020 has 3 facility staff signatures under Need Apron. On 10/6/2020 at 4:30 PM, V3, Social Service Director, (SSD), stated, I had the Activity people assess (R9) for the need of a smoking apron starting on 9/9/2020. I want to have as many observers give their opinion on if he needs a smoking apron. I need one more persons' signature for the need of an apron for the assessment to be completed. V3 further stated that if she was advised of R9 needing a smoking apron she would get him one and the process would not take weeks to complete. V3 also stated that in relation to R9's smoking apron need assessment the staff did not date the document when they signed it. On 10/08/2020 at 10:55 AM, V24, Activity Aide, stated, I did not know there was an in-service the other day and that (R9) needed a smoking apron. (R9) does have trouble holding his cigarette with his right hand and he is shaky. On 10/29/2020 at 9:00 AM, V1, stated, (R9's) smoking apron assessment should not have taken that long to complete. The facility policy and procedure Smoking Safety, dated 1/22/2019, documents, A Smoking Safety Assessment will be completed to determine the level of assistance and supervision needed during smoking, the ability to carry and store materials, and if a smoking apron is indicated. The plan of care shall reflect the results of this assessment. This assessment will be completed upon admission, quarterly and with significant change.

Based on interview and record review, the facility failed to provide discharge planning to ensure a safe and orderly discharge to post-discharge care for 2 of 3 residents (R200, R201) reviewed for discharge planning in the sample of 23. This failure resulted an Immediate Jeopardy when R200 was involuntarily discharged to a homeless shelter without discharge planning to ensure appropriate available services for [MEDICAL TREATMENT], surgery consultation appointment and insulin medications for diabetes. Subsequently, R200 was treated in the emergency room due to lack of appropriate services. In addition, R201 was involuntarily discharged to a local hotel without medications to treat his mental illness, pain, hypertension and migraines. R200's lack of medications including insulin and lack of coordination to receive [MEDICAL TREATMENT] has the likelihood of leading to hospitalization for [MEDICAL CONDITION] and diabetes. This could lead to death. R201's lack of medications and medical monitoring could lead to his psychiatric decline and potential hospitalization . The IJ was identified to have begun on 6/17/20 when R200 was involuntarily discharged to a local homeless shelter without adequate discharge planning to ensure he had care/services including transportation to [MEDICAL TREATMENT] and medication to treat his current medical condition. The IJ was identified on 8/3/20. V1, Administrator and V3, Regional Corporate Nurse were notified of the Immediate Jeopardy on August 3, 2020 at time 11:14 AM. The surveyors confirmed through observations, record review and interview that the Immediate Jeopardy was removed on 8/7/20, but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings include: 1. R200's Face sheet, undated, documented he was admitted on [DATE] and had the following Diagnoses: [REDACTED]. R200's Significant Minimum Data Set (MDS), dated [DATE], documented R200 required extensive assistance of one-person physical assistance for bed mobility, dressing, and limited assistance with one-person physical assistance for walking and toileting. The MDS documents R200 balance was Not steady, only able to stabilize with staff assistance. Incident Investigation Summary dated 6/17/2020 at 3:33 PM, documents R200 received [MEDICAL TREATMENT] on 6/17/2020. The incident summary documents V4, Nurse Practitioner (NP), and V11, Social Service Assistant (SSA), were informed by V34, Transportation Driver, that R200 put something in his pocket when he was picked up after his [MEDICAL TREATMENT] appointment. The incident summary documents, 2 stubs of marijuana that measured about ¼ inch long and 2 pieces of something like crack cocaine, were found on R200. The incident summary further documents the (city) Police arrived and did a field test but couldn't confirm the tested product to be crack cocaine. The summary documented the local Police said there was nothing they could do for the marijuana due to it being legal in Illinois, and (facility) uses federal money for its operation, and it is illegal. R200's Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents, dated 6/17/2020, authored by V11 documents, On the date of transfer or discharge, you will be relocated to (local homeless shelter). R200's Hospital Admission emergency room (ER) Report dated, 6/18/2020 at 11:12PM, documents R200 walks short distances with or without assistance and presented with cuts on legs that were present on arrival. The ER report also documents R200's medication list to include [MEDICATION NAME] and [MEDICATION NAME]for his Diabetes Mellitus and [MEDICATION NAME] for his hypertension. The ER report documents R200 having fallen in the last 3 months and uses ambulatory aides to assist with walking. The Report states R200 presented to the ER due to chest tingling, and the tingling reportedly got a little worse tonight. R200 stated he also feels a little short of breath. R200 reported he has had some chills and hot flashes. The report further documented, He (R200) stated he is currently homeless and states he is waiting on a check from the government to get back into a nursing facility. On 7/22/2020 at 1:27 PM, V1, Administrator, stated due to illegal drugs found on R200, the facility could discharge R200 and stated, It was a spur of the moment thing. V1 denied having transportation set up or services for R200 to get to and from [MEDICAL TREATMENT] at time of discharge and nor did he know if he had been at [MEDICAL TREATMENT] after discharge date of [DATE]. V1 confirmed R200 had a wheelchair, walker and can walk some too. (R200) isn't always in a wheelchair. V1 then stated, I have no idea how (R200) gets to [MEDICAL TREATMENT] now. Community Based [MEDICAL TREATMENT] Progress Note dated 6/19/2020 at 10:00AM, documents in part, Phone call made to (R200's) sister/emergency contact to follow up on pt's (patients) location. She (sister) reports pt has not been located. Informed her ED (Emergency Department) records show pt was there last night at 2255 (10:55PM) c/o (complaints of) chest pain. Pt was discharged however he (R200) informed them he was homeless and would like to sleep in the hospital bed a little longer. On 7/23/2020 at 4:08PM, V23, [MEDICAL TREATMENT] Facility Administrator stated R200's last [MEDICAL TREATMENT] treatment was on 6/17/2020. V23 stated she received a phone call on 6/17/2020 from the facility stating R200 was found behind the dumpster at the [MEDICAL TREATMENT] clinic and putting something in his bag. V23 further stated she attempted to call V1, Administrator, for more information but was unable to reach him. V23, stated she was able to reach V4, Nurse Practitioner/NP, who confirmed R200 was discharged from the facility. V23 stated R200 should have had [MEDICAL TREATMENT] on 6/19/20. V23 stated on 6/18/2020 she spoke with R200's sister and R200's sister stated she was unaware where R200 was and was actively still searching. Social Service Note dated 6/19/20 at 11:29 AM, documented R200 had contacted V11 and asked for the number he should call to appeal his involuntary discharge from the facility because he had lost it. The Note documented V11 gave him the number and asked R200 to come get his belongings. R200's June 2020 Medication Administration Record [REDACTED]. Inject 5 unit subcutaneously (sq) before meals; [MEDICATION NAME] Solution Pen-injector 100 units per milliliter (ml) to inject 5 units sq one time a day; and [MEDICATION NAME] Tablet 1000 milligram (mg), twice daily for diabetes. The POS documented the facility should notify the physician if R200's blood sugar levels were less than 70 and greater than 350. Facility document entitled, Appointment Reminder, undated, documents R200 having an appointment with vascular surgery on 6/18/2020 at 12:10 PM for his [MEDICAL TREATMENT] catheter. R200's June 2020 MAR indicated [REDACTED]. R200's June 2020 documented R200 should receive Nephro-Vite Tablet, 1 mg, daily for kidney failure. The POS documented R200 was receiving [MEDICAL TREATMENT] on Monday, Wednesday and Friday weekly. The POS documented the facility should do the following with regarding to R200 receiving [MEDICAL TREATMENT]: Obtain Vital Signs, Blood Pressure/Pulse and monitor pre and post [MEDICAL TREATMENT] for: altered mental status, lethargy, [MEDICAL CONDITION], chest pain, shortness of breath, abdominal pain, nausea, vomiting, unusual itching, bleeding at site, bruises, abnormal muscle cramps, redness, swelling, tenderness, or signs of infection at [MEDICAL TREATMENT] site; Observe [MEDICAL TREATMENT] catheter (right chest wall) for any signs or symptoms of drainage, redness, bleeding; and Report any abnormal findings to physician and to cover the site with a dressing as needed. R200's Community Survival Skills Assessment, dated 5/27/2020, recommendation: The resident does not appear to be capable of unsupervised outside pass privileges at this time. Elopement/Unauthorized Leave Risk Review for R200, dated 6/14/2020, documents, R200 Becomes agitated, confused and/or disoriented or displays consistently poor judgement (i.e., would not be able to safely care for him/herself outside of the facility). On 7/21/2020 at 2:00 PM, V11, stated she was not sure whether R200 left with his medications at his time of discharge because he was discharged as an involuntary discharge. V11 stated she didn't know because she doesn't do anything with his meds. V11 stated that residents who are discharged Against Medical Advice or Involuntary Discharge don't generally get their medications and she had no idea what happened to R200's medications. On 7/22/2020 at 9:00AM, V7, Receptionist, stated he recalled on 6/17/20 three police officers came to the facility and the facility discharged R200 after that. V7 recalls speaking to R200's sister after R200's discharge and she was not aware of R200's discharge nor his whereabouts. V7 stated R200's sister thought R200 was discharged to the streets. V7 stated R200 was on foot when he left the facility. On 7/28/2020 at 9:28AM, V3, Regional Nurse, stated she would expect the facility to coordinate services such as the care plan with [MEDICAL TREATMENT]. On 7/28/2020 at 9:55AM, V3 stated, I would have assured (R200) had a safe discharge. On 7/28/2020 at 10:10AM, V4, Nurse Practitioner, stated, I was under the impression you get your medication. I was under impression you get your medication no matter what kind of discharge, except narcotics. When asked by surveyor if she would expect the facility to follow the Plan of Care for R200, V4 stated that would be the expectation. V4 was asked if she was aware the facility failed to provide the plan of care from [MEDICAL TREATMENT] and would she have expected the facility to coordinate care with [MEDICAL TREATMENT], and she said she was not aware, and the facility should have the care plan from [MEDICAL TREATMENT]. 2. R201's Progress Note dated, 6/21/20 at 2:08 PM documented, Staff and residents report that resident appeared to be in drunken state and was violent by hitting another resident. The resident that claims to have been hit, guardian asked that the police be called, and charges pressed on him. Writer has moved the resident (R201) to the 3rd floor for safety of that resident. Staff is told that resident cannot come off the 3rd floor currently. The facility's Final Investigation Report for R201's Resident to Resident Abuse, dated 7/13/20, documents, on 6/20/20 at 5:30 PM, R201 had a resident to resident altercation with R203. The Report documented staff witnessed the occurrence and separated the residents. The report documented staff indicated R201 may have been under the influence of alcohol. The report documented R201 was moved to a different floor. The Report documented R201 was involuntary discharged to the community. R201's Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents, dated 6/23/20 documented, Reason: The safety of individuals in this facility is endangered. The Involuntary Discharge Notice documented R201 would be transferred to a local hotel on 6/23/20 with V11 supervising the discharge. The Involuntary Discharge Notice was signed by V1, Administrator. The Involuntary Discharge documents, Pursuant to Section 483.12(a)(7) of the federal regulations, this facility will provide sufficient preparation and orientation to ensure your safe and orderly transfer or discharge from this facility. On 7/21/20 at 3:19 PM, V1 stated, We discharged (R201) because he was involved in a resident altercation with (R203). I got a call at home, they told me (R201) was outside smoking and came back in, staff said when he came back, he seemed intoxicated. He went into (R203)'s room and started messing with her things. She told him to leave. I guess that is when he supposedly hit her. Staff separated them and moved him to the third floor. On 7/22/20 at 1:25 PM, V1 stated, (R201) had an immediate order of protection placed on him. (R203)'s Power of Attorney (POA) filed the order of protection after (R203) told him about what happened. We cannot accommodate his needs because of the order of protection. R201's Medical [DIAGNOSES REDACTED]. Lack of Coordination, Major [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION] Reflux Disease, [DIAGNOSES REDACTED] Migraine. R201's June 2020 POS documented he received the following [MEDICAL CONDITION] medications for [MEDICAL CONDITION] and Major [MEDICAL CONDITION]: [MEDICATION NAME] Sodium ER ( Extended Release) Tablet 24 Hour, 250 mg, give 1 tablet by mouth in the morning, [MEDICATION NAME] Sodium ER Tablet Extended Release 24 Hour, 500 mg, give 1 tablet by mouth two times per day; [MEDICATION NAME] Tablet, 30 mg, 1 tab at bedtime; [MEDICATION NAME] Tablet, 7.5 mg, 1 tablet by mouth in the morning; [MEDICATION NAME] HCl, 5 mg tablet, 1 tablet by mouth three times a day for anxiety; [MEDICATION NAME], HCL Extended Release 24 Hour, 150 mg, one tablet daily. R201's June 2020 POS documented he received the following medications for migraines: [MEDICATION NAME], 25 mg as needed for migraines; and [MEDICATION NAME] Tablet, 25 mg, give 1 tablet by mouth two times a day. R201's June 2020 POS documented he received the following hypertensive medications: [REDACTED]< (less than) or = (equal to) 60 or SBP (systolic blood pressure) < or = 110. R201's June 2020 POS documented he received [MEDICATION NAME] Tablet 800 mg, 1 tablet three times daily related to chronic pain. On 7/28/20 at 10:00 AM, V3 stated the nurses should have given a discharge summary of the medications to R201 upon discharge. V3 stated V26, Licensed Practical Nurse (LPN), should know what R201 was given at discharge. On 7/28/20 at 2:45 PM, V26, LPN, stated I don't remember discharging (R201), You would think I would remember an Involuntary Discharge, but I don't. When asked, if you would have taken the time to give discharge instructions, a written list of medications and a supply of medications V26 stated, Yes, you would think I would have remembered that. On 7/24/20 at 12:50 PM, V11, SSA, stated, It's my fault there wasn't a progress note on (R201)'s discharge and no discharge instructions. I think it was around 1:00 PM. The facility driver (V34) and I took him to a (Local Hotel). He had $100.00, I think. No discharge assessment was done. On 7/28 20 at 10:10 AM, V4, Nurse Practitioner, stated, I was under the impression you are to get your meds no matter what kind of discharge, except narcotics, we only give 3 days' worth. On 7/28/2020 at 2:57PM, V44, Pharmacist, stated medications for residents under third party vendor such as Medicaid belong to the resident, and only those medications under Medicare A belong to the facility. Follow-up email dated 7/29/2020 at 8:06AM, written by V44, Pharmacist, stated R200, R201, did not receive Medicare A benefits. After multiple request from the survey team, the facility was not able to provide R201's discharge planning including a list of what medications he was to receive and instructions on how to administer those medications at the time of R201's discharge. As of 7/30/20, the facility had not provided a policy regarding the disposition of medications upon involuntary discharge of residents. The Immediate Jeopardy that began on 6/17/20 was removed on 8/7/20 when the facility took the following actions to remove the Immediacy: 1.The facility located R200. R200 is currently residing at a local homeless shelter. The Facility reached out to the shelter. R200 was under the care of the local shelter's Physician. The Local Shelter confirmed he was receiving his medications and was going to [MEDICAL TREATMENT]. 2.The facility located R201 at a local apartment complex. 3. V55, LCSW, in serviced the Interdisciplinary Team (IDT) on Discharge Planning Process, F660, Post-Discharge Plan of Care, EFE Fact Sheet on 8/6/20. 4.V3, Regional Corporate Nurse, V10, Vice President of Operations, and V56, New Administrator as of 8/6/20, in-service the IDT on pre and post discharge planning including the Initial Assessment (utilizing Q0500 Section of the RAI 3.0 Manual) on admission in relation to discharge planning, daily review of potential discharges, pre and post-discharge planning including care and services which includes equipment, medications and follow-up Physician's appointments. V19, Social Service Director and V11, Social Service Assistant will be responsible for setting up car and services including equipment, medications and physician's appointments for discharging residents. Completed 8/7/20 5.V3, V10 and V56 in serviced IDT on the revised Facility's Discharge & Transfer Policy. Completed on 8/7/20 6.V3, V10 and V56 reviewed Post-Discharge Plan of Care including discharge beings at admission, care and services pre and post discharge including equipment, medications and follow up Physician's appointments, EFE (Equipped for Equality) Fact Sheet. Completed on 8/6/20 7. Any potential discharges will be discussed by the IDT prior to proceeding to ensure a safe discharge unless an immediate danger to themselves and others is at high risk. Ongoing 8.The IDT will discuss in the daily morning meeting potential discharges including pre and post discharge care and services including equipment, medications and follow up physician's appointment to ensure a safe and appropriate discharge. Ongoing 9.The IDT will then review in the daily morning meetings the progress of any ongoing or potential discharges in relation to post-discharge care and services including equipment, medications, financial needs and follow up physician's appointments to ensure a safe and appropriate discharge. Ongoing 10.The Facility's Discharge and Transfer Policy has been reviewed and updated by V3 and V10 to include initiating discharge planning as per individualized resident need based off of an initial assessment (utilizing Q0500 of the RAI 3.0 Manual) on admission, Power of Attorney (POA)/Family discussion as appropriate, review and discussion of pre and post discharge care and services including equipment, medications and follow up Physician's appointments. Completed 8/7/20 11. A comprehensive audit of all residents with potential discharge planning or current discharge planning has been completed. Completed 8/7/20. 12.All residents have been interviewed in relation to their individual Discharge Plan. Completed 8/7/20.

Based on observation, record review and interview, the facility failed to assess, monitor, and implement progressive interventions to prevent the formation and to promote healing of pressure ulcers for 4 of 5 residents (R209, R213, R214, R219), reviewed for pressure ulcers in a sample of 23. This failure resulted in R209's current pressure injuries/ulcers declining, and she developed two new facility acquired Stage 2 pressure ulcers. Findings include: 1. R209's [DIAGNOSES REDACTED]. [MEDICAL CONDITION] with (Acute) Exacerbation. R209's Minimum Data Set, dated dated [DATE], documents she is cognitively intact. The MDS documents she has more than one pressure ulcer and is at risk for developing new pressure areas. The MDS further documents R209 requires 2-person extensive physical assist for bed mobility and toilet use. R209's Admission/Re-Admission Assessment, dated 5/19/2020 documents R209 had 3 unstageable pressure injuries/ulcers with the following measurements: 1) 0.6 centimeters (cm) cm by (x) 0.8 cm x 0.2 cm ulceration to upper buttock with moist slough (dead necrotic tissue) to wound bed; 2) 4.8 cm x 4.0 cm x ulceration to lower buttock with dry eschar (dead tissue) to the wound bed; and 3) 5.0 cm x 2.2 cm x 0.2 cm ulceration to the middle buttock with moist slough to wound bed. R209's Care Plan, dated 5/19/2020, documents R209 has a potential for impairment to skin integrity related to incontinence of stool. R209's Care Plan dated 5/26/2020, documents R209 is resistive to care including turning and repositioning. The Care Plan documents Allow the resident to make decisions about treatment regime, to provide sense of control. Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care. R209's Braden Scale for Predicting Pressure Ulcer Risk (Braden Scale) dated 5/20/2020, documents R209 was at high risk for pressure ulcers. The Braden Scale documents R209 responds to verbal commands but cannot always communicate discomfort or the need to be turned or has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. The Braden Scale documents R209 can make occasional slight changes in body or extremity position but unable to make frequent or significant changes independently and requiring moderate to maximum assistance in moving. R209's Physicians Order Sheet dated 5/20/2020, documents Santyl Ointment 250 unit/gm apply to the 2 areas on the right rear thigh topically every evening shift for nonstageable wound. R209's physician's orders [REDACTED]. R209's Wound documentation dated 5/27/2020, documents R209 had 5 pressure ulcers with the following measurements; 1) Right Thigh distal (situated away from the center of the body) 2cm x 1.8cm x slough; 2) Right thigh proximal 3.0 cm x 4.4 cm (centimeters) x (by) necrosis; 3) Right buttock 5 cm x 2.9 cm x red; 4) Sacrum 2.6 cm x 1.9 cm; and 5) left buttock 9.9 cm x 8.1 cm. There was no documentation there was a change in R209's pressure ulcer treatment even though she now had developed two additional pressure injuries/ulcers. The Wound documentation did not document the Stage of the pressure ulcers, the color, tissue type, exudate (drainage), odor, [DIAGNOSES REDACTED] (redness of skin) and condition of the peri wound. From 5/27 through 6/24/20, the wound documentation was inconsistent. The documentation including the location of the pressure ulcers changed throughout. There was no documentation in R209's medical record throughout this time that V25, R209's Physician, made any changes in treatment orders for R209's pressure injuries/ulcers. R209's Physician Orders, dated 6/24/2020, documents refer to plastic surgery for [REDACTED]. Resident was admitted from area hospital with wound. It is becoming worse. R209's Progress Note created by V4, Nurse Practitioner (NP), dated 6/25/2020, documents Chief Complaint/Reason for this Visit: [MEDICAL CONDITION] (congested heart failure), large open wound to right buttocks. The Progress Note documents She also has an open wound to her right buttocks. The wound was present when she was admitted from the hospital. The wound is becoming worse. Wound Nurse has been caring for it but states it is now starting to tunnel. She has been using medicated cream and changing dressing daily. She (R209) is unable to transfer herself and is up in her wheelchair for many hours of the day. She (R209) tells me that it does hurt at times. She has no other concerns today. There was no documentation in R209's medical record regarding the facility obtaining services from the plastic surgeon for debridement of R209 pressure ulcers. R209's Wound documentation, dated 7/6/2020, documents pressure injury to the right thigh has tunneling. There was no documentation in R209's medical record that there were any changes in treatment to R209's pressure injuries/ulcers. R209's Wound Clinic Progress Note, dated 7/20/20, documented R209 had a pressure ulcer to her right ischium measuring 2 cm x 2.2. cm by 0.7 cm, a pressure ulcer to her left buttock measuring 10.5 cm x 2.4 cm x 0.1 cm, a pressure ulcer to her coccyx measuring 1.5 cm x 0.3 cm x 0.1 cm and a pressure ulcer to her sacrum measuring 2 cm x 5.6 cm x 0.1 cm. The Progress Note documented that staff were to keep pressure off the pressure ulcers as much as possible and to apply xeroform/border form daily on all pressure areas. In addition, staff were to apply Destin and [MEDICATION NAME] twice daily to the pressure ulcer on her left buttock. R209's Braden Scale for Predicting Pressure Ulcer Risk dated 7/21/2020, documents R209 was at moderate risk for pressure ulcers. The Braden Scale documents R209 responds to verbal commands but cannot always communicate discomfort or the need to be turned or has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. The Braden Scale documents R209's ability to walk as being severely limited or non-existent, and R209 not being able to bear own weight and/or must be assisted into the chair or wheelchair. The Braden Scale further documents R209 makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently and requires moderate to maximum assistance in moving. R209's Skin-Pressure/Diabetic/Venous/Arterial Wound Report, dated 7/21/2020, documents R209 had two new facility acquired Stage 2 pressure ulcers with one to her sacrum measuring 2 cm x 5.6 cm by 0.1 cm and one on her coccyx measuring 1.5 cm x 0.3 cm x 0.1 cm. The Report documented that these were first observed on 7/20/20. The report documented R209 had a Stage 3 pressure ulcer to her right ischium measuring 2 cm x 2.2 cm x 0.7 cm with tunneling/undermining of 4.8 cm. This report did not document the pressure injury which was noted on the Wound Clinic Report to her left buttock. R209's Physicians Orders, dated 7/21/2020, documents clean right ischium, coccyx, sacrum with wound cleanser. Apply sterile [MEDICATION NAME] gauze and cover with border foam dressing daily, on evening shift. On 7/22/2020 at 10:20 AM R209 stated, I can't get the proper care. Can take up to an hour and half to answer the light and get help. Here recently they put me to bed at 12:30 PM. I pulled my light and they answer it and leave. After a while they stopped answering the light. Finally, at 5:00 PM, they were ready to get me up. I have never refused to let them do my treatment. I want to make sure I'm not stuck in the bed all day. It's depressing. I try not to cry. There are days when it is hard to live here. I want to go home but if my infection is not gone and my wounds aren't better, I will be stuck here. On 7/23/2020 at 9:40 AM, R209 was lying on her back in bed. V39 and V18 Certified Nurse's Aides (CNAs) assisted R209 onto her side. V6, ADON was in the room evaluating R209's pressure ulcers. There were multiple deep red creases to R209's back, buttocks and thighs. R209's buttocks and perineal area ranged from fire engine red to dark non blanchable red in color. R209 had a ½ moon shaped deep red non-blanching Stage 1 pressure ulcer and an unstageable pressure ulcer the size of a quarter with 100% slough on her sacrum. V6, ADON, evaluated these two areas, one pressure ulcer measuring 9.6 centimeters squared (cm2). R209 had a pressure ulcer to her right medial thigh approximately the size of a nickel with slough noted in wound bed. V6 measured this pressure ulcer as 7.1 cm2. R209 had a Stage 1 pressure ulcer the size of a quarter to her right inner thigh. V6 measured this pressure ulcer as 1.6 cm2. R209 had two Stage 2 pressure ulcers, one finger width apart on her coccyx. V6 measured these pressure ulcers as one area measuring 128cm2. On 7/23/2020 at 9:40 AM V39 stated that this was the first time coming into R209's room. V39 stated Coming in to help get her cleaned up. On 7/23/2020 at 9:45 AM V18 stated, She pulled the light and said she needed cleaned up. V18 stated she had not repositioned R209 today. V18 stated She is getting a shower and will get up then. On 7/23/2020 at 10:00 AM R209 stated, Had a bowel movement last night. They cleaned me up and took the dressing off because it was soiled. No one came back in and put another one on. No one has come back in. I have been on my back since they changed me last night. On 7/23/2020 at 10:30 AM V29, Licensed Practical Nurse (LPN), stated, I have not performed any treatments on (R209) as of yet this morning. I would expect the dressing to be in place. If it (dressing) was removed or came off, I would expect the staff to notify me immediately so I can do the treatment. Moisture and pressure would cause pressure areas and cause them to get worse. On 7/28/2020 at 9:45 V37, Registered Nurse/RN at wound clinic stated (R209) will continue to have new open areas if the resident is not repositioned. On 7/30/2020 at 12:20 PM V2, Director of Nursing (DON), stated If the resident refused to turn and reposition or refused treatment, I would expect the staff to document that in the progress notes. I would expect the staff to provide the resident with education discussing the risk versus the benefits so the resident could make an informed decision. Can't say that it wasn't done if not documented, but I would expect it to be documented in the progress if it was done. The Facility was unable to provide documentation of the education performed with the resident and documentation of the resident's refusals to turn and/or reposition. 2) R214's Care Plan, revised on 5/27/2020, documents R214 having [MEDICAL CONDITION], having an Activities of Daily Living (ADL) self-care performance deficient related to [MEDICAL CONDITION], and incontinence. The Care Plan also documents R214 is to lie down after meals. The Care Plan further documents R214 has potential for skin impairment r/t (related to) decreased mobility, fragile skin, incontinence. R214's MDS dated [DATE], documents R214 has moderately impaired cognition and requires extensive assistance of 2 staff persons physical assistance for bed mobility, transfers and toileting. The MDS documented R214 was at risk for pressure ulcers and had one Stage 2 pressure ulcer at the time of this assessment. The MDS further documents R214 having the following Diagnoses: [REDACTED]. R214's physician's orders [REDACTED]. Apply bordered foam dressing. Change q (every) 3 d (days) et (and) PRN (as needed) for soilage and dislodgement (sic). There were no other orders for pressure ulcer treatment. On 7/23/2020 at 9:03AM, R214 sat in her room in her wheelchair with her hand on her head moaning. There was a pervasive urine odor in the room. At 9:50AM, surveyor asked V21 and V22, CNAs, when the last time R214 was repositioned and or toileted. V22, CNA, said ask (V20/CNA) and she can tell you how long she (R214) has been up, and I think she has been up since this morning. On 7/23/20 at t 9:05AM, V20 stated R214 was gotten up at 6:30 AM. V20 stated she hasn't had time to change or reposition R214 because she (V20) is too busy giving showers. V20 stated R214 was gotten up because she (V20) must give 17 residents a shower in one day. V20 stated that Corporate changed the schedule for showers whereby afternoons and nights don't do showers and so she hadn't had time to take care of R214. V20 said when she comes in the morning residents are always wet. On 7/23/20 at 9:55 AM, V20 and V22 stood R214 up. There was dressing on R214's right gluteal dated 7/18/20 and deep red creases were noted to the outer edges of her bilateral buttocks. R214 had an opened pressure ulcer to her coccyx that was not covered with a dressing. There was a pervasive urine odor and V22 stated, That's her wound, not urine. The Care Plan revised on 7/27/2020, further documents R214 having pressure ulcer on coccyx and right gluteal r/t (related to) inc (incontinence) of B&B (bowel and bladder). Facility Wound Log dated 7/28/2020, documents R214 had a new Stage 2 facility acquired pressure ulcer to her coccyx with initiation date of 7/23/20. The Wound Log further documents R214 had a facility acquired pressure ulcer to her right upper buttocks measuring 0.4 cm by 0.3 cm with initiation date of 7/23/20. Facility Wound assessment dated [DATE], documents R214's facility acquired coccyx pressure ulcer measured 2.1 cm x 1.7cm by 0.1 cm with light exudate and serous drainage. The assessment documented the primary dressing to be a foam dressing and to be on a turning/repositioning program. R214's Treatment Administration Record (TAR) dated July 29, 2020, documents no treatments for R214. On 7/23/2020 at 10:00AM, V2, Director of Nurse (DON) stated It (wound) is ordered to be changed every three days and she would have expected the dressing to be changed every 3 days and more often if needed. V2 stated that residents should be toileted at least every 2 hours and more frequent and should be repositioned then as well. 3) On 7/23/2020 from 9:15AM, R213 remained in her wheelchair in her room. At 9:30AM, V20 stood R213 up and removed her incontinent brief. R213 had deep white creases and urine was noted dripping from the incontinent brief onto her inner thighs. On R213's right buttock was a red circular mark that remained reddened for greater than five minutes and was not blanchable. When V20 observed R213's buttocks, V20 stated, That wasn't there this morning when I got her up. At that time, V20 stated she had not repositioned R213. V20 stated that she had been passing trays, doing resident's showers and answering call lights. V20 stated she got R213 up at 7:15 AM. Facility Wound Log dated 7/28/2020 fails to list any reddened area to R213's right upper buttock. Care Plan revised on 1/20/2020, documents R213 having a self-care performance deficit r/t Dementia and the potential for impairment to skin integrity r/t fragile skin, incontinence, [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. On 7/23/2020 at 10:00AM, V2, DON, stated, residents should be toileted at least every 2 hours and more frequent, and should be repositioned then as well. 4) R219's Significant Change MDS, 6/22/20, documents R219 is severely cognitively impaired. The MDs documents she requires extensive assistance of two staff persons for mobility, transfers and toilet use. The MDS documents she is at risk for pressure ulcers. R219's Current Care Plan, undated, documents she has [DIAGNOSES REDACTED]. R219's Care Plan Focus, initiation date of 4/10/19, documented I have a potential for impairment to skin integrity r/t (related to) fragile skin, incontinent, [MEDICAL CONDITION] and ASA (aspirin) use. On 7/23/20, from 8:54 AM to 10:30 AM, based on 15-minute observations, R219 was in her room sitting in a specialized chair watching T.V. There was a mechanical lift sling/pad under R219. R219's knees were contracted. At 9:11 AM, V11, Social Service Assistant and V39, CNA were in R219's room. V39 was asked when R219 had been checked for incontinence and repositioned last. V39 stated that would have been around 7:00 AM when R219 was placed in the specialized chair. V39 went to the hall and brought back a mechanical lift. V11 and V39 hooked R219's sling to the mechanical lift and attempted to move R219 to R219's bed. The mechanical lift noted to rise both up and down to what appeared to this surveyor the right heights. V39 stated the lift was not raising high enough and disconnected R219 from the sling. V11 and V39 left the room with the mechanical lift. On 7/23/20 at 9:29, V40, Rehab Director, V11, and V41, Medical Records, returned to R219's room with a different mechanical lift. These staff members attempted to use the lift again and stated the lift was not going high enough. The lift rose to the same level as prior lift and staff again stated the lift was not raising high enough to get R219 over the chair arms of the chair. The staff then brought in a new battery to try on the lift. The lift was then checked again, and staff continued to say the lift was not rising high enough to transfer R219. On 7/23/20 at 9:43 AM, R219 was restless in chair, fidgeting, reaching for the floor and end of chair. R219 attempting to scoot forward and move R219's legs were off the end of the chair. V41 instructed R219 to move back in chair. On 7/23/20 at 9:45 AM, V41, V11 and V29, LPN, all entered R219's room stating they were going to reposition R219. They used the mechanical lift sling to pull R219 up into chair. All 3 staff agreed that a resident should be checked for incontinence and repositioned every two hours. V11 stated that R219 was last checked for incontinence and change of position at 7:00 AM by V39. On 7/23/20 at 10:06 AM, V2, DON, V6 DON, V42 LPN, and V43 CNA entered R219's room. R219 was moved in R219's chair to the side of the bed as the staff discussed how they would move R219. V43 left the room and came back with the same mechanical lift from the hall that had been used previously. R219's lift sling was hooked to the lift and R219 was raised in the air. The mechanical lift again raised to the height it had been raised before. V2 and V6 stated the lift was not going high enough again. V43 then stepped in at 10:15 AM, three hours and 15 minutes after R219's last incontinence check, and stated: Yes, it is. V43 then maneuvered the lift and chair to allow R219 to be able to be transferred from the front of the chair instead of over the chair arms and into the bed. This surveyor asked if R219 was wet. V2 (DON) stated, no as the disposable brief did not turn color to show it is wet. The surveyor requested to observe R219's skin. R219 was rolled on R219 left side. R219 had deep indentations noted to her bilateral upper legs into the buttocks area around the edges of the disposable brief, both areas were noted to be red in appearance. Facility's Pressure Ulcer Prevention Policy, dated 11/28/2012 with revisions on 1/15/18 documents Purpose: to prevent and treat pressure sores/pressure injury. The Policy documented 2. Inspect the skin several times daily during bathing, hygiene, and repositioning measures. The Policy documented 5. Turn dependent resident approximately every two hours or as needed and position the resident with pillows or pads protecting boney prominence as indicated. It documents 7. Whenever possible, encourage resident to change position at regular intervals as able to promote circulation. Wheelchair resident may be instructed to shift weight from one buttock to the other. 8. If redness does not disappear within 30 minutes the turning schedule may be shortened to 1 hour. Maintain clean/dry skin during daily hygiene measures. Inspect the skin several times daily during bathing, hygiene, and repositioning measures. May use lotion on dry skin. Change bed linen per schedule and whenever soiled with urine, feces, or other material. Turn dependent residents approximately every two hours or as needed and position resident with pillow or pads protecting bony prominences as indicated. Whenever possible, encourage resident to change position at regular intervals as able to promote circulation. Wheelchair residents may be instructed to shift weight from one buttock to the other. If redness does not disappear within 30 minutes the turning schedule may be shortened to one hour.

Based on interview and record review the facility failed to develop and implement person-centered interventions to address residents' behavioral health care needs for 2 of 3 residents (R200, R222) reviewed for behavioral health in the sample of 23. This failure resulted in R222 hallucinating, having delusions and refusing medications which resulted in psychiatric hospitalization s three times in five months. Findings include: 1.R222's Electronic Medical Record (EMR) dated 8/2020 documents [DIAGNOSES REDACTED]. R222's only Behavior Health Note, dated 3/2/20, written by, V36, Licensed Clinical Social Worker from a Behavioral Health Consultant Group, (R222) is a [AGE] year old Caucasian female who was seen at the nurse's desk on her hall at the nursing home. Nursing Home staff report that (R222) believes she is pregnant and will be having a baby boy in September, and they have confirmed multiple times that she is not pregnant. Staff report that (R222) has been refusing [MEDICAL CONDITION] medication, and the writer witnessed her walking in the hall, shouting 'They said I'm [MEDICAL CONDITION] and I'm not. I don't need you crazy people'. The writer introduced herself and described her role and encouraged (R222) to talk about what is bothering her so the writer can assist her. (R222) reported 'you can't help me, I'm sorry,' and started pacing the hallway. She is alert and oriented X (times) 2, intense eye contact. Speech is loud, mood is grandiose. Insight, judgement and impulse control impaired. She denies suicidal ideation/homicidal ideation, displays response to internal and external stimulus. She is recommended for individual therapy and psychiatric services. Prognosis is limited. ASSESSMENT and PLAN document, [MEDICAL CONDITION] disorder, [MEDICAL CONDITION] type. PLAN: Cognitive Behavior Therapy/Dialectical Behavior Therapy (CBT/DBT) skills training to assist in managing moods and symptoms. Individual therapy to stimulate cognition, help develop healthy coping skills, and learn psychoeducation. Psychiatric diagnostic evaluation. Follow up as needed (prn). R222's Care Plan Focused Problem, dated 3/10/20, documented I have been diagnosed with [REDACTED]. I require attention in the priority skilled areas: self-maintenance, ADLS hygiene, dressing, grooming, care of personal space, diet and nutrition, personal safety, social skills and symptom management. The Goal documented I will engage in skills training addressing 2x per week. The Interventions documented Encourage resident to practice skill regularly. Emphasize detailed instructions, modeling, repetition, or role playing in reality-based scenarios. Introduce skill gradually, with clear explanations, Offer appropriate behavior incentives, positive feedback and reinforcement for [MEDICATION NAME] skill. R222's Care Plan Focused Problem, dated 3/11/20 documented I have a behavior problem delusion r/t (related to) [MEDICAL CONDITION]. I think I'm pregnant and I'm having a baby boy. The Care Plan interventions documented Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately. Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Care givers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and or unacceptable to the resident. There was no documentation in R222's medical record that the facility implemented cognitive behavioral therapy/dialectical behavioral therapy, or any other recommendations made by V36 on 3/2/20 to address R222's behavior health needs. There is no documentation in R222's medical record of the facility's implementation of skills training for R222. The Facility's Petition for Involuntary/Judicial admitted d 4/21/20 documented R222 was sent to hospital because she was experiencing visual hallucinations, seeing God and angels, delusional thinking (i.e. thinking she is pregnant), refusing medication, combative with staff, yelling disruptive and not easily redirect. R222's Petition for Involuntary/Judicial Admission, dated 6/24/20, documented she was sent to hospital due to experiencing visual hallucinations, seeing God and angels, thinking that she is pregnant with multiple babies, refusing medications, combative with staff, yelling and disruptive and not easily redirected. R222's Discharge Instructions from Hospital, dated 7/1/20 document Follow up with Psychiatrist at (Facility). Take medications as prescribed. If you experience side effects, please notify clinical provider. Avoid use of alcohol or illicit drugs. There is no documentation in R222's medical record that she is being seen by a Psychiatrist. There was no other documentation from the Behavioral Health Consultant Group that R222 was seen after her hospitalization on [DATE]. R222's Medication Administration Record [REDACTED] [MEDICATION NAME] (an antianxiety medication), 30 milligrams (mg) every AM and [MEDICATION NAME] ([MEDICATION NAME]), 50 mg every AM on 7/2/20 and 7/3/20. R222 refused her [MEDICATION NAME] which should be given daily, 16 days in July 2020. R222 refused [MEDICATION NAME] (medication to treat [MEDICAL CONDITION] reflux disease) which should be given daily, 20 days in July. R222 refused [MEDICATION NAME], a diuretic, to be given daily, 9 days in July. R222 refused her AM dose of Quetiapine (an antipsychotic medication), 9 days in July. She refused her PM dose of Quetiapine, 11 days in July. There was no documentation in R222's Care Plan or medical record that the facility attempted to implement progressive interventions to address R222's refusal of medication. The Petition for Involuntary/Judicial Admission, dated 8/3/20 documented she was having visual hallucinations, claiming to be raped in April by her angels, claiming to be pregnant with twins, being physically and verbally aggressive with staff and other residents. R222's Progress Note, written by V19 Social Service Director (SSD) dated 8/3/20 at 12:29 PM documents, Receptionist brought resident to SS (Social Service) office and she told writer that she (R222) was raped. Writer spoke with resident and she stated that she was raped four months ago by three different men. Writer asked her if she knew who raped her and she said Vurt and(NAME)and writer asked her what was the third person name and she called me illiterate b**** and that she is not going to talk to me anymore. Resident stood up and grabbed writer and shook writer and writer said let's go talk to Director of Nurses (DON) and Assistant Director of Nurses (ADON) so you can tell them what happen. Writer took her to DON office and writer notified Administrator. R222's Progress Note written by V2 Director of Nurses (DON) dated 8/4/20 document, on 8/3/20 Writer was made aware of a situation by social service regarding resident. Resident became violent with social service grabbing and shaking her. This is when the writer took over the inquiry. Resident claims to have been raped in April. Resident told writer that three guardian angels raped her and now she is pregnant with twins. When writer attempted to ask questions regarding the rape the resident became belligerent. Resident repeatedly states that the three guardian angels came in her room through the window and attacked her. While attempting to complete a skin assessment, resident became angry and agitated, stating she was done talking about this. Resident told writer 'you're not going to touch me, get out of my room.' Writer exited the room. Facility contacted Police Department regarding the rape allegation. A police officer came to interview the witness around 11 am. On 8/4/20 at 11:20 AM, V19 Social Service Director (SSD) was asked if (R222) was put on any type of behavioral programming when she returned from the last hospital admission on 7/1/20. V19 stated, No, but she (R222) spoke with (V36, Licensed Clinical Social Worker from Behavioral Health Consultant Company). V19 stated I usually work from 5:00 PM to 10:00 PM, so I normally text (V11 Social Service Aide) or email her to let her know what needs to be done the next morning, and sometimes I'm on the meeting with speaker phone. I've said in the phone calls on the morning meetings, I ask them What are we going to do about (R222)? I have been working with V4 Nurse Practitioner (NP) on behaviors by keeping an eye on this person, I should have documented it probably, but I didn't. On 8/10/20 at 12:00 PM, V3, Corporate Registered Nurse (RN) Consultant stated, Interventions should have been put into place to ensure (R222) took her medications. At 2:27 PM, V3 stated R222 has not been seen by a psychiatrist or psychologist while residing in the facility. 2. R200's Face sheet, undated, documented he was admitted on [DATE] and had the following Diagnoses: [REDACTED]. R200's Care Plan Focused Problem, dated 1/10/20, documented I have [DIAGNOSES REDACTED]. The Interventions documented Administer medications as ordered by physician, encourage participation in activities of choice and interest, encourage sharing feelings of loss, encourage socialization. R200's Care Plan Focused Problem, dated 3/26/20 documented I have a history of criminal behavior. I have demonstrated stability during the admission screening process and does not appear to present at risk. Fits criteria for an 'identified offender'. The Interventions documented Evaluate the resident's ability to control impulses. If substance abuse is suspected, utilize appropriate blood/urine testing, limit setting, counseling and consequences. R200's Care Plan Focused Problem, dated 5/14/20 documented I have a mood problem r/t (related to) DX (diagnosis) of [MEDICAL CONDITIONS] disorder. The Interventions documented Behavior health consults as needed (psycho-geriatric team, psychiatrist etc.) Progress Note authored by V36, Licensed Clinical Social Worker (LCSW), dated 3/9/2020, documents, R200 was seen for chief complaint of anxiety and was referred by V25, Medical Director. The progress note documented R200 has chronic anxiety disorder and with a recommendation for: Plan BCT (Behavior Change Technique) /DBT (Dialectical Behavior Therapy) skills training to assist in managing moods and symptoms individual and group therapy to help develop healthy coping skills and stimulate cognition. There was no documentation in R200's medical record that the facility implemented V36's recommendations which she made on 3/9/20. R200's Community Survival Skills Assessment, dated 5/27/2020, recommendation: The resident does not appear to be capable of unsupervised outside pass privileges at this time. Social Services notes, written by V11, Social Service Assistant (SSA), dated 6/10/2020, documents Writer met with (R200) to see how things are going. He (R200) is doing well. He has not exhibited any criminal behavior since admission. Elopement/Unauthorized Leave Risk Review for R200, dated 6/14/2020, documents, R200 Becomes agitated, confused and/or disoriented or displays consistently poor judgement (i.e., would not be able to safely care for him/herself outside of the facility). Social Services note dated 6/17/2020 1:10 PM, documents: Writer (V11) spoke with resident (R200) to let him know that he needs to stop asking other residents and staff members for cigarettes and food. Resident denied that he is asking staff and other residents for items he states that he has money of his own and that he can buy the things that he needs. Writer informed him that this type of behavior will not be tolerated and if he keeps this up, he will be giving an involuntary discharge (IVD). He is doing this on a daily basis and when staff question him about it, he denies. R200's Care Plan was not updated with progressive interventions to address R200 asking staff and residents for money. Incident Investigation Summary dated 6/17/2020 at 3:33 PM, documents R200 received [MEDICAL TREATMENT] on 6/17/2020. The incident summary documents V4, Nurse Practitioner (NP), and V11, Social Service Assistant (SSA), were informed by V34, Transportation Driver, that R200 put something in his pocket when he was picked up after his [MEDICAL TREATMENT] appointment. The incident summary documents, 2 stubs of marijuana that measured about ¼ inch long and 2 pieces of something like crack cocaine, were found on R200. The incident summary further documents the (city) Police arrived and did a field test but couldn't confirm the tested product to be crack cocaine. The summary documented the local Police said there was nothing they could do for the marijuana due to it being legal in Illinois, and (facility) uses federal money for its operation, and it is illegal. 7/23/2020 8:30 AM, V11, Social Service Assistant stated that there were no behavioral services for residents. She said there were no services such as alcohol programing or counseling services. She said the facility used to have some classes such as anger management and/or things like how to do socialization. The facility Policy and Procedure for Behavior Management Program dated 11/28/12 documents To establish a system for identifying behaviors and implementing appropriate interventions consistent with the individualized plan of care and to ensure that each resident receives appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. Guidelines include Services: Mental health rehabilitative services and behavior management program for Mental Illness (MI) and Intellectual Disabilities (ID) may include, but are not limited to: Consistent implementation during the resident's daily routine and across settings, of systemic plans which are designed to change inappropriate behaviors; Medications prescribed to change inappropriate behavior to alter manifestations of psychiatric illness; Provision of a structured environment for those individuals who are determined to need such structure (e.g., structured socialization activities to diminish tendencies toward isolation and withdrawal); Development, maintenance and consistent implementation across settings of those programs designed to teach individuals the daily living skills they need to be more independent and self-determining including, but not limited to, grooming, personal hygiene, mobility, nutrition, vocational skills, health, drug therapy, mental health education, money management, and maintenance of the living environment; Crisis intervention service; Individual, group, and family psychotherapy; Development of appropriate personal support network; and Formal behavior modification programs.

Based on observation, interview and record review, the facility failed to complete an initial assessment, and provide needed care and services to a newly admitted resident for one of one residents (R159) reviewed for care and services of a newly admitted resident in the sample of 61. This resulted in R159 not receiving ordered Intravenous (IV) antibiotics until 42 hours after admission causing inadequate levels of antibiotic in her system to treat her [DIAGNOSES REDACTED]. The immediate jeopardy began on 2-21-20 when R159 was admitted to the facility and staff did not complete the admissions process by ordering medications, notifying the physician of the admission, identifying the care needs and initiating protocols based on the admission assessment, providing meal service and setting up proper equipment for the resident to enable herself to turn and reposition while in bed. The IJ was identified 3/4/20. V1, Administrator, V6, Corporate Nurse and V2, Interim Director of Nursing were notified of Immediate Jeopardy on 03/04/20 at 10:14 AM. The surveyors confirmed by observations, record reviews and interviews that the Immediate Jeopardy was removed on 03/06/20 but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings include: On 02/23/20 at 10:00 AM, R159 was in her room alone. She was lying in bed with an anxious look on her face. R159 was tearful, shaking and grimacing while she spoke and explained she had not received any medication, had not received any meal service, had not been turned or repositioned or given a bed with side rails for turning and repositioning herself (R159 is a paraplegic with no ability to move her lower body from the waist down), provided personal care needs and had no fluids of provided since being admitted on [DATE]. R159 was had a disheveled appearance with oily, unclean hair that was not brushed or combed. R159 stated she had not had a bed bath or shower since her arrival. R159 stated she performs her own urine self-catherization and asked on 02/22/20 for soap and a basin of water and V7, Certified Nurse's Aide, CNA, stated the facility did not have soap in the building to give her. R159 was provided a basin of water and a urinal. On 02/23/20 at 10:00 AM, R159's urinal was on the bedside table several feet away out of reach from R159. There was no water basin observed in the room or bathroom. R159 stated she was in severe pain rating it Beyond 10 out of 10 on the pain scale. R159 stated she had severe pain in her head and back and stated she felt like she was running a fever. R159 further stated that she felt isolated in her room with no television remote and cannot get up to turn it on and her bedside table was across the room. R159's call light was observed behind her hanging off the bed out of her reach. R159 stated she was admitted to the facility from the hospital for Intravenous (IV) medication treatment due to being diagnosed with [REDACTED]. R159 stated V2, Director of Nursing (DON) told her on 02/23/20 at 9:30 AM that she was not in the facility's system and no one really knew she was here. Website www.mayclinic.org documents Meningitis is an inflammation of the membranes (meninges) surrounding your brain and spinal cord. The swelling from meningitis typically triggers symptoms such as headache, fever and a stiff neck. Most cases of meningitis in the United States are caused by a [MEDICAL CONDITION] infection, but bacterial, parasitic and fungal infections are other causes. Some cases of meningitis improve without treatment in a few weeks. Others can be life-threatening and require emergency antibiotic treatment. The website documented Meningitis complications can be severe. The longer you or your child has the disease without treatment, the greater the risk of [MEDICAL CONDITION] and permanent neurological damage, including: Hearing loss, Memory difficulty, Learning disabilities, Brain damage, Gait problems, [MEDICAL CONDITION], Kidney failure, Shock, and Death. On 02/23/20 at 11:20 AM, V2 was observed preparing to hang two IV medications for R159. V2 stated that R159 was not put into the facility's system and therefore the medications did not get ordered properly. V2 was observed to hang [MEDICATION NAME] (an antibiotic) 1 gm (gram) at 125 milliliters per hour through left forearm PICC (Peripherally inserted central catheter) line. At 11:40 AM, V2 was observed to hang [MEDICATION NAME] (an antibiotic) 2 gm IV at 1 drop per minute. The physician's orders [REDACTED]. This order was never carried out by staff on 02/22/20. On 02/23/20 at 11:40 AM, V2 stated she had a call out to the physician regarding pain medication. V2 stated that no pain medications were ordered at this time. At 1:00 PM, V2 stated she was still waiting on the call from the physician regarding R159's pain medications and that she could not give any medications until the physician called back. On 2/23/20 at 12:35 PM, R159 was observed in bed. R159 stated she has had no change in her condition. At 1:30 PM, 2:00 PM, 2:20 PM, 3:00 PM and 3:35 PM, R159 remained in extreme pain and had not received any pain medications. On 2/23/20 at 3:50 PM, V2, DON stated she had not heard from the physician regarding the pain medications for R159. The POS, dated 02/23/20 at 3:30 PM, documented the order as [MEDICATION NAME] tablet 5-325 mg ([MEDICATION NAME]-[MEDICATION NAME]) give 1-2 tablets by mouth every 6 hours as needed for moderate pain. On 02/23/20 at 7:28 PM, the Medication Administration Record [REDACTED]. On 02/29/20 at 10:01 AM, V38, Pharmacist, stated that an emergency physician to pharmacist call had been conducted on 02/23/20 at 4:29 PM in which the physician agreed to the order for the [MEDICATION NAME] for R159. On 02/25/20 at 3:07 PM, V17, LPN stated she was the admitting nurse for R159 on 02/21/20. V17 stated R159 arrived at the facility approximately 5:30 PM via ambulance from the hospital. V17 stated she began the admission process around 5:50 PM and was only able to complete the initial skin, pain and diet portions of the admission. V17 stated she did not put any medications or look to see what was ordered. V17 stated V2, DON was in the facility when R159 arrived, but was gone when she had to stop doing the admission due to having to return to her medication pass for her other residents. V17 stated that at approximately 8:30 PM, she informed V2, DON that she was unable to finish R159's admission and was told to pass the admission to the next nurse on duty to finish. V17 stated she gave this information to V44, LPN (night nurse). On 03/03/20 at 1:17 PM, V44, LPN stated she worked on 02/21/20 starting at 10:00 PM. She recalled being informed by V17, LPN of R159's admission, but was not informed to finish her admission. V44 stated the facility's computer system was down when she arrived until 5:30 AM. She stated she (V44) did not do any assessments, give any medications or go into R159's room during her shift. V44 stated she reported to V31, LPN the next morning that the system was down and that she did not know anything about R159. V44 further stated that V1, Administrator and V2, DON should have been aware that the system was down, and she would not have informed them due to it being a routine situation. On 02/23/20 at 12:05 PM, V31, LPN stated that 2/22/20 was her first day and she and was not aware that R159 required IV antibiotics and pain medications, that she did not receive meal service or that she required turning and repositioning assistance. V31 stated she was aware that R159 had been admitted over the weekend but was not sure what day. On 03/03/20 at 10:50 AM, V41, LPN stated that she worked on 02/22/20 helping to orient V31, LPN. V41 stated that at 11:00 AM, she answered a call light for R159. She stated she was not aware that anyone was even in the room. She stated R159 asked for something to eat and told her that she was admitted the night before and had not been fed yet. V41 stated that R159 told her that she was in extreme pain as well and had not been given any medications. V41 stated that V44, LPN (night nurse 02/21/20) had not made her aware that R159 had been admitted during the morning nursing report. V41 stated she did not believe that V44 knew that R159 was admitted either. V41 then helped V31 input some of the medications into the computer and notified V46, LPN/MDS Coordinator and V2, DON at this time that no one knew that R159 was in the building and that R159 had been neglected by not receiving any services up until this time. On 02/23/20 at 11:45 AM, V7, Certified Nursing Assistant (CNA) stated that she was aware R159 was in her room but did not know when she was admitted . On 02/22/20 at 12:00 PM, V7 stated she came into R159's to get her breakfast tray and was told by R159 that she did not receive a tray. V7 stated she told V41, LPN about the missing tray. V7 she did not follow up to see if R159 got a lunch tray or not. On 02/23/20 at 11:50 AM, V30, Registered Nurse (RN) stated she knew R159 was admitted to the facility but did not know what day. V30 stated she was not aware that R159 required IV antibiotics and pain medications and that she had not received meal service or required turning and repositioning assistance. On 02/23/20 at 10:00 AM, R159 was observed to have a bed without a side rail on the right side and a bed rail on the left side that was non-functioning. According to R159, she was unable to move her lower body without help from staff or having bed rails. On 02/23/20 at 11:30 AM, V2, DON was made aware. On 02/24/20 at 9:00 AM, R159 was observed in the same side lying position from the day before. R159 stated that staff had not assisted her in turning and repositioning since the day before. There were no pillows to support her lower limbs for pressure relief. On 02/23/20 at 10:00 AM, R159 stated she had not received a meal since her admission on 02/21/20. On 2/23/20 at 11:45 AM, V5, Dietary Manager, confirmed R159 was not in the facility's system and therefore a meal ticket was not generated for her to receive meals. On 02/26/20 at 11:31 AM, V20, Medical Director, stated he was not aware that R159 was admitted to the facility until 02/23/20 in the early afternoon when he received an order request for pain medication for R159. V20 stated he was not aware R159 was admitted on [DATE] and did not even know who the hospital physician was who was cared for R159 while she was in the hospital. V20 stated he was not aware that IV medications, pain medications, assistance for turning and repositioning or meal service or fluids were not provided to R159 until 02/23/20. He also stated that he was not aware that isolation precautions were not initiated until 02/24/20. He stated that a resident with the type of systemic infections as R159 has, isolation precautions should have been initiated with at least gowns, gloves and masks until R159 was no longer in danger of increased complications from the infections and isolation was otherwise not warranted. V20 was not made aware of R159's care needs until he met her on 02/24/20 at 1:49 PM. V20 stated he would expect the facility to follow standards of practice from accepting a resident, following the protocols for medication management especially with IV therapy and pain management and providing a safe, therapeutic environment to ensure the residents needs are met. V20 stated the fact that the facility did not follow through with the admission process, the facility failed to set up the reasonable care measures to care for and provide effective treatment and services for R159. V20 stated he would expect the facility staff to provide continuous treatment according to the hospital discharge orders received. V20 stated he gave a verbal order for [MEDICATION NAME] trough on 02/24/20 and was not aware that had not been drawn as of 02/26/20. V20 stated that if a [MEDICATION NAME] trough result was low, it was indicative that the therapeutic levels were not adequate to be effective with the serious infections R159 had. V20 stated it was standard of practice that if a resident was on [MEDICATION NAME] then a trough level must be drawn after every third dose in order to monitor the levels and adjust the dosage accordingly. On 02/19/20 at 10:00 AM, a hospital lab report prior to her admission to the facility documented R159's [MEDICATION NAME] trough level was 8.4 mcg/ml. On 02/28/20 at 1:30 AM, a Nurse's Note documented R159's [MEDICATION NAME] trough level was 5.7 micrograms per milliliters (mcg/m). Normal range is 10.0 - 20.0 mcg/ml. The Nurse's Note documented that the pharmacist ordered another trough to be drawn prior to giving the next dose at 6:00 AM. On 02/28/20 at 8:47 AM, a lab report documented R159's trough level was 8.0 mcg/ml. The POS, dated 02/28/20, documented a new order to give [MEDICATION NAME] 1.25 gm IV starting at 6:00 PM. The MAR indicated [REDACTED]. On 02/29/20 at 10:01 AM, V38, Pharmacist stated that [MEDICATION NAME] is an antibiotic used to treat bacterial infections, such as meningitis [MEDICAL CONDITION] blood infections. He stated that a blood trough level must be drawn after every third dose due to the risk of a patient becoming toxic which would affect organs of the body negatively. A low trough level is indicative of the wrong dose of antibiotic or that the medication was not given as often as needed to kill off the infective agent. V38 stated that protocol with a person with meningitis should have [MEDICATION NAME] trough levels of 15.0 - 20.0 mcg/ml in order to metabolize properly to fight the infection. V38 stated that R159's trough levels are critically low, indicating the [MEDICATION NAME] was not effective enough to fight off the infection. He further stated that [MEDICATION NAME] in IV form was used in a longer period of weeks to months to fight off the infection and that with critical trough levels this would prolong her healing process. On 02/23/20, the policy and procedure titled, Admission Agreement (Facility) was reviewed. It documented under, Contract Between Resident and Facility: B. Facility Agreement: 2. The facility shall offer personal care, room, board, dietary services and laundry services. The facility will also offer nursing care, activities, restorative and rehabilitative services and psychosocial care as identified in the resident's plan of care established by the facility to the extent required by the facility standards and in accordance with the policies of the facility. 3. Medicines, treatments or special diets will be offered to the resident if ordered by the physician, the facility Medical Director . 4. The facility will offer equipment required under facility standards. 5. The facility will exercise reasonable care toward the resident. The Immediate Jeopardy that began on 2/21/20 was removed on 3/6/20 when the facility took the following actions to remove the immediacy: 1. An audit utilizing the Admission Audit will be completed to identify all New Admissions in the last 30 days. Those identified will have assessments completed and care and services provided based off these assessments that includes Medication Administration, Pain Management, Nutrition, Hydration and Activities of Daily Living. 2. Vice President of Operations will be in-servicing all staff March 5 and March 6, 2020 at 10:00 AM, 2:00 PM, 4:00 PM, and 6:00 PM with completion date of March 6, 2020. Any staff not in-serviced will be removed from the schedule until such time as they are in-serviced. 3. Admission Audits were started on March 4, 2020 and will be completed by March 6, 2020 by nurse consultant staff. 4. Notification of all New admission will be sent by Business Development all Department Heads prior to the New Admission arrival via email. 5. Staff will be notified by Business Office Manager/internal admission coordinator of all new or pending admissions via resident admission communications on bright paper along with admission checklist to verify completion of all admission items for shift to shift communications beginning 3/5/20 and ongoing. 6. Director of Nurse's/Designee will provide Communication/Report of Pending Admission to the Facility Staff utilizing the Communication board starting 3/5/20 and ongoing. 7. Manager on Duty will verify availability of medications and meals provided on weekends and submit (Manager on Duty) checklist to Administrator beginning 3/5/20 and ongoing. 8. Nursing Manager/Designee will complete new admission audit utilizing the Admission Audit of the new admission's medical record to ensure the Initial Assessment has been completed and care and services based off these assessments are being provided including Medication Administration Pain Management, Nutrition, Hydration and Activities of Daily Living. This audit will be ongoing with all new admission. 9. Nursing staff on the floor will complete change of shift report via Physical Walking rounds throughout unit beginning 3/5/20 and ongoing. 10. Nursing staff on the floor will complete Medication Reconciliation on New Admission to ensure medication are in house and accurate as per order beginning 3/5/20 and ongoing. 11. Licensed Nursing Staff, including the Director of Nurse's will be educated on completion of new admissions including Assessments and Medications Administration. Vice President of Clinical Operations will be in-servicing all staff on March 5 and 6, 2020 at 10:00 AM, 2:00 PM, 4:00 PM, and 6:00 PM with completion date of March 6, 2020. Any staff not in-serviced will be removed from the schedule until such time as they are in-serviced. 12. License Nursing Staff working the unit will be educated on providing change of shift report via Physical Walking Rounds. VP of Clinical Operations will be in-servicing all staff on March 5 and 6, 2020 at 10:00 AM, 2:00 PM, 4:00 PM and 6:00 PM with completion date of March 6, 2020. Any staff not in-serviced will be removed from the schedule until such time as they are ins-serviced. 13. Licensed Nursing Staff, including the Director of Nurse's will be re-educated on utilization of communication board for shift to shift report. Vice President of Clinical Operations will be in-servicing all staff on March 5 and 6, 2020 at 10:00 AM, 2:00 PM, 4:00 PM and 6:00 PM with completion date of March 6, 2020. Any staff not in-serviced will be removed from the schedule until such time as they are in-serviced. 14. Unlicensed Nursing staff will be educated on providing change of shift report via Physical Walking Rounds. This included CNAs and will be verified by nursing leadership. Vice President of Clinical Operations will be in-servicing all staff on March 5 and 6, 2020 at 10:00 AM, 2:00 PM, 4:00 PM and 6:00 PM with completion dated of March 6, 2020. Any staff not in-serviced will be removed from schedule until such time as they are in-serviced. 15. Unlicensed Nursing staff will be educated on providing Activities of Daily Living based off the initial assessment. Vice President of Clinical Operations will be in-servicing staff on March 5 and 6, 2020. Any staff not in-serviced will be removed from the schedule until such time as they are in-serviced.

Based on observation, interview and record review, the facility neglected to provide needed care and services to a newly admitted resident for one of one resident (R159) reviewed for neglect in the sample of 61. This failure resulted in R159 not receiving ordered Intravenous (IV) antibiotics until 42 hours after admission causing inadequate levels of antibiotic in her system to treat her [DIAGNOSES REDACTED]. Finding includes: The Facility's policy and procedure titled, Abuse Prevention and Reporting - Illinois, dated 12/10/18, documented The resident has the right to be free from abuse, neglect, misappropriation of resident property. The Policy documented Neglect is defined as the failure to provide goods and services to a resident that are necessary to prevent physical harm, pain, mental anguish or emotional distress. On 02/23/20 10:00 AM, R159 was lying in bed with an anxious look on her face. R159 was tearful, shaking and grimacing while she spoke and explained she had not received any medications, had not received any meal service, had not been turned or repositioned or given a bed with side rails for turning and repositioning herself (R159 is a paraplegic with no ability to move her lower body from the waist down), provided personal care needs and had no fluids of provided since being admitted on [DATE]. R159 stated she was in severe pain rating it Beyond 10 out of 10 on the pain scale. R159 stated she had severe pain in her head and back and stated she felt like she was running a fever. R159's call light was behind her hanging off the bed out of her reach. R159 stated she was admitted to the facility on [DATE] from the hospital for Intravenous (IV) medication treatment due to being diagnosed with [REDACTED]. R159 stated V2, Director of Nursing (DON) told her on 02/23/20 at 9:30 AM that she was not in the facility's system and no one really knew she was here. On 02/25/20 at 3:07 PM, V17, Licensed Practical Nurse (LPN) stated she was the admitting nurse for R159 on 02/21/20. V17 stated R159 arrived at the facility approximately 5:30 PM via ambulance from the hospital. V17 stated she began the admission process around 5:50 PM but was unable to complete. She stated she did not put any of R159's medications into the system. V17 stated she gave this information to V44, LPN (night nurse). On 03/03/20 at 1:17 PM, V44, LPN stated she worked on 02/21/20 starting at 10:00 PM. She recalled being informed by V17, LPN of R159's admission, but was not informed to finish her admission. V44 stated the facility's computer system was down when she arrived until 5:30 AM. She stated she did not do any assessments, give any medications or go into R159's room during her shift. V44 stated she reported to V31, LPN the next morning that the system was down and that she did not know anything about R159. On 02/23/20 at 12:05 PM, V31, LPN stated that day, 2/22/20, was her first day and she was not aware that R159 required IV antibiotics and pain medications, that R159 did not receive meal service or that she required turning and repositioning assistance. V31 stated she was aware that R159 had been admitted over the weekend but was not sure what day. On 02/23/20 at 11:45 AM, V7, Certified Nursing Assistant (CNA) stated that she was aware R159 was in her room but did not know when she was admitted . V7 stated on 02/22/20 at 12:00 PM she came into R159's to get her breakfast tray and was told by R159 that she did not receive a tray. V7 stated she told V41, LPN about the missing tray. On 03/03/20 at 10:50 AM, V41, LPN stated that she worked on 02/22/20 helping to orient V31, LPN. V41 stated that at 11:00 AM, she answered a call light for R159. She stated she was not aware that anyone was even in the room. She stated R159 asked for something to eat and told her that she was admitted the night before and had not been fed yet. V41 stated that R159 told her that she was in extreme pain as well and had not been given any medications. V41 stated that V44, LPN (night nurse 02/21/20) had not made her aware that R159 had been admitted during the morning nursing report. V41 stated she did not believe that V44 knew that R159 was admitted either. V41 then helped V31 input some of the medications into the computer and notified V46, LPN/MDS Coordinator and V2, DON at this time that no one knew that R159 was in the building and that R159 had been neglected by not receiving any services up until this time. The physician's orders [REDACTED]. This order was never carried out by staff on 02/22/20. On 02/23/20 at 11:20 AM, V2 hung two IV medications for R159. V2 stated that R159 was not put into the facility's system and therefore the medications did not get ordered properly. On 02/23/20 at 11:40 AM, V2 stated she had a call out to the physician regarding pain medication. V2 stated that no pain medications were ordered at this time. At 12:35 PM, R159 was observed in bed. R159 stated she has had no change in her condition. At 1:00 PM, V2 stated she was still waiting on the call from the physician regarding R159's pain medications and that she could not give any medications until the physician called back. At 1:30 PM, 2:00 PM, 2:20 PM, 3:00 PM and 3:35 PM, R159 remained in extreme pain and had not received any pain medications. At 3:50 PM, V2, DON stated she had not heard from the physician regarding the pain medications for R159. On 02/23/20 at 7:28 PM, the Medication Administration Record [REDACTED]. On 02/23/20 at 11:30 AM, V2, DON was made aware R159 had no siderails on her bed to assist her with turning and repositioning. On 02/24/20 at 9:00 AM, R159 was observed in the same side lying position from the day before. R159 stated that staff had not assisted her in turning and repositioning since the day before. There were no siderails on her bed. There were no pillows to support her lower limbs for pressure relief. On 02/26/20 at 11:31 AM, V20, Medical Director, stated he was not aware that R159 was admitted to the facility until 02/23/20 in the early afternoon when he received an order request for pain medication for R159. V20 stated he would expect the facility to follow standards of practice from accepting a resident, following the protocols for medication management especially with IV therapy and pain management and providing a safe, therapeutic environment to ensure the residents needs are met. V20 stated the fact that the facility did not follow through with the admission process, the facility failed to set up the reasonable care measures to care for and provide effective treatment and services for R159. V20 stated he would expect the facility staff to provide continuous treatment according to the hospital discharge orders received. V20 stated he gave a verbal order for [MEDICATION NAME] trough on 02/24/20 and was not aware that had not been drawn as of 02/26/20. V20 stated without the trough levels, there is no indication of effective antibiotic levels to treat infections. On 02/28/20 at 8:47 AM, a lab report documented R159's trough level was 8.0 mcg/ml. The POS, dated 02/28/20, documented a new order to give [MEDICATION NAME] 1.25 gm IV starting at 6:00 PM. The MAR indicated [REDACTED]. On 02/29/20 at 10:01 AM, V38, Pharmacist stated that [MEDICATION NAME] is an antibiotic used to treat bacterial infections, such as meningitis [MEDICAL CONDITION] blood infections. He stated that a blood trough level must be drawn after every third dose due to the risk of a patient becoming toxic which would affect organs of the body negatively. A low trough level is indicative of the wrong dosing or that the medication was not given as often as needed to kill off the infective agent. V38 stated that protocol with a person with meningitis should have [MEDICATION NAME] trough levels of 15.0 - 20.0 mcg/ml in order to metabolize properly to fight the infection. V38 stated that R159's trough levels are critically low, indicating the [MEDICATION NAME] was not effective enough to fight off the infection. V38 further stated that [MEDICATION NAME] in IV form was used in a longer period of weeks to months to fight off the infection and that with critical trough levels this would prolong her healing process.

Based on observation, interview and record review, the Facility failed to assess and treat pressure injury for one of 7 residents (R70) reviewed for pressure ulcers/injury in the sample of 61. This failure resulted in R70 sustaining a left heel abrasion which declined to an unstageable pressure ulcer with no change in treatment for 49 days. Findings include: On 02/23/20 at 9:38 AM, R70 stated he has open area on left foot but doesn't know what happened. R70 stated it is a little sore. He stated the nurses change his dressing on the left heel on most days. R70's Care Plan dated 8/9/18 documents R70 has the potential for impairment of skin integrity related to fragile skin. The Care Plan Interventions dated 8/09/18 documented staff are to assess/record changes in skin status and report pertinent changes in skin status to physician. A Nurse's Note dated 1/8/2020 at 11:05 AM documents, During routine rounds resident noted to be bleeding from his left heel; upon assessment abrasion noted 2.1 (centimeters) x (by) 1.5 (centimeters) x 0.1 (centimeter). The Note documented the area was cleansed, dressing applied and V32, Nurse Practitioner was made aware. R70's physician's orders [REDACTED]. R70's Care Plan was not updated to address R70's new left heel pressure injury and how staff were to relieve pressure. R70's Skin Condition Report, dated 1/14/20 documents an abrasion on R70 left heel measured 1.5 cm by 1.5 cm by 0.1 cm with no signs or symptoms of infection. The report documented the abrasion with pink granulation maceration noted at peri wound. R70's Skin Condition Report, dated 1/21/20 documents the abrasion on R70's left heel measuring 2.5 cm by 2.0 cm with wound bed pink. R70's Skin Condition Report, dated 1/29/20, documents the abrasion on R70's left heel measured 1.8 cm by 2.0 cm by 0.2 cm. The Report documented 100 % granulation to R70 wound bed with moderate serosanguinous exudate (fluid that is yellowish with small amounts of blood) with no signs of infection. R70's January 2020 Treatment Administration Record documented R70 did not receive the treatment to his left heel on 1/11, 1/19, 1/23 and 1/28/20. R70's Skin Condition Report, dated 2/6/20 documents the abrasion on R70's left heel measured 2.0 cm by 1.8 cm by 0.2 cm. There was no documented in change in treatment although R70's pressure ulcer had not improved in four weeks. R70's Skin Condition Report, dated 2/13/20 documents the abrasion on R70's left heel measured 2.0 cm by 1.8 cm by 0.2cm with moderate amount of serosanguinous exudate, no pain or odor. R70's Skin Condition Report, dated 2/21/20 documents an abrasion measuring 1.7 cm by 2.5 cm by 0.2 cm with 100 % granulation; moderate serosanguinous exudate and no signs or symptoms of infection. There was no documented change in treatment although R70's pressure ulcer had not improved in six weeks. R70's February TAR documented R70 had not received the treatment to his pressure ulcer on 2/7, 2/10, 2/12, 2/16 and 2/18/20. On 02/25/20 at 2:01 PM, V13, Licensed Practical Nurse (LPN) removed the dressing from R70's left heel. R70 had quarter size round unstageable pressure ulcer with the entire wound base covered with yellow slough (a layer of dead tissue). V13 stated R70's wound was not an abrasion. V13 stated she would call it a wound but didn't know what type of wound it was. She stated, You would need to ask the DON (Director of Nursing) about it. Skin-Pressure/Diabetic/Venous/Arterial Wound Report dated 2/25/20 at 3:23 PM documented by V26, Assistant Director of Nursing, documented R70 had a facility acquired unstageable pressure injury to his left heel which was first observed on 1/8/20. The Report documented the wound was worsening and measured 2 centimeters by 2.3 centimeters with necrosis/100% white slough. V26 documented Treatment changed to left heel cleanse with normal saline. Apply Santyl (ointment which debrides necrotic tissue) to wound bed and cover with dry dressing. Change daily and prn (as needed). Wound started as trauma and has since declined. The NPUAP (National Pressure Ulcer Advisory Panel) at https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf documents the definition, Unstageable Pressure Injury: Obscured full- thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. 49 days after R70's initial treatment of [REDACTED]. [REDACTED]. In addition, R70's Physician order [REDACTED]. days. On 2/25/20 at 2:50 PM V27, LPN, stated, The area on (R70's) left heel has never been an abrasion. It was a deep tissue injury from him using that heel to move himself with his wheelchair. On 2/25/20 at 2:25 PM V43, Nurse Practitioner, stated she has been here for three weeks and she was just asked to assess R70's heel today. She stated she would probably call it a Stage II, but it did have slough covering the base of the wound. On 3/5/20 V6, Regional Nurse, stated she would expect staff to get a different treatment order if a wound is not improving. The Facility's policy, Pressure Ulcer Prevention, dated 11/28/12 documents to prevent and treat pressure sores/ pressure injury 11. Use positioning devices or pillows, rolled blankets, etc. to reduce pressure and friction/shearing from heels, toes, and malleolus (a bony projection with a shape likened to a hammer head especially each of those on either side of the anke) as indicated. 12. Encourage resident to maintain proper nutrition and hydration, providing supplements.

A. Based on observation, record review and interview, the facility failed to implement progressive interventions to prevent falls for 1 of 3 residents (R74) reviewed for falls in a sample of 61. This failure resulted in R74 falling and sustaining bruises to her forehead, lacerations to her eyebrow and finger, a nasal bone fracture and fractured teeth. Findings include: R74's Profile and [DIAGNOSES REDACTED]. R74's Care Plan Focus, dated 10/10/19, documented she was at risk for falls injury related to [MEDICAL CONDITIONS], Stroke, Dementia, [MEDICAL CONDITION] and a history of falls. Care Plan Intervention dated 3/5/19 documented that therapy was to screen R74 for wheelchair positioning. Care Plan Intervention dated 4/1/19 documented she would be placed on the Falling Star Program (program to identify residents at risks for falls) with a star placed outside her door, on devices and in her room. Care Plan Intervention, dated 8/19/19, documented Dycem (a non-slip pad) to w/c (wheelchair). R74's Fall Occurrence Report documents R74 to have had 4 recent falls, on 8/29/19, 10/5/19, 10/19/19, 1/10/20 and 2/19/20. R74's Fall Investigation Report, dated 8/29/19 at 6:35PM, documents an un-witnessed fall. The Report documented R74 was sitting on the floor in front of her bed, stating she slid off the bed. No injuries were noted. Fall IDT (Interdisciplinary Team) note, dated 8/30/19 at 10:07AM, for the fall on 8/29/19, documents a root cause of R74's fall was R74 was sitting on the edge of the bed with a new intervention for non-skid strips at bedside. R74's Fall Investigation Report, dated 10/5/19 at 4:30 AM, documents a witnessed fall. The Report documented R74 was observed on the floor in her room on her left side at the foot of the bed. R74's roommate at the time stated R74 attempted to self-transfer out of bed and fell . Range of motion was at baseline and no injuries were noted. R74's Nurse's Note, dated 10/5/19 at 2:34 PM, documents R74 complaining of left hip pain upon movement and R74 was sent to the emergency room for further evaluation. R74's Hospital Discharge Note, dated 10/8/19 documents a [DIAGNOSES REDACTED]. R74 returned to the facility on [DATE]. R74's Interdisciplinary Team (IDT) note, dated 10/8/19 at 10:17 AM, for the fall on 10/5/19, documents a root cause of R74's fall was R74 was self-transferring out of bed with a new intervention to move R74 closer to the nurse's station upon return to the facility. R74's Fall Investigation Report, dated 10/19/19 at 9:26 AM documents an un-witnessed fall in R74's room next to the bed. The Report documented no injuries were noted. The Report documents the new intervention was to educate R74 on using the call light for help and the dangers of self-transferring. R74's IDT note, dated 10/21/19 at 11:01 AM, for the fall on 10/19/20, documents a root cause of R74's fall was R74 was self-transferring from the wheelchair to the bed with new interventions for a medication review, continued skilled therapy and to encourage an evening snack. There were no documented interventions to address R74's need for increased supervision and lack of safety awareness to prevent future falls. R74's Minimum Data Set (MDS), dated [DATE], documents R74 as having severe cognitive impairment, requiring an extensive assist of two with transfers, an extensive assist of one with toileting and only able to balance self with staff assist. R74's Fall Investigation Report, dated 1/10/20 at 11:36 AM, documents a witnessed fall in the dining room. The Report documents no injuries were noted. The Report had no root cause identified for R74's fall. The Report documented the new intervention was for staff to monitor R74 in the dining room and provide frequent reminders not to self-transfer. R74's Care Plan was not revised after the fall on 1/10/20 with interventions to prevent R74 from future falls and injury. R74's Fall Risk Assessment, dated 2/19/20, documents R74 as being at risk for falls. R74's Fall Investigation Report, dated 2/19/20 at 9:30 AM, documents an un-witnessed fall by the activity room. R74 sustained a bruise to the forehead area and a laceration to the eyebrow area and finger. The Report documented R74 was sent to the emergency room for further evaluation. R74's Hospital X-ray report dated 2/19/20 documents R74 sustained a displaced [MEDICAL CONDITION] of the nasal bone and fractured teeth. R74 then returned to the facility on [DATE]. R74's IDT note, dated 2/23/20 at 12:16 PM, for the fall on 2/19/20, documents a root cause of R74's fall was she was reaching for the door with new interventions for therapy to assess for positioning and to monitor the bruising and abrasions until healed. There were no documented interventions to address R74's lack of safety awareness and need for increased supervision. On 2/23/20 at 12:33PM, R74 had bruises and abrasions to the nose, eyes and forehead area. When asked what happened, R74 stated I fell . R74 unable to recall how the fall occurred. On 2/25/20 at 1:29 PM, R74 was up in her wheelchair, there was no non-skid material in the wheelchair and no identifier on the wheelchair for the Falling Star Program. R74's room was observed with non-skid strips under the bed, not in front on the bed and no identifiers outside or inside the room for the Falling Star Program. On 2/27/20 at 9:50 AM, V22 and V23, Certified Nurse's Aides (CNAs) were doing a two-person gait belt transfer with R74. The wheelchair was not locked prior to the transfer onto the toilet or when transferring back to the wheelchair. The gait belt was loose and not tight around the resident. On 2/25/20 at 1:29PM, V44, Licensed Practical Nurse (LPN) stated she thinks R74 is on the Falling Star Program for fall prevention. On 2/26/20 at 11:40 AM, V20, R74's Physician, stated R74 is cognitively impaired and educating a resident with impaired cognition is not an appropriate intervention to prevent falls. On 3/5/20 at 2:05 PM, V2, Director of Nurses (DON), states If a resident has a Brief Interview of Mental Status (BIMS) of 5, they aren't going to be able to retain the education. The facility Policy and Procedure titled Fall Prevention Program, dated 11/21/17, documents the facility will determine the individual needs of each resident by assessing the risk of falls and will implement appropriate interventions to provide necessary supervision. B. Based on observation, interview and record review the facility failed to implement effective interventions to prevent residents at risk for elopement from leaving the facility for 7 of 7 residents (R7, R10, R20, R52, R53, R56, R71) reviewed for elopement in the sample size of 61. Finding include: 1. R56's Care Plan dated 12/6/2019 documents: I require use of a (resident monitoring device bracelet) alarm r/t attempts to exit the facility. On 2/24/20 at 9:50 AM R56 in her room stated, I just cleaned up the Senator's office and he just left for the day. R56 stated I go outside by myself and with others for walks. Throughout the survey, R56 was seen ambulating independently, getting on and off the elevator unsupervised, going from the 3rd floor down to the 2nd floor. R56's Social Service Note dated 12/15/2019 at 11:18 AM documents: (R56) Resident is sitting in the activity room with writer and other residents. 3rd floor staff reports that she had been trying to get out all morning and ask if she could stay with me for a while. Resident was with writer for 3 hours. R56's Social Service Note, written by V4, Social Service, dated 12/15/2019 at 4:13 PM documents (R56) Resident was found by writer in the main entrance of Hospital and resident was sitting in the doorway. She appeared confused and safe. She stated that she drove here, and her car was in the parking lot. Writer told resident to get in my car and we came back to the facility. On 2/24/2020 at 12:40 PM V4 stated, I can't remember what 3rd floor staff called me on my cell phone because I was home. V4 stated, It was snowing that day, and staff stated they didn't see any footprints. V4 stated, The administrator called me and told me to go pick her up at local hospital. On 2/25/2020 at 2:55 PM V27 Licensed Practical Nurse (LPN) was interviewed regarding R56 elopement and stated, CNA (unknown) stated she couldn't find (R56). V27 stated We then started looking around for her and called a Code Purple. We went outside and jumped into our cars. I called 911 and the police were involved. The police told us that she was at the local hospital because the hospital had called. V27 stated (R56) was wearing black yoga pants, black long sleeve sweater. It was snowing like crazy that day. V27 stated (R56) went downstairs on the elevator to the 1st floor and went outside. V27 stated Those doors down there don't activate an (alarming bracelet). On 2/25/2020 at 9:00 AM V1, Administrator, stated, I didn't do any investigation on (R56's) elopement because the resident didn't get injured or anything. V1 stated, We watched the video where the resident (R56) walked out the doorway on the first floor. V1 stated, The alarm did not go off because the first floor is uninhabited. V1 stated, The other facility in town called us and told us that the local hospital called them that a resident (R56) was on their property. V1 stated, I called (V4, Social Service) and told her to pick up the resident and return her back to facility. 2. The facility has four floors. The first floor is the basement floor and three floors above the basement floor. There is a main elevator which residents, facility staff and visitors can use to access all floors. There is no resident monitoring system alarm on this elevator. On 2/25/2020 at 10:05 AM, this surveyor took the elevator from the 3rd floor down to the 1st floor/basement. Heading east down the hallway was a double wooden door that had a large red in colored sign reading STOP door is alarmed. This surveyor opened the door and no alarm sounded and walked east down a hallway and exited out of the building. There were no alarms going off. At 10:09 AM V28, Facility Transporter observed outside in parking lot stated, I didn't hear any alarms going off. On 2/27/2020 at 9:10 AM, this surveyor took the elevator from the 3rd floor to the 1st floor. Heading east down the hallway, opening the double wooden door with the STOP sign and continued east down the hallway and exiting the building without any alarms or staff present. 3. The following residents have been care planned for wandering and elopement behaviors and who have access to the first floor/basement: R7's Minimum Data Set ((MDS) dated [DATE], documents R7 requires limited assistance of one staff for activities of daily living. R7's MDS documents R7 has severe cognitive impairment. R7's Social Service Note dated 11/13/2019 documents (R7) Resident tried to leave the building while all managers were in morning meeting. R7's Care Plan dated 11/14/19 documents (R7) I require use of an alarming bracelet. The Care Plan documented 11/13/18: R/T (related to) attempts to exit the facility. [DIAGNOSES REDACTED]. The Care Plan Intervention dated 11/20/19 documented Assess for and record any alarming bracelet related problems and report them to the physician. Observe for the following issues: Development of skin problems. Provide alarm as ordered: Alarming bracelet. R10's MDS, dated [DATE], documents R10 requires limited assistance of one staff for activities of daily living. R10 MDS documents R10 has severe cognitive impairment. R10's Care Plan, dated 11/15/19 documents I require use of an alarming bracelet alarm, resident attempts to exit the facility. [DIAGNOSES REDACTED]. The Care Plan documented that R10 was an elopement risk and wanderer. R20's MDS, dated [DATE], documents R20 requires limited assistance of one staff person for activities of daily living. The MDS documents R20 has severe cognitive impairment. The MDS does not document R20 has wandering behavior. R20's Care Plan dated 2/17/20 documents: I am an elopement risk/wanderer r/t exit seeking. R52's MDS, dated [DATE], documents R52 requires limited assistance from one staff person for ADLs and has moderately impaired cognition. R52's Care Plan dated 12/18/19 documents I am an elopement risk/wanderer. R53's MDS, dated [DATE], documents R53 requires limited assistance from one staff person for ADLs. The MDS also indicates a Brief Interview Mental Status being cognitively intact. The MDS for Section Wandering-Impact contain zeros in the code boxes. R53's Care Plan, dated 12/13/19, documents, I require use of an alarming bracelet alarm R/t (related to) attempts to exit the facility. The Care Plan Interventions document Respond to alarm promptly. Redirect her away for exits as needed. Provide alarm as ordered. R53's Nurse's notes dated 12/17/19 documents: (R53) Resident wandering the floor, redirected to room several times. Writer heard door alarm going off resident attempted to go out the east end door to the stairs. Writer and CNA (Certified Nurse's Aide) attempting to redirect resident to room with resident being aggressive, pointing finger in staff faces stating 'I'm God'. Resident stated, 'As soon as I can get downstairs, I'm calling 911 to make a report because I'm not supposed to be here'. R53's Nurse's note dated 12/14/2019 documents Communication with Family Data: resident sister also said she was afraid resident may try to leave the bldg (building) and wanted an alarm bracelet. She was told that she had one on (put on this morning when resident found propelling another resident on another floor). She said that the resident didn't have one on and an aide told her it was on a leg. The sister went immediately to her to check that. She said her sister would never do what we told her that she did. R53's Social Service note dated 12/14/2019 documents: Staff notified writer that this resident tried to escape out the 2nd floor door. Writer gave the CNA, an alarming bracelet to put on the resident. R71's MDS dated [DATE], documents R71 requires limited assistance of one staff person for ADLs. The MDS documents R71 has severe cognitive impairment. R71's Care Plan dated 10/10/19 documents I am an elopement risk/wanderer (exit seeking) r/t exit seeking. Interventions: Assess for fall risk. Monitor for fatigue and weight loss. The Care plan documented R71 had a (resident monitor device bracelet on her right ankle. R71's Activity Note dated 10/12/2019 documents (R71) got out of her wheelchair while in the activity room [ROOM NUMBER] times, so we decided to take her back down to the Certified Nurse's Assistant (CNA's). And she ended up back in the lobby area, another family member and resident were getting ready to leave out the door. I let them out (R71) wanted to go too, so she shoved me 3 times and told activity aide and I that we were stupid idiots. We tried to change her mind, but she got madder, she continued to call us names and walked out the door. Nurse notified. Facility's Policy and Procedure Missing Resident/Elopement dated 11/15/2017 documents All personnel are responsible for reporting a cognitively resident attempting to leave the premises, or suspected of missing, to the Charge Nurse as soon as practical. This includes any resident that did not sign out on pass and/or did not notify a staff member of his or her leaving. The Policy documents 3) Should an employee discover that a resident is missing from the facility, he or she should: Complete incident report and notify the state agency according to reporting guidelines. Document appropriate notations in the medical record. 4) Upon return of the resident to the facility, The Director of Nursing or Charge Nurse should: 7. Complete the incident report, indicating when resident returned and condition of resident. 8. Make appropriate entries into the resident's medical record. Complete a new Elopement Risk Assessment and update plan of care as appropriate.

Based on observation, record review, and interview, the facility failed to administer tube feeding to maintain nutritional status and failed to administer tube feeding as ordered for 2 of 2 residents (R61, R205) reviewed for enteral feedings in a sample of 61. This resulted in R61 having a significant weight loss of 26 pounds (Lbs) in 6 months. Findings include: 1. R61's Profile and [DIAGNOSES REDACTED]. V18, R61's son is listed as the responsible party. R61's Minimum Data Set (MDS), dated [DATE] fails to document a weight loss. R61's Care Plan, dated 1/2/20 document R61 requires tube feeding due to Dysphagia. Interventions include having a Registered Dietician (RD) evaluate quarterly and as needed, monitor caloric intake, monitor weight and report to the physician any weight loss. R61's physician's orders [REDACTED]. R61's weight records and Dietician notes were reviewed and document the following weights: August 2019 - 163 pounds (lbs.); September 2019 - 143 lbs.; October 2019 - 137; November 2019 - 140 lbs.; December 2019 - 143 lbs.; January 2020 - 143 lbs.; February 2020 - 137 lbs. R61's Dietician note, dated 9/20/19, by V19, RD, documents a significant weight loss of 20 lbs in one month. R61's Body Mass Index (BMI) is 24.5 and R61's laboratory results showed a low [MEDICATION NAME] and total protein level. R61's POS, dated 9/23/19 documents the tube feeding was increased from 65 ml/hour to 75 ml per hour at night for twelve hours per day due to weight loss per RD recommendation. R61's Dietician note, dated 10/7/17, by V19, documents a weight of 137 lbs. and a BMI of 23.5. This is a 6 lb. weight loss in one month. V19, documents this is acceptable despite triggered significant weight loss. All parties aware of weight loss which was desired by family as expressed in care plan meetings this year. R61's Dietician note, dated 11/1/19, by V19, documents a weight on 10/25/19 of 141 lbs. with a BMI of 24.4 and this is acceptable despite triggered significant weight loss. All parties aware of weight loss which was desired by family as expressed in care plan meetings this year. R61's Dietician note, dated 12/16/19, by V19, documents a weight on 12/16/19 of 143 lbs. and a BMI of 24.4 and this is acceptable despite triggered significant weight loss. All parties aware of weight loss which was desired by family as expressed in care plan meetings this year. R61's Dietician note, dated 1/7/20, by V19, documents a weight of 143 lbs. with a BMI of 24.4 and this is acceptable despite triggered significant weight loss in 6 months noted. Labs assessed for 12/16/19 with a low [MEDICATION NAME] noted. R61's Dietician note, dated 2/6/20 by V19, document a February weight of 137 lbs. and a BMI of 23.5 and this is acceptable despite triggered significant weight loss from months ago. Labs assessed 2/14/20 with a low [MEDICATION NAME] noted. On 2/26/20 at 10:08 AM, V18, R61's Son and Responsible Party stated he has never requested that R61 lose weight and he has not been notified of the weight loss. R61 states he lives further away from the facility and relies on the facility to notify him of any changes with R61. On 2/26/20 at 10:56 AM, V19, stated R61's weight loss was planned per family request due to her reaching the obese range. V19 stated a past Director of Nurses (DON) of the facility told her there was a care plan meeting and the family requested R61 loose some weight. V19 did not verify this information with the family. V19 stated R61's weights have been all over the place and R61 does not have swelling or anything medical going on that could cause the weight variances. V19, stated R61 is at the low end of meeting her caloric needs. On 2/26/20 at 11:40 AM, V20, R61's Physician, stated he was not notified of R61's weight loss. V20 stated he looks at the BMI of a resident and that 25 is ideal, anything less than that is not. V20 was notified of R61's BMI by the surveyor and stated that is not an ideal BMI for R61 and R61 has not had anything medical going on that would explain a medical reason for her weight loss. On 3/5/20 at 2:05 PM, V2, Director of Nurses (DON) stated she would expect staff to notify the physician and/or family of a change in condition and to follow tube feeding orders as ordered by the physician. The facility Dietician - Nutritional Risk Referral Policy and Procedure, dated 5/9/19, documents Nutritional Risk may include, but not limited to: New / Re-admission tube feeding, Nutritional related abnormal labs, Significant weight change or gradual weight change on at risk residents. The facility Nutrition Risk Policy and Procedure, dated 2014, documents Residents who may be at high nutrition risk will be promptly identified and appropriate protocols will be implemented to prevent avoidable weight losses and nutritional decline. Once a resident has been suspected as high nutrition risk, immediate interventions, will be implemented by the facility to prevent the resident from experiencing avoidable weight loss. The facility Physician - Family Notification - Change in Condition Policy and Procedure, dated 11/13/18, documents The facility will inform the resident, consult with the resident's physician, the resident's legal representative when there is a significant change in the resident's physical, mental, or psychosocial status. 2. R205's Profile and [DIAGNOSES REDACTED]. R205's MDS, dated [DATE], documents 205 is cognitively intact and receives greater than 501 ml of fluid intake and greater than 51% of total calories are received through tube feeding. R205's Care Plan, dated 2/10/20, documents R205 requires tube feeding with interventions for the RD to evaluate quarterly and as needed, monitor caloric intake and estimated needs, and make recommendations for changes to tube feedings as needed. R205's POS, dated 2/7/20, documents an order for [REDACTED]. On 2/23/20 at 10:50 AM, the [MEDICATION NAME] 1.5 tube feeding was observed infusing at 85 ml/hour, not the 65 ml/hour as ordered. On 2/24/20 at 9:07 AM, the [MEDICATION NAME] 1.2 tube feeding was observed infusing at 85 ml/hour, not the [MEDICATION NAME] 1.5 at 65 ml/hour as ordered. On 2/24/20 at 3:10 PM, the [MEDICATION NAME] 1.2 tube feeding continued at 85 ml/hr. V30, Registered Nurse (RN) states the tube feeding should be infusing at 65 ml/hour not 85 ml/hour. I should have looked at the rate, I didn't think to do that. This resident should be receiving 1.5, not the 1.2. On 2/25/20 at 1:50 PM, there was no tube feeding hanging or infusing with no ADLs occurring during observation. On 2/25/20 at 1:50 PM, V3, Licensed Practical Nurse (LPN), states she is going to hang one (tube feeding) in a little while. On 3/5/20 at 2:05 PM, V2, Director of Nurses (DON) stated she would expect staff to notify the physician and/or family of a change in condition and to follow tube feeding orders as ordered by the physician. The facility Dietician - Nutritional Risk Referral Policy and Procedure, dated 5/9/19, documents Nutritional Risk may include, but not limited to: New / Re-admission tube feeding, Nutritional related abnormal labs, Significant weight change or gradual weight change on at risk residents. The facility Nutrition Risk Policy and Procedure, dated 2014, documents Residents who may be at high nutrition risk will be promptly identified and appropriate protocols will be implemented to prevent avoidable weight losses and nutritional decline. Once a resident has been suspected as high nutrition risk, immediate interventions, will be implemented by the facility to prevent the resident from experiencing avoidable weight loss. The facility Physician - Family Notification - Change in Condition Policy and Procedure, dated 11/13/18, documents The facility will inform the resident, consult with the resident's physician, the resident's legal representative when there is a significant change in the resident's physical, mental, or psychosocial status.

Based on observation, interview and record review, the facility failed to assess, monitor and provide adequate pain control for 1 of 1 residents (R159) reviewed for pain management in the sample of 61. This failure resulted in R159 being in extreme pain for over 2 days after initial admission. Findings include: R159's Hospital After Visit Summary, dated 2/21/20, documents R159's reasons for admission to the hospital were Back Pain, Meningitis, Spinal Abscess, Bacteremia, [MEDICAL CONDITION] Resistant Staph Aureus Bacteremia and [MEDICAL CONDITION]. On 02/23/20 at 10:00 AM, R159 was lying in her bed with an anxious look on her face. R159 was tearful, shaking and grimacing while she spoke and explained she had not received any pain medication since her admission on 02/21/20. R159 stated she was in severe pain rating it Beyond 10 out of 10 on the pain scale. R159 stated she had severe pain in her head and back. R159 stated she was admitted to the facility from the hospital for Intravenous (IV) medication treatment due to being diagnosed with [REDACTED]. R159 stated V2, Director of Nursing (DON) told her on 02/23/20 at 9:30 AM that she was not in the facility's system and no one really knew she was here. On 02/25/20 at 3:07 PM, V17, LPN, stated she was the admitting nurse for R159 on 02/21/20. V17 stated R159 arrived at the facility approximately 5:30 PM via ambulance from the hospital. V17 stated she did not put in any medications or look to see what was ordered. V17 stated V2, DON, was in the facility when R159 arrived, but was gone when she had to stop doing the admission due to having to return to her medication pass for her other residents. V17 stated that at approximately 8:30 PM, she informed V2 that she was unable to finish R159's admission and was told to pass the admission to the next nurse on duty to finish. V17 stated she gave this information to V44, LPN (night nurse). On 03/03/20 at 1:17 PM, V44, LPN, stated she worked on 02/21/20 starting at 10:00 PM. She recalled being informed by V17, LPN of R159's admission, but was not informed to finish R159's admission. She stated she did not do any assessments, give any medications or go into R159's room during her shift. On 02/23/20 at 12:05 PM, V31, LPN stated that 2/22/20 was her first day and she and was not aware that R159 required pain medications. On 03/03/20 at 10:50 AM, V41, LPN stated that she worked on 02/22/20 helping to orient V31, LPN. V41 stated that at 11:00 AM, she answered a call light for R159. V41 stated that R159 told her that she was in extreme pain as well and had not been given any medications. V41 stated that V44, LPN (night nurse 02/21/20) had not made her aware that R159 had been admitted during the morning nursing report. On 02/23/20 at 11:40 AM, V2 stated she had a call out to the physician regarding R159's pain medication. V2 stated that no pain medications were ordered for R159 at this time. On 2/23/20 at 12:35 PM, R159 was in bed. She stated she has had no change in her condition or pain. At 1:30 PM, 2:00 PM, 2:20 PM, 3:00 PM and 3:35 PM, R159 remained in extreme pain and had not received any pain medications. On 2/23/20 at 1:00 PM, V2 stated she was still waiting on the call from the physician regarding R159's pain medications and that she could not give any medications until the physician called back. At 3:50 PM, V2, DON stated she had not heard from the physician regarding the pain medications for R159. The physician's orders [REDACTED]. The POS also documented the following diagnoses, in part as, Meningitis, [DIAGNOSES REDACTED] of Vertebra, [MEDICAL CONDITION], Bacteremia and Acute and Subacute [DIAGNOSES REDACTED]. On 02/23/20 at 4:00 PM, the Medication Administration Record (MAR) documented R159's pain assessment at 10 out of 10 on the pain scale. There were no pain medications documented as given at this time. R159's MAR, dated 2/23/20 at 7:28 PM, documented [MEDICATION NAME] 5-325 mg two tablets were given to R159. This was approximately 49 hours after her initial admission. On 02/24/20 at 9:00 AM, R159 was observed as anxious, tearful, shaking and complained of 10 out of 10 pain on the pain scale. She stated she had finally received pain meds last evening around 10:30 PM, but it did not completely relieve her pain and she did not see another nurse the rest of the night. She further stated she was in such severe pain that she did not sleep well. On 2/24/20 at 9:10 AM, V3, Interim Assistant Director of Nursing gave R159 [MEDICATION NAME] 5-325 mg two tablets. R159 told V3 at this time that her pain level was 10 out of 10 on the pain scale. R159's MAR, dated 2/24/20, documented at 5:43 PM, R159 rated her pain at 5/10 on the pain scale. It documented she received one [MEDICATION NAME] 5-325 mg tablet. R159's Nurse's Note, dated 2/24/20 at 7:23 PM, documented R159's pain was still at 5/10 on the pain scale. R159's MAR, dated 2/24/20, documented 7:31 PM, the MAR documented one tablet of [MEDICATION NAME] 5-325 mg was given. On 02/25/20 at 9:00 AM, R159 stated her pain level was 10 out of 10 on the pain scale and had not had any medication for pain since the day before. At 10:30 AM, R159 stated she still had not received anything for pain and had just talked to V43, Nurse Practitioner (NP) and that she was supposed to get something. At 11:20 AM, R159 still had not received anything. On 2/25/20, at 11:30 AM, V2, DON stated she would check into R159's pain medication administration. On 2/25/20, at 1:50 PM, R159 was tearful, shaking and stated she had not received anything yet for pain. R159's lunch tray was observed sitting on her bedside table untouched. She stated she could not eat due to being in too much pain and feeling nauseous. On 2/25/20, at 2:00 PM, V43, NP, stated she had seen R159 earlier in the morning and written orders for [MEDICATION NAME] 200 mg three tablets every six hours for pain to offset the time between her doses of [MEDICATION NAME]. V43 was not aware that R159 had not received any pain medications that day. R159's MAR and the Medication Admin Audit Report did not document R159 received any [MEDICATION NAME] on 02/25/20. The MAR documented at 3:53 PM, V27, LPN gave R159 [MEDICATION NAME] 5-325 mg two tablets with pain rated 8/10 on the pain scale. R159's MAR dated 2/26/20, at 6:33 AM documented R159 received one tablet of [MEDICATION NAME] 5-325 mg. At 9:00 AM, R159 stated at the time her pain medication was given (6:33 AM) her pain was 5/10 on the pain scale, but the nurse would only give her one pill instead of two. On 02/26/20 at 11:31 PM, V44, LPN documented on R159's MAR, R159's pain was 5/10 on the pain scale and no pain medications were given. On 2/27/20, at 11:20 AM, R159 stated she had been sent to the hospital to get labs drawn and had not received any medications yet. R159 rated her pain 6/10 on the pain scale at this time. On 2/27/20, R159's MAR did not document R159 had not received any pain medications prior to her being sent out to the hospital for laboratory test. The Care Plan, dated 02/21/20, documented R159 was identified as having pain with interventions listed, in part as, Administer [MEDICATION NAME] (specify medication) as per orders. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Monitor/document for side effects of pain medication. Observe for new onset or increased agitation, restlessness, confusion, hallucinations, nausea, vomiting .Report occurrences to the physician. Monitor/record pain characteristics and as needed: Quality, Severity, Anatomical location, Onset, Duration, Aggravating factors and Relieving factors. Monitor/record/report to nurse resident complaints of pain or requests for pain treatment. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, withdrawal or resistance to care. Provide the resident with reassurance that pain is time limited. Pain - non-verbal sounds, vocal complaints, facial expressions and/or protective body movements or postures that indicate pain. The Minimum Data Set (MDS), dated [DATE], documented R159 was cognitively intact and required extensive assist of two staff for bed mobility, transfers, locomotion, dressing and toilet use; required extensive assist of one staff for hygiene and bathing; and set up and supervision with eating. It documented R159 had pain with vocal complaints and frequency daily. On 03/05/20, the policy and procedure titled, Pain Management Program was reviewed. It documented Purpose: To establish a program which can effectively manage pain in order to remove adverse physiologic and physiological effects of unrelieved pain and to develop an optimal pain management plant to enhance or promote physiological and psychological wellness. The Policy documented It is the goal of the facility to facilitate resident independence, promote resident comfort, preserve resident dignity and facilitate life involvement. The purpose of this policy is to accomplish that goal through effective pain management program. The pain management program includes the following components: Documentation of pain assessment and monitoring, assessment of non-verbal residents for signs and symptoms of pain, pain control mechanisms available. 10. Documentation of assessments and the resident's response to the pain management made with each assessment. 11. The resident's physician will be notified of the resident's complaints of pain which are not controlled by comfort measures, including pain medications.

Based on interview and record review, the Facility failed to administer medications as ordered by the physician for 5 of 30 residents (R51, R59, R159, R160, R255) reviewed for medications in the sample of 61. This failure resulted in R51 requiring emergency medical treatment and hospitalization for opioid overdose. Findings include: 1. On 02/23/20 at 1:35 PM, R51 was sitting in her wheelchair in her room. She stated she doesn't remember being in the hospital or why she was there. R51 was alert and oriented to person and place, speaking with clear speech, pleasant and friendly, stating she just finished lunch. On 2/26/20, R51's Electronic Medical Record documented her Medical [DIAGNOSES REDACTED]. R51's Progress Notes, dated 1/20/20 at 6:45 PM, document, Res (Resident) in hallway, speech is garbled, head is hyperextended, eyes are glazed and pupils pinpoint +1, not oriented to person or place, only self (barely) eyes are unable to track movement, lungs clear to auscultation, skin is warm, left hand noted to be discolored and flaccid, VS (Vital Signs) 146/97 (blood pressure) 98.7 (temperature degree Fahrenheit) 130 (pulse) 20 (respirations) SPO2 (Oxygen saturation level) 95% RA (Room Air). 911 called due to resident condition. V32, Nurse Practitioner, called for cond (condition) report and in agreement with ER (emergency room ) eval (evaluation) 911. R51's hospital MD Progress Notes, dated 1/21/20 at 2:43 PM, documents under Impression: Acute toxic/metabolic [MEDICAL CONDITION], improved s/p (status / post) [MEDICATION NAME] ([MEDICATION NAME]) in the Emergency Department; iatrogenic drug overdose (alleged co-administration of multiple sedating medications) at SNF (Skilled Nursing Facility). www.merriam-webster.com/dictionary/iatrogenic: documents the medical definition of iatrogenic: induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures. R51's Emergency Department Documents, dated 01/20/20, documents R51 was transported to the hospital via ambulance on 01/20/20 at 7:10 PM. This document included description of chief complaint: Pt (Patient) was brought in per EMS (Emergency Medical Service) from (Facility) with decreased LOC (Level of Consciousness), pt was found leaning to the right, equal grip strength, pt has pinpoint pupils and follows very few commands. R51's Hospital Medical Records, Nursing Intervention, dated 1/20/20 at 7:56 PM, documents, Explained to (V27), nurse at (Facility) that patient is coming around and acting more like herself. (V27) states there will be an investigation about the medication schedule. Another Nursing Intervention in R51's Hospital Medical Records, dated 1/20/20 at 7:55 PM, documents: Called (Facility) and spoke with (V27), patient received all her nighttime meds and her 8 PM meds at one time. Pt got her [MEDICATION NAME] and [MEDICATION NAME] early because it was due at 9 and she got it at 6, pt got all her night meds at the same time. The Emergency Department Impression and Plan, dated 01/20/20 at 10:22 PM by V33, emergency room Physician, documents, will admit for iv (intravenous) fluids, iv abx (antibiotics), observation after Nacaine ([MEDICATION NAME]) iv. Plan: Admit to Inpatient Unit. The www.[MEDICATION NAME].com website documents, [MEDICATION NAME] is a medication used for the treatment of [REDACTED]. R51's Hospital Discharge Summary, dated 01/22/20 at 4:25 PM, documents, The patient was admitted to the hospital. She was noted to be lethargic, somnolent (abnormally drowsy), and encephalopathic (an altered mental state that is sometimes accompanied by physical changes per MedicineNet) in the ED (Emergency Department), and she responded to 6 mg total [MEDICATION NAME] ordered by the ED physician. Her [MEDICAL CONDITION] was felt to be toxic/metabolic in the setting of Urinary Tract Infection [MEDICAL CONDITION] and likely over-administration of sedating medications in a short period just prior to admission. These medications were slowly reintroduced at appropriate intervals while hospitalized and were ultimately not all restarted or were changed to lower doses. The same Discharge Summary documents, The following includes patient education materials and information regarding your injury/illness: Hospital Summary: I was in the hospital because: Unresponsive. The medical name for this condition is UTI, Opioid Overdose. R51's January 2020 Medication Administration Record (MAR) documents the following physician ordered medications on the 2:00 PM to 10:00 PM shift on 01/20/20: 1. [MEDICATION NAME] (Medication to treat [MEDICAL CONDITION] and nerve pain) 300 milligrams (mg) one capsule 3 times daily (6 AM, 3 PM, 10 PM) ordered to be given at 3:00 PM. 2. Glatopa (Medication to treat [MEDICAL CONDITION]) 20 mg/milliliter (ml) injected subcutaneously every evening, ordered to be given at 6:00 PM. 3. [MEDICATION NAME] ([MEDICAL CONDITION] medication to treat depression) 30 mg one tablet at bedtime ordered to be given at 8:00 PM. 4. [MEDICATION NAME] ([MEDICAL CONDITION] medication to treat depression, obsessive-compulsive disorder, social anxiety disorder and panic disorder) 100 mg one tablet at bedtime to be administered at 9:00 PM. 5. [MEDICATION NAME] (Narcotic to treat severe pain) 50 mg one tablet 3 times daily (6 AM, 12 noon, 8 PM) ordered to be given at 8:00 PM. According to R51's Medication Administration Audit Report this medication was documented as administered at 7:43 PM on 01/20/20. R51's January 2020 MAR documents all the above medications were initialed by V35 with a check mark in the box corresponding to the date and time they were to be given on 01/20/20, which indicated that she did administer all of those medications on that date. Medications that were not given, [MEDICATION NAME] and [MEDICATION NAME], had a 6 in the box, which indicated the reason they were not given is because R51 was in the hospital. There were no administration times on the MAR, only check marks indicating the medications were given. R51's Medication Administration Audit Report, printed on 02/25/20 for R51's medications that were administered on 01/20/20, V35, Licensed Practical Nurse (LPN), documented at 7:43 PM on 01/20/20 that she gave R51's medications, [MEDICATION NAME], Glatopa, [MEDICATION NAME] and [MEDICATION NAME]. The Report documented V35 administered R51's [MEDICATION NAME] at 8:58 PM. On 1/28/20 at 1:40 PM, V2, Director of Nursing (DON), stated she did not do a Medication Error Report for R51's incident on 01/20/20 because there was no medication error made, even though R51's MAR and Medication Administration Audit form documented the medications were given. R51's Controlled Drug Administration Record for her [MEDICATION NAME] also documented that V35 did give R51 a dose of [MEDICATION NAME] that was scheduled for 8:00 PM, even though hospital medical records show R51 was not in the building at that time. V2 stated all controlled medications are counted every shift change. V2 stated V35 only made a transcription error. V2 stated V35 said she signed out some medications that she had not given to R51 in error because R51 was already out of the building at the time those medications were ordered to be given. V2 stated the hospital just assumed R51 had overdosed, but could not prove it because they did not do a toxicology screen. On 02/26/20 at 2:43 PM, V34, Assistant Vice President of Clinical Operations, presented an unsigned, undated document regarding R51's Medical Record Review of her hospitalization , which she stated V6, Regional Nurse, just completed on the morning of 2/26/20, which documented, Upon a comprehensive thorough investigation, including Medical Record review, staff interviews, it was undetermined on whether (R51's) medications were administered per Physician Orders. On 02/26/20 at 11:40 AM, V20, R51's Primary Care Physician (PCP), stated he was not notified of R51's overdose or hospitalization on [DATE], but stated he is not surprised because there is no narcotic supervision by the nursing staff in the facility. V20 stated he has educated the nurses on the Passero Sedation Scale, which has specific guidelines for determining if a resident should receive a narcotic medication based on their assessment. V20 stated the nurses do not use the Passero Scale. RN.com states the Passero Opioid-Induced Sedation Scale (POSS) enables the nurse to determine a patient's level of sedation before and after the administration of an opioid. A POSS score of S, 1, or 2 indicates an acceptable level of sedation, whereas a score of 3 or 4 indicated over-sedation and the need for a reversal agent. On 2/27/20 at 4:55 PM, V42, R51's daughter/POA, stated V27, the nurse who takes care of her mother sometimes, had called her on 1/20/20 at about 6:30 PM and told her that he had seen R51 come out of her room in her wheel chair and her head fell back, and he thought she had had a stroke so he had called 911. V42 stated the doctor in the emergency room told her that R51 was given too much pain medicine that caused an overdose, but that when she went back to the facility to demand answers, V27 told her R51 didn't get any pain medicine, but stated R51 must have gotten all of her other medicines at one time. V42 stated V27 told her R51 must have gotten her medicines around dinner time because it was given before he got there at the start of his shift. On 1/28/20 at 2:05 PM, V35 stated on 01/20/20 when she was R51's nurse, she did give R51's medication at the wrong time. V35 stated R51 was complaining of pain so V35 decided to give her dose of [MEDICATION NAME] that was scheduled for the night shift early. V35 stated she got wrote up and suspended for one day and had to be trained by the DON on doing a medication pass. V35 stated she did not give all the medications she signed out, but could not remember what medications she gave and what she did not give, because she waited until she had finished all her duties that evening and then went back and signed out her medications. V35 stated she was not sure exactly what time she gave R51 her medications on 01/20/20, but she worked the 2:00 PM to 10:00 PM shift on that date. V35 stated she knows she can give medications an hour before they are ordered or an hour after they are ordered, except for narcotics. On 3/3/20 at 2:20 PM, V35, LPN, stated on 1/20/20 she gave R51 her medications at about 4:30 PM or 5:00 PM on that evening, but nothing before supper. V35 stated R51 was yelling that she was in pain, so she did go ahead and give her the 6:00 PM [MEDICATION NAME]. V35 stated R51 was communicating with her without problem when she gave her her medications. On 2/29/20 at 10:45 AM, V37, Hospitalist/Medical Doctor at local hospital where R51 was treated on 1/20/20 for an opioid overdose, stated the drug, [MEDICATION NAME], strictly reverses symptoms of an opioid overdose. V37 stated she would assume V39, Emergency Department Physician, would have seen some improvement with the administration of the initial dose of [MEDICATION NAME], or he would not have administered two more doses. V37 stated [MEDICATION NAME] would not have improved any other condition other than an opioid overdose. She stated it would not have improved the signs and symptoms associated with a Urinary Tract Infection [MEDICAL CONDITION]. On 2/29/20 at 11:00 AM, V38, Pharmacist, stated [MEDICATION NAME] only works on opioid receptors, and a suspected opioid overdose would have been the only reason it would have been given. He stated [MEDICATION NAME] given along with all of R51's other mind sedating medications given at the same time would explain her being lethargic. V38 stated he has never heard of [MEDICATION NAME] being administered to treat lethargy or unresponsiveness from a UTI. 2. On 02/29/20 at 2:03 PM, R59's Medication Error Report, dated 01/23/20, documents R59 had a medication error on 1/23/20 when the nurse gave her AM and Noon medications at the same time. According to the medication error report, R59 felt a little sleepy but was OK. R59's Physician order [REDACTED]. R59's January 2020 MAR documents she was to receive the following medications on 1/23/20 at 9:00 AM: [MEDICATION NAME] 100 mg one tablet; [MEDICATION NAME] 5 mg one tablet; [MEDICATION NAME] 20 mg two tablets; [MEDICATION NAME] 25 mg give one tablet; Losartan 100 mg one tablet; Duloxetine 60 mg one capsule; [MEDICATION NAME]-[MEDICATION NAME] 3 tablets; [MEDICATION NAME] 20 mg give one tablet; [MEDICATION NAME] 2.5 mg one tablet; [MEDICATION NAME] ER 25 mg one tablet; [MEDICATION NAME] 10 mg one tablet; [MEDICATION NAME] 25 mg one tablet; [MEDICATION NAME] 50 mg one tablet; Potassium Chloride 20 mEq (milliequivalents)/15 mls. R59's MAR documents the following medications ordered to be given on 1/23/20 at Noon: [MEDICATION NAME] 10 mg one tablet; [MEDICATION NAME] 25 mg one capsule, Potassium Chloride 20 mEq/15 mls. R59 received two doses at one time of each of her noon medications on 1/23/20 when V41, LPN, administered her 9:00 AM and 12:00 PM medications all at the same time. On 2/29/20 at 12:45 PM, R59 stated, I'm ok. I don't have anything else to say. On 03/3/20 at 10:55 AM, V41 stated she made a medication error on R59 on the day shift on 01/23/20 by giving R59 her morning medications and noon medications at the same time. V41 stated she put R59's morning medications in a cup and signed them out on her MAR on the computer, but when she went to give R59 the medications at 9:04 AM, R59 refused to take them at that time. V41 stated when she started her noon medication pass at 11:00 AM on 01/23/20, she gave R59 her morning medications, including her liquid potassium, and then also administered her noon doses of [MEDICATION NAME], and Potassium Chloride. V41 stated she reported this medication error to V32, Nurse Practitioner, who stated it was considered double dosing, and said to monitor the resident. V41 stated she received a counseling from V45, Corporate Nurse, and two other corporate nurses, regarding the steps she should take if a resident refuses their medication,and was told not to go back and give medications after the one hour time frame was past. V41 stated the Facility has not had any inservices for nurses regarding medication administration or medication errors since she made the error with R59's medication. 3. On 02/23/20 at 09:47 AM, R255 stated the nurses missed some of his IV antibiotics when he was first admitted . R255 stated he still has some pain in his right side and is worried that he still has an infection. On 02/24/20 at 11:23 AM V13, LPN, stated R255 missed his IV antibiotics because his Peripherally Inserted Central Catheter (PICC) line had come out and he couldn't get his IV's until it was replaced. She did not know how long his PICC line was out. V13 stated sometimes it takes a few days for R255's Medical Doctor (MD) to get back to the Facility with an order that is needed to send R255 out to the hospital to get his PICC line replaced. R255's Patient Discharge Plan, dated 1/23/2020 at 3:44 PM, documents under Follow-up Instructions: Contact hospital's (Medical Imaging Service), ( included telephone number to call) for any of the following: If PICC line or Midline Catheter appears to be coming out. The Facility did not notify the Medical Imaging Service when R255's PICC line came out. R255's Minimum Data Set (MDS), dated [DATE], documents he is alert and oriented to person, place, time and situation. R255's Physician Orders, dated 1/24/20, documented the order: [MEDICATION NAME] HCI in NaCl (normal saline) 1.25-0.9 Gram/150 ml %; Directions: use 1.25 Grams intravenously two times a day related to urinary tract infection. R255's EMR documents his Medical [DIAGNOSES REDACTED]. R255's Patient Discharge Plan, dated 1/23/20 at 3:44 PM, documents under new medications: [MEDICATION NAME] 1.25 Grams/150 ml intravenously every 12 hours; continue until drain removed. R255's discharge orders also included a laboratory order, dated 1/23/20, that documented his [DIAGNOSES REDACTED]. R255's Order Recap Report, dated 03/05/20 at 9:06 AM, documents the following orders: 01/23/20 [MEDICATION NAME] HCI in Normal Saline Solution 1.25-0.9 Gram/150 ml-% Use 1.25 gram intravenously two times a day related to Urinary Tract Infection, site not specified (N39.0) Vanco trough every Friday; fax to (Infectious Disease Clinic); 01/26/20 may have today's IV when returns from an outing; 02/03/20 Single lumen PICC line to be reinserted; 02/12/20 and 02/14/20 d/c (discontinue) PICC line. R255's emergency room Hospital Records, dated 2/7/20 and ordered by ER physician at 7:09 PM, document under Follow Up: Make sure you keep your follow up appointments. I will send an order for [REDACTED]. R255's January 2020 and February 2020 MARs were reconciliated with his Medication Administration Audit Report, dated 02/25/20 for medications administered 1/24/20 through 2/25/20. According to both reports R255's IV antibiotic, [MEDICATION NAME], was not given or was given at the wrong times on the following dates: 1/24/20: the 8:00 AM dose was administered at 3:47 PM and the 8:00 PM dose was administered just 6 hours later at 9:36 PM. 1/25/20: the 8:00 AM dose was administered at 10:23 AM and the 8:00 PM dose was not given. 1/26/20: the 8:00 AM dose was administered at 2:45 PM and the 8:00 PM dose was not given. 1/27/20: the 8:00 AM dose was administered at 11:46 AM and the 8:00 PM dose was administered at 9:13 PM 1/28/20: the 8:00 AM dose was administered at 11:10 PM and the 8:00 PM dose was administered at 9:39 PM 1/29/20: the 8:00 AM dose was administered at 5:23 PM and the 8:00 PM dose was administered just 3 hours later at 8:35 PM 1/30/20: the 8:00 AM dose was administered at 12:45 PM and the 8:00 PM dose was not administered because V2, DON, stated it was contaminated, but the next day the pharmacy stated they had sent out 4 doses on 1/30/20, but no explanation was given as to why one of the other doses was not administered. 1/31/20: the 8:00 AM dose was administered at 11:17 AM and then R255 pulled out his PICC line when removing his shirt. 2/1/20 No antibiotics given due to the PICC line being out. 2/2/20 No antibiotics given due to the PICC line being pulled out. 2/3/20 No antibiotics given. Nurses Note, dated 2/3/20, documents the PICC line to be replaced in the AM. 2/4/20 PICC line reinserted, but no antibiotics given due to medication on hold, but no order found stating medication on hold. 2/5/20 the 8:00 AM dose was administered at 10:42 AM and the 8:00 PM dose was not administered. 2/6/20 the 8:00 AM dose was administered at 9:54 AM and the 8:00 PM dose was not administered. 2/7/20 neither the 8:00 AM dose nor the 8:00 PM dose was administered as ordered. 2/8/20 the 8:00 AM dose was administered at 7:48 AM and the 8:00 PM dose was not administered. 2/9/20 the 8:00 AM dose was administered at 11:37 AM and the 8:00 PM dose was not administered. 2/10/20 the 8:00 AM dose was administered according to the MAR by V2, but there was no documentation time on the Medication Administration Audit Report, and the 8:00 PM dose was not given. 2/11/20 the 8:00 AM dose was administered by V2 at 11:32 AM and the 8:00 PM dose was not given. 2/12/20 No 8:00 AM dose was given and the medication was discontinued before the 8:00 PM dose was due to be given. On 3/6/20 at 9:20 AM, V6, Regional Nurse, stated she would expect nurses to give residents their medications as ordered by the physician. The Facility's Medication Administration Policy, dated 1/1/2015, documents, Medications must be administered in accordance with a physician's orders [REDACTED]. (for example), the right resident, right medication, right dosage, right route, and right time. Medications may not be pre-poured, e.g., only prepare and administer medications for one resident at a time. This policy also documents If a medication and/or treatment error occurs, the licensed nurse will: a. Immediately notify the attending physician, b. Describe the error and the resident's response in the Nurse's Notes, c. Complete an incident report, d. Identify the error on the 24 hour report, and e. Monitor the resident's status. The policy further documents, When Class II medications (e.g. [MEDICATION NAME]) are administered, the medication is - a. Recorded on the Medication Administration Record by a licensed nurse, and b. Accounted for on the resident's individual, 'Control Substance Record' by a licensed nurse. 4. On 02/23/20 at 10:00 AM, R159 was observed in bed tearful, shaking and grimacing while she spoke and explained she had not received any medications for pain or for her infections. R159 stated she was admitted to the facility on [DATE]. R159 stated she was in severe pain rating it Beyond 10 out of 10 on the pain scale. R159 stated she had severe pain in her head and back and stated she felt like she was running a fever. R159 stated she was admitted to the facility from the hospital for IV medication treatment due to being diagnosed with [REDACTED]. R159 stated V2, DON, told her on 02/23/20 at 9:30 AM that she was not in the facility's system and no one really knew she was here. R159's After Visit Summary from her hospitalization , dated 2/21/20, documents her Medication List: START: [MEDICATION NAME] (muscle relaxer) 10 mg tablet Take 1 tablet by mouth 3 times daily, last given 2/21/20 at 8:10 AM- R159 missed at least 6 doses of this medication; [MEDICATION NAME] (antibiotic) 300 mg capsule Take 1 capsule by mouth every 12 hours, last given 2/21/20 at 8:11 AM- R159 missed at least 4 doses of this medication; Sodium Chloride 0.9% solution 50 ml with [MEDICATION NAME] (antibiotic) 2 g (gram) Inject 2 g into the vein daily, last given 2/21/20 at 12:58 PM- R159 missed one dose of this medication; [MEDICATION NAME] (antibiotic) 1-0.9 GM/250 ml-% solution IV piggyback Inject 250 mls into the vein every 12 hour hours, last given 2/21/20 at 2:19 PM- R159 missed 3 doses of this medication; CONTINUE: [MEDICATION NAME] (for nerve pain) 100 mg capsule Take 200 mg by mouth nightly at bedtime, last given 2/20/20 at 8:33 PM- R159 missed 2 doses of this medication; [MEDICATION NAME] (antidepressant) 15 mg tablet Take 15 mg by mouth nightly at bedtime, last given 2/20/20 at 8:34 PM- R159 missed 2 doses of this medication; [MEDICATION NAME] (muscle relaxer) 4 mg tablet Take 4 mg by mouth 3 times daily, last given 2/21/20 at 12:20 PM- R159 missed at least 5 doses of this medication. On 02/23/20 at 11:20 AM, V2 was observed preparing to hang two IV medications for R159. V2 stated that R159 was not put into the facility's system and therefore the medications did not get ordered properly. V2 was observed to hang [MEDICATION NAME] 1 gm (gram) at 125 ml/hr through left forearm PICC line. At 11:40 AM, V2 was observed to hang [MEDICATION NAME] 2 gm IV at 1 drop per minute. R159's physician's orders [REDACTED]. At 2:41 PM, this order was discontinued by V27, LPN, and a new order for the same medication was submitted by V27 to start at 4:00 PM on 02/22/20. This order was never carried out by staff on 02/22/20. On 02/23/20 at 11:40 AM, V2 stated she had a call out to the physician regarding pain medication. V2 stated that no pain medications were ordered at this time. At 12:35 PM, R159 was observed in bed. She stated she has had no change in her condition. At 1:00 PM, V2 stated she was still waiting on the call from the physician regarding R159's pain medications and that she could not give any medications until the physician called back. At 1:30 PM, 2:00 PM, 2:20 PM, 3:00 PM and 3:35 PM, R159 remained in extreme pain and had not received any pain medications. At 3:50 PM, V2, DON stated she had not heard from the physician regarding the pain medications for R159. R159's MAR documented R159 received the first dose of [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 5/325 mg on 02/23/20 at 7:28 PM. R159's POS, dated 02/23/20 at 3:30 PM, documented the order as [MEDICATION NAME] tablet 5-325 mg ([MEDICATION NAME]-[MEDICATION NAME]) give 1-2 tablets by mouth every 6 hours as needed for moderate pain. On 02/24/20 and 02/25/20, R159 continued to report extreme pain in her head and back and was not receiving pain medications as ordered. The Controlled Drug Administration Record Tablet for R159 documented on 02/23/20, 16 tablets of [MEDICATION NAME] 5-325 mg were received at the facility. On 02/29/20 at 10:01 AM, V38, Pharmacist, stated that the facility received and signed for 16 tablets of [MEDICATION NAME] 5-325 mg on 02/24/20 at 1:36 AM. V38 stated that an emergency physician to pharmacist call had been conducted on 02/23/20 at 4:29 PM in which the physician agreed to the order for the [MEDICATION NAME] for R159. However, R159 did not receive the first dose of [MEDICATION NAME] until 7:28 PM. On 02/25/20 at 3:07 PM, V17, LPN, stated she was the admitting nurse for R159 on 02/21/20. V17 stated R159 arrived at the facility approximately 5:30 PM via ambulance from the hospital. V17 stated she began the admission process around 5:50 PM and was only able to complete the initial skin, pain and diet portions of the admission. V17 stated she did not put in any medications or look to see what was ordered. V17 stated V2, DON, was in the facility when R159 arrived, but was gone when she had to stop doing the admission due to having to return to her medication pass for her other residents. V17 stated that at approximately 8:30 PM, she informed V2 that she was unable to finish R159's admission and was told to pass the admission to the next nurse on duty to finish. V17 stated she gave this information to V44, LPN (night nurse). On 03/03/20 at 1:17 PM, V44, LPN, stated she worked on 02/21/20 starting at 10:00 PM. She recalled being informed by V17, LPN of R159's admission, but was not informed to finish her admission. She stated she did not do any assessments, give any medications or go into R159's room during her shift. On 03/03/20 at 10:50 AM, V41, LPN, stated that she worked on 02/22/20 helping to orient V31, LPN. V41 stated that at 11:00 AM, she answered a call light for R159. She stated she was not aware that anyone was even in the room. V41 stated that R159 told her that she was in extreme pain as well and had not been given any medications. On 02/26/20 at 11:31 AM, V20, Medical Director, stated he was not aware that R159 was admitted to the facility until 02/23/20 in the early afternoon when he received an order request for pain medication for R159. V20 stated he was not aware that IV medications and pain medications were not provided to R159 until 02/23/20. V20 stated he would expect the facility to follow standards of practice from accepting a resident, following the protocols for medication management especially with IV therapy and pain management. V20 stated the fact that the facility did not follow through with the admission process, the facility failed to set up the reasonable care measures to care for and provide effective treatment and services for R159. V20 stated he would expect the facility staff to provide continuous treatment according to the hospital discharge orders received. R159's POS, dated 02/28/20, documented a new order to give [MEDICATION NAME] 1.25 gm IV starting at 6:00 PM. R159's MAR dated 02/29/20 at 6:00 PM, [MEDICATION NAME] 1.25 gm IV was blank as not given. On 02/29/20 at 10:01 AM, V38, Pharmacist stated that [MEDICATION NAME] is an antibiotic used to treat bacterial infections, such as meningitis [MEDICAL CONDITION] blood infections. He stated that a blood trough level must be drawn after every third dose due to the risk of a patient becoming toxic which would affect organs of the body negatively. A low trough level is indicative of the wrong dosing or that the medication was not given as often as needed to kill off the infective agent. V38 stated that protocol with a person with meningitis should have [MEDICATION NAME] trough levels of 15.0 - 20.0 mcg/ml in order to metabolize properly to fight the infection. V38 stated that R159's trough levels are critically low, indicating the [MEDICATION NAME] was not effective enough to fight off the infection. He further stated that [MEDICATION NAME] in IV form was used in a longer period of weeks to months to fight off the infection and that with critical trough levels this would prolong her healing process. 5. On 02/23/20 at 10:30 AM, R160 was observed with a PICC line in his left forearm. R160 stated it was used for his IV antibiotics. R160 denied having any other IV access. R160's POS, dated 02/12/20, documented an order for [REDACTED]. The Medication Admin Audit Report for R160 documented: On 02/12/20 at 7:31 PM, V50, LPN, administered Sodium Chloride Solution 0.9 % 10 ml IV to R160. On 02/14/20 at 7:37 PM, V50, LPN, administered Sodium Chloride Solution 0.9 % 10 ml IV to R160. On 02/17/20 at 5:29 PM, V50, LPN, administered Saline flush Solution 0.9 % 5 ml IV to R160. On 02/18/20 at 8:05 PM, V27, LPN, administered Saline Flush Solution 0.9 % 5 ml IV to R160. At 8:59 PM, V27, LPN administered Sodium Chloride Solution 0.9 % 10 ml IV to R160. On 02/19/20 at 6:08 PM, V50, LPN, administered Saline Flush Solution 0.9 % 5 ml IV to R160. On 02/20/20 at 8:47 PM, V27, LPN, administered Saline Flush Solution 0.9 % 5 ml IV to R160. At 8:48 PM, V27, LPN administered Sodium Chloride Solution 0.9 % 10 ml IV to R160. On 02/21/20 at 1:30 PM, V48, LPN administered [MEDICATION NAME] 1.5 gm IV to R160. At 1:31 PM, V48, LPN administered [MEDICATION NAME] flush 3 ml to R160. On 02/22/20 at 11:20 AM, V31, LPN, administered [MEDICATION NAME] 1.5 gm IV to R160. At 11:21 AM, V31 gave [MEDICATION NAME] flush 3 ml IV to R160. At 7:27 PM, V27, LPN administered Saline Flush Solution 0.9 % 5 ml and Sodium Chloride Solution 10 ml IV to R160. On 02/23/20 at 9:37 PM, V27, LPN administered Saline Flush Solution 0.9 % 5 ml IV to R160. At 9:38 PM, V27, LPN administered Sodium Flush Solution 0.9 % 10 ml IV to R160. On 02/24/20 at 9:30 PM, V17, LPN administered Saline Flush Solution 0.9 % 5 ml IV to R160. At 9:35 PM, the Report documented V17, LPN administered Sodium Chloride Solution 0.9 % 10 ml IV to R160. On 02/25/20 at 3:07 PM, V17, LPN stated she does not do anything with the PICC lines because she was not allowed to due to being a LPN. On 02/25/20 at 3:12 PM, V27, LPN stated he does not touch a resident's PICC line and that anything to do with it has to be done by a RN.

Based on observation, interview, and record review, the facility failed to promptly assess, treat, and monitor identified pressure ulcers for 3 of 4 residents (R100, 102, 104), reviewed for pressure ulcers in the sample of 13. This failure resulted in the deterioration of ulcers for R100. Findings include: 1. On [DATE] at 11:25AM, R100 was lying on his right side in bed with bilateral heel protectors. R100 was wearing an incontinent brief and the indwelling urinary catheter bag was attached to the catheter tubing and was not secured to his leg. The incontinent brief had liquid brown stool oozing out of the outer edges of the incontinent brief, down to his left thigh, left hip, and extended upwards to his mid back. There were two incontinent pads underneath him. V7, Registered Nurse (RN), and V15, Certified Nursing Assistant (CNA), went into R100's bathroom to wash their hands prior to caring for R100. V7 rolled R100 closer to the edge of the bed as V15 assisted R100 with positioning on his right side of the bed. Upon removal of R100's incontinent brief by V15, a large open wound to his left buttock was observed without benefit of a dressing. The left buttock had copious amounts of liquid brown stool inside and around the perimeter of the wound bed extending upwards of his mid back. A small border foam dressing, undated, was secured directly above the left buttock extending across his mid back, with large amounts of liquid, brown stool on top of the dressing. Present was a small foam dressing to R100's left posterior upper hip, dated [DATE], with large amounts of liquid, brown stool on top, beside, and below the dressing, and a foam pressure dressing, dated [DATE], was affixed to his left posterior thigh. V7 removed a large amount of 6 by 6 size gauze and soaked them with normal saline and squeezed the gauze on top of the left upper hip wound, and brown stool ran down into the exposed left buttock wound. V7 disposed the gauze into the garbage, and with the same soiled hand, took the wound cleanser and sprayed it on top of the left buttock open wound, as liquid stool ran down on top of the left posterior thigh dressing. V7 then proceeded to cleanse the wound bed of the left buttock wound with a wound cleanser, and applied Dakins solution to a handful of gauze. As V7 proceeded to wipe the soaked gauze, he applied the gauze in a circular motion from the outer edge to the inner wound bed. V7, with the same soiled gauze, re-entered the wound bed and removed copious amounts of stool. V7 continued to wipe the left buttock open wound bed using the soaked gauze. V7 then stated, That's about all (stool) that's in there. Upon completion, brown stool was visible on the inner and outer edges of the wound and brown stool remained on the soaked gauze. V7 washed his hands and left the room to gather more supplies, leaving the entire left buttock wound bed exposed. Upon returning to R100's room, V7 washed his hands, donned gloves, and removed the border dressing above R100's left buttock, cleansed the area, then removed the left posterior hip dressing. After cleansing the left posterior hip, V7 then packed the left posterior hip with soaked gauze and applied a foam dressing. After, V7 using the same gloved hand, applied soaked gauze, packed the left buttock, and applied a foam dressing. V7 then left the bedside to wash his hands and change gloves. V7 returned to the bedside, removed R100's left posterior thigh soiled dressing, cleansed the left posterior thigh, and packed the wound with soaked gauze, and covered the area with a protective foam dressing. V7 did not change his gloves after removing the soiled dressing and applying the clean, soaked gauze to the wound bed. Throughout the observation of R100's dressing changes, there were no remnants of R100 having a pressure dressing covering his left buttock, nor was it noted within his bed, sheets, and incontinent brief. On [DATE] at 12:14 PM, V15, CNA, stated, When (V7) came in (R100's room) earlier, I told him (V7) there was no dressing on this (R100's) wound. On [DATE] at 12:40PM, V7, RN, stated in part when asked by surveyor if he had already performed dressing changes to R100's wounds prior to observation by surveyor, No, night shift, this is why it's so frustrating when there's no dressings on. On [DATE] at 3:39PM, V9, Regional Corporate Nurse (Regional Nurse), stated the expectation for nurses is to follow physician's orders [REDACTED]. R100's Care Plan, dated [DATE], documents, Monitor dressing to ensure it is intact and adhering. Report loose dressing to nurse. Date initiated [DATE]. R100's Care Plan, dated [DATE], documents R100 was admitted to the facility on [DATE]. The Care Plan also documents R100 having contractures to his left and right hand, [MEDICAL CONDITION], and having an indwelling catheter related to his skin breakdown. The Care Plan further documents interventions to include: Report pertinent changes in skin status to physician and any other notable changes or observations. R100's (MONTH) 2019 Treatment Administration Record (TAR) documents the following treatments were not documented as being done on the following dates and shifts: 1. Left hip [DATE] (day shift); 2. Left heel [DATE] and [DATE] (day shift); 3. Left thigh and buttock [DATE] and [DATE] (day shift), [DATE] and [DATE] (day shift); and 4. Scrotum [DATE] and [DATE] (evening shift). R100's TAR (provided by the facility at the time of the survey) does not list the evening nor night shift treatment to R100's left hip from [DATE] through [DATE], and through [DATE]. The TAR for (MONTH) 2019 further documents as follows: Right Thigh and Scrotum (sic): Zinc oxide ointment every shift for Wound Care. On [DATE] at 2:13 PM, V27, Nurse Practitioner (NP), stated she would not expect zinc oxide to be applied as a treatment for [REDACTED]. V27 further stated Hospice will be following R100, and going forward Hospice will be caring for R100's wounds and pain management. R100's Physicians Order, dated [DATE] at 1:38 PM, documents, Left Thigh and Buttock: Cleanse with NS (normal saline), Apply wet to dry dressing with Dakins solution and cover with foam dressing. The physician's orders [REDACTED]. R100's Physicians Order, dated [DATE] at 6:52 PM, documents, Left Hip: Apply Dakins and foam dressing every day shift for wound healing. R100's Physicians Order, dated [DATE] at 10:15AM, documents, Cleanse wound to right posterior thigh, pack loosley (sic) with Dakins wet to dry, cover with dry dressing every shift. Facility Wound Assessment, dated [DATE], documents the following: NPAUP (National Pressure Ulcer Advisory Panel) PRESSURE INJURY STAGING DEFINITIONS: A Stage 3 Pressure Injury as full-thickness skin loss, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. The Report documents a Stage 4 Pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. The Report further documents the following regarding R100's pressure ulcers (PU) 1c. Measurement - Length x (by) Width x Depth in Centimeters (cm). The Report further documents R100 having the following: Stage 4 Left Buttock ulcer, Stage 3 Left Lateral Heel ulcer, Stage 4 Left Posterior Hip ulcer, Posterior Scrotum (no type of wound or staging listed), and Right Posterior Thigh: (no type or staging of wound listed). All wounds were listed as in-house acquired. Physician Wound Evaluation and Management Summary, dated [DATE], documents R100 having multiple wounds, having fecal incontinence, and no medications found to be affecting wound healing in clinical context. The Summary further documents: 1. Stage 4 pressure wound of the left buttock with greater than 130 days in duration, measuring 11(length) x 9.5 (width) x 2 cm (depth), wound extended to sacrum, coccyx and right buttock, with a recommendation for a low air loss bed. 2. Wound of the left posterior upper thigh with greater than 73 days in duration, measuring 9 x 8 x not measurable, with a recommendation for a gel cushion to his chair. 3. Stage 3 pressure wound of the left lateral heel with greater than 73 days in duration, measuring 0.3 x 0.5 x 01cm, with a recommendation for a sponge boot. 4. Wound of the left posterior hip with greater than 35 days in duration, measuring 4.5 x 3.5 x not measurable. 5. R100's wound to his posterior scrotum documents being resolved on [DATE]. 6. Wound of the right posterior upper thigh greater than 35 days in duration, measuring 6.5 x 4 x not measurable cm. The wound evaluation and summary further documents: Other Diagnosis: [REDACTED]. Treatment Recommend PICC (Peripherally inserted central catheter) line placement and [MEDICATION NAME] 1 g (gram) IV (intravenous) Q (every) 8h (hours) for 5 weeks. [MEDICATION NAME] BID (twice daily) for 60 days. The Dressing Treatment Plan lists the following as treatments for R100's wounds: Left buttock, left posterior upper thigh, left posterior hip, and right posterior upper thigh having primary dressing of Dakins Solution with a dry protective dressing with a secondary dressing of foam with border to be applied three times daily. The Dressing Treatment Plan also documents R100's left lateral heel to receive a sterile gauze with a sterile pad covering. Facility Wound assessment dated [DATE], documents the following for R100: Wound 1: Stage 4 Coccyx, measuring 11.8 x 6 x 3; Wound 2: Stage 3 Left Heel measuring 2.0 x 2.0; Wound 3: Stage 4 Left Trochanter/Hip: 5.3 x 4 x 1; Wound 4: Stage 4 Left buttock measuring 9.6 x 6.5 x 3; Wound 5: Stage 4 Left Posterior Upper Thigh measuring 6.5 x 4.5 x 2; and Wound 6: Stage 4 Right Posterior Upper Thigh measuring 6.5 x 4 x 1.5. R100's most recent skin risk assessment provided by the facility, dated [DATE], documents R100 being chair fast, completely immobile, constantly moist, having very limited sensory perception, and scoring a 10, indicating a high risk for skin breakdown. R100's (MONTH) 2019 Medication Administration Record [REDACTED]. Use 1 gram intravenously three times a day for Cellulitius 6 Weeks Begin after PICC line insertion -Start Date- [DATE] 2200 (10:00PM). Most laboratory results for R100 dated [DATE], document R100's serum [MEDICATION NAME] being 4.5, with normal limits between 3.5 to 5.7, and Total Protein being 8.1 with normal limits between 6.4 to 8.9. Registered Dietitian (RD) assessment dated [DATE] for R100, documents, RD consult for continued chronic and serious wounds. Meds reviewed. The RD Assessment further documents in part, B. Labs/diagnostics [DATE] labs assessed total protein and [MEDICATION NAME] WNL (within normal limits). Social Service Note dated [DATE] at 6:58AM, documents, LATE ENTRY: Writer (V4, Social Services Director) spoke with residents (sic) brother, sister and resident (R100) to explain that we will no longer have a wound doctor rounding at our facility. Writer concerned that resident would not get his needs met. Minimum Data Set ((MDS) dated [DATE], documents in part R100 having a Brief Interview for Mental Status (BIMS) score of 14, indicating cognition in tact. On [DATE] at 10:10AM, R100 stated he does not always get his dressing changes as ordered and not three times a day always. On [DATE] at 11:20AM, V3, LPN, stated R100's TAR for (MONTH) (2019) did not reflect his wound to his right thigh until she Put the right thigh treatment on the TAR yesterday ([DATE]). V3 further stated, he (R100) did not receive Zinc oxide ointment to his right thigh, that was only for his scrotum at the time, and that was a transcribing error, we can't prove that he got the right treatment, which was supposed to be Dakins solution and cover with a dressing, which is what is listed on the TAR as of yesterday. On [DATE] at 11:25 AM, V3, LPN, stated she measured and documented on the Facility's Wound Assessment on [DATE] regarding R100's wounds. V3, further stated she has not had training from the facility on wound documentation or measurements of wounds. On [DATE] at 2:13 PM, V27, Nurse Practitioner (NP), stated in part, the expectation is for nurses to be trained by the facility in wound care, provide treatments as ordered, and with accurate documentation, and each wound should be listed separately on the TAR. On [DATE] at 5:48 PM during phone interview, V17, Wound Physician/MD (Medical Doctor), stated she has been following R100's wound care at the facility and would expect all dressing changes to be done per her treatment recommendations, especially R100 given his multiple wounds and condition, and to be listed correctly on the TAR. V17 also stated she would expect to be notified with treatment refusals, including dressing changes, and the expectation is to follow infection control during care, including dressing changes and catheter care per professional standards of practice. V17 stated she would expect the nurses to call her if there were any discrepancies or questions regarding treatment orders. V17 further stated fecal material could contribute to the deterioration of R100's wounds and that R100 was already receiving an intravenous (IV) antibiotic. 2. Progress note dated [DATE] at 1:27PM, documents, R102 was admitted on [DATE] to the facility with the following [DIAGNOSES REDACTED]. The Progress Note further documents R102 met with V4, Social Services Director (SSD) to discuss Hospice. MDS dated [DATE], documents R102 being extensive assistance for Activities of Daily Living (ADLs). Facility Wound Report dated [DATE], documents in part, R102 having a Stage 4 coccyx wound that was facility acquired. The Report lists the measurements as 6.5 cm (centimeters) in length by 6 cm wide x 2.5 cm depth. physician's orders [REDACTED]. TAR for R102 documents in part, Coccyx wound: Pack with Dakins soaked Kerlix, cover with foam dressing every shift related to PRESSURE ULCER OF SACRAL REGION, UNSTAGEABLE. The TAR dated [DATE] (day shift) does not have an entry that the treatment was performed to R102's coccyx wound as ordered. Discharge Record dated [DATE] at 10:40PM, documents R3 expired on [DATE] at 10:40PM. 3. On [DATE] at 10:42AM, R104 stated, don't always get my wounds done on time. physician's orders [REDACTED]. The frequency listed is every day and evening shift. Physicians Order, dated [DATE] at 1:57 PM, documents, Skin prep to left ankle, and skin prep to bilateral heels. The frequently listed is every day and evening shift. TAR dated [DATE] through [DATE] documents R104 having not received skin prep to her bilateral heels, sacrum, nor left ankle on [DATE] on the evening shift, nor skin prep to her sacrum. Scale for Predicting Pressure Score Risk, dated [DATE], documents R104 having a score of 12, indicating high risk. Skin and Wound Evaluation dated [DATE] at 6:16PM, documents, R104 having a Stage 4 pressure ulcer to her sacrum upon admission. On [DATE] at 4:23, V3, LPN, stated R4's bilateral heels and left ankle was receiving skin prep due to her history of pressure ulcers. Facility Policy entitled Dressing Change, dated [DATE] and revised on [DATE], documents in part: 1. Guidelines: 1. Prior to beginning treatment a. Check physician order [REDACTED]. Ensure resident has been assessed for pain and medicated if needed. The Policy further documents in part, 10. Remove soiled dressing and place in plastic trash bag. 11. Remove soiled gloves and place in plastic trash bag. 12. Wash hands. 13. Apply clean gloves 14. Clean area/wound. 15. Observe wound. 16. Apply prescribed ointment and/or dressing per doctor order. 17. Secure dressing in place. 18. Remove gloves and discard in plastic bag. 19. Initial and date the dressing prior to securing to resident. 23. Sign the Treatment Administration Record (TAR). Facility Policy entitled Skin Condition Assessment & Monitoring - Pressure and Non-Pressure, dated [DATE], and latest revision on [DATE], documents in part, Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown pressure injuries and assuring interventions are implemented. Guidelines: Pressure will be assessed and measured at least weekly by licensed nurse and documented in the resident's clinical record. The policy also states in part, Each resident will be observed for skin breakdown daily during care. Changes shall be promptly reported to the nurse who will perform the detailed assessment. The policy further states in part that nurses are to have sufficient supply of clean disposable gloves to perform assessments on multiple areas. Conduct hand hygiene in accordance with facility standard/universal precautions. The policy also states in part, 3. Dressings which are applied to pressure ulcers shall include the date of the licensed nurse who performed the procedure. Dressing will be checked daily for placement, cleanliness, and signs and symptoms of infection. Facility Policy entitled Physician order [REDACTED]. Guidelines: When receiving physician's orders [REDACTED].' tab and according to the instructions for the type of order that is received. The policy also documents in part, 5. If a treatment, be sure to put in the directions the specific area(s) to be treated. The policy further documents in part, 3. Notify the resident's physician, for verification, and 5. Following a physician visit, a licensed nurse will check for any orders that require confirmation. The orders will be confirmed by the nurse and the instructions for the order will be completed.

Based on observation, interview, and record review the facility failed to ensure a turning and repositioning program was initiated, a Moisture Associated Skin Damage (MASD) wound did not deteriorate into a pressure wound, and failed to ensure a wound was cleansed prior to applying a dressing for one of three residents (R2) reviewed for pressure ulcers in a sample of 22. These failures resulted in R2 developing a MASD wound which then deteriorated into two pressure wounds with necrotic tissue requiring surgical debridement. Findings include: A Pressure Ulcer Prevention policy dated 11/28/12 gives its stated purpose as, To prevent and treat pressure sore/pressure injury. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protecting bony prominences as indicated. R2's Minimum Data Set ((MDS) dated [DATE] documents that R2 is totally dependent on two people for bed mobility, transfers, and requires extensive assistance of two people for toileting. R2's pressure ulcer risk assessment dated [DATE] documents that R2 has slightly limited sensory perception, is occasionally moist, and chairfast which contributes to R2 being assessed as at risk for the development of pressure ulcers. R2's Wound Physician's (V11) note dated 4/2/19 documents that R2 developed two moisture associated skin damage wounds, one to the right and the left lower medial buttocks. This same note documents that R2's right buttock wound measured 1.5cm (centimeters) long x 1cm wide without measurable depth and R2's left buttock wound measured 4.5cm long x 3cm wide x 0.2cm deep. V11's wound progress note dated 4/9/19 documents that R2's right buttock wound had deteriorated from the previous assessment resulting in thick adherent devitalized necrotic tissue covering 100% (percent) of the wound bed. This note also documents R2's right buttock wound was larger than on 4/2/19 measuring 7cm long x 5 cm wide which required surgical debridement. This same note documented that R2's left buttock wound had also deteriorated resulting in thick adherent devitalized necrotic tissue covering 100% of the wound bed. This note further documents that R2's left buttock wound was larger than it had been on 4/2/19 measuring 5cm long x 3cm which required surgical debridement. R2's care plan intervention dated 2/27/19 states, Educate the resident/family/caregivers as to causes of skin breakdown, including transfer/positioning requirements; importance of taking care during ambulating/mobility/good nutrition and frequent repositioning. This same care plan does not document R2 is on an every two hour turning and reposition program or address R2's extensive and total dependence for mobility. On 4/29/19 at 11:15a.m. V3 (Day Shift Manager) verified that R2's buttocks wounds had worsened. V3 stated that V11 originally classified R2's buttocks wounds as MASD but V3 stated that she thinks R2's wounds look more like pressure ulcers. V3 stated that R2 has taken a decline in his activities of daily living abilities and requires extensive to total assistance with care. V3 stated that R2 was not on an every two hour turning and repositioning program prior to developing his buttocks wounds and R2 continues to not be on a turning and reposition program because, That just sets us up for failure. On 4/29/19 at 2:25p.m. R2 was laying in bed. R2 had been incontinent of stool and was being provided incontinence care by V15 (Certified Nurse Aide/CNA) and V16 (CNA). R2's right and left buttocks dressing was loose and soiled with fecal material. V16 removed the soiled dressing and proceeded to cleanse around the lower edge of R2's wounds with the same wash cloth V16 used to cleanse the fecal material from R2's buttocks. Once R2's incontinence care was complete, V15 rolled R2 onto his back so R2 was laying on his open wound. V15 and V16 left R2's room to notify V5 (Registered Nurse) that R2 needed a new dressing to R2's right and left buttocks. At approximately 3:00p.m. V15 and V5 entered R2's room to apply R2's buttocks dressing. V15 assisted R2 to roll to the right side while V5 prepared the dressing supplies. Without cleansing R2's wound, V5 applied a medicated ointment and dressing then covered the wound with an adhesive dressing. V5 stated that she did not cleanse R2's buttocks wounds prior to applying a clean dressing because R2's wounds had just been cleansed during incontinence care by V15 and V16. On 4/30/19 at 3:05p.m. V11 stated that when R2's right and left buttocks wounds first developed around 4/2/19, V11 diagnosed those wounds as MASD. V11 stated that R2's right and left buttocks wounds deteriorated as a result of pressure injury. V11 also verified following that deterioration, R2's wounds enlarged and required surgical debridement. V11 stated that, although, R2 had taken a recent decline in cognition, R2's nutrition was good and V11 would not have expected R2 to develop a pressure injury. V11 stated that R2's right and left buttocks pressure injury could have been preventable if R2 had been on a turning and repositioning program. V11 stated that R2's wounds should have been cleansed by V5 using wound cleanser or normal saline after R2 received incontinence care and prior to V5 applying the clean dressing.

Based on observation, interview and record review, the facility failed to provide timely assessments, monitoring, treatments and services to prevent infection, promote healing and prevent the development of new pressures ulcers for 5 of 12 (R14, R33, R111, R234, R284) reviewed for pressure ulcers in the sample of 65. This failure resulted in pressure ulcers developing as deep tissue injuries, stage IV and unstageable due to staff not timely turning and re-positioning, treatments/dressings not being done and not following physician's orders [REDACTED]. Findings include: 1. On 04/03/19 at 9:00 AM, R234 was observed lying in bed on her bottom with head of bed only slightly up at 10-degree angle. There were two heel protector boots on the bedside table. R234's heels were directly on the mattress. At 9:15 AM, 9:30 AM, 9:50 AM, 10:15 AM and 10:50 AM, R234 remained in the same position in bed. Staff were not seen turning or repositioning R234. 04/03/19 10:35 AM, V37 and V38, family stated R234 had a pressure ulcer on her bottom but did not know what condition it was in or if it had healed. V37 stated he was not aware of any other skin breakdown. V37 also stated R234 had not been out of bed except to go to [MEDICAL TREATMENT]. He stated she most always lays on her bottom. On 04/04/19 at 1:15 PM, an incontinence/skin check was observed for R234. When the left heel was observed, R234 had a deep tissue injury on the left heel that had a dangling bandage attached by one corner, rolled up edges and was soiled. There was no date on this bandage. The bandage was open exposing the large dark brown area on the heel. V25 then replaced the non-skid sock without ensuring the bandage was secure. V25 and V35, CNA's stated they did not know about the heel or coccyx/right buttock. The coccyx/right buttocks were observed to have a large open area that was black with yellow spots and bleeding in some areas. The area was exposed and was observed with a soiled rolled up bandage with brown drainage and with no date. R234 complained of the bottom hurting, however V25 and V35 did not position R234 that would offload the coccyx area. When V27, LPN was asked when the dressings had been changed, she stated she had no idea because the wound nurse no longer worked at the facility and was not sure if evenings or night staff changed the dressings. On 03/23/19, the Minimum Data Set (MDS), documented R234 had no pressure ulcers. On 04/02/19, the MDS documented R234 had a BIMS of 6, moderately impaired, and required total assist of two for bed mobility, transfers, dressing and toileting. The care plan, dated 03/22/19, documented R234 had a pressure ulcer to the left heel with interventions listed, in part as, monitor dressing to ensure it is intact and adhering. Report loose dressing to treatment nurse; the resident needs to turn/reposition at least every two hours, more often as needed; resident requires pressure relieving/reducing device on bed/chair, float bilateral heels; weekly treatment documentation to include measurements of each area of skin breakdown's width, length, depth, type of tissue and exudate . On 04/02/19, a Weekly Skin Observation documented R234's skin was intact with no concerns. On 04/03/19, a POS documented order for cleanse with normal saline, apply calcium alginate and foam dressing on sacrum in the evening The Treatment Administration Record (TAR), dated (MONTH) 2019, documented R234's sacrum dressing was not done on 04/05, 04/08, 04/09 or 04/10. On 04/11/19 at 2:10 PM, V42, Nurse Practitioner (NAP), stated that she was not aware of the condition of the pressure ulcer on R234's bottom. She stated she had not seen the open area on R234's bottom. She stated she did look at it today and thought it was moisture related [MEDICAL CONDITION]. However, V42 stated that R234 rarely produces any urine. She also stated that until today, she was not aware of R234 having pain on bottom. V42 stated she was not aware that an ulcer existed on the left heel. V42 also stated that V45, wound doctor had not evaluated R234's pressure ulcers. V29, 3rd floor manager, stated she had only seen the pressure ulcer on the bottom upon initial admission. Both V29 and V42 agreed the pressure area to the coccyx/buttocks was worse. V42 stated R234 was up in the reclining chair and has ordered that R234 be up in the chair at least once per day. 2. On 04/03/19 at 9:00 AM, R111 was observed up in his wheelchair in his room. At 9:30 AM, R111 stated he has open areas to his buttocks and left heel and usually gets dressing changes every couple of days in the afternoon. He stated that sometimes he sits up in his wheelchair all day without anyone repositioning him. R111's call light was observed dangling off the side of his bed, out of reach. R111 stated he had not had dressing changes for a couple of days. On 04/03/19 at 9:50 AM, 10:20 AM and 11:00 AM, R111 was up in the same position in the wheelchair. He stated no one had come in to lay him down and that his bottom really hurts. At 12:30 PM, V27, LPN stated R111 had an open area on his bottom that was painful and will sometimes refuse to have treatment done because it causes pain. V27 was not sure if he had orders for pain medication prior to dressing changes. She also stated R111 had a pressure ulcer on the left heel. From 11:00 AM to 1:50 PM in 15 to 20-minute intervals, R111 was observed in his wheelchair and stated staff had not been in to reposition him or do dressing changes. At 4:00 PM, V27, LPN and V34, CNA were observed during care for R111. R111 had an open area to the coccyx area that had multiple layers of slough, white macerated edges and had serosanguineous drainage on the incontinent pad. There was no dressing on this area. V27, LPN stated that R111 had no dressing orders, just ointment. There were no visible signs of any ointment being on the open area at that time. V27 was observed to cleanse between the buttocks with normal saline and apply [MEDICATION NAME] cream. No dressing was applied. The left heel was observed to have a large pink, white and dark brown areas covering the back of the left heel. There was a heavily soiled bandage with dark brown serosanguineous drainage that had soaked through the bandage. V27 cleansed with normal saline then applied calcium alginate and covered with foam dressing. On 04/01/19, the POS documented the following diagnoses, in part as, [MEDICAL CONDITIONS], Transient Cerebral Ischemic Attack (TIA), [MEDICAL CONDITION], chronic pain and Diabetes Mellitus. On 03/30/19, an order for [REDACTED]. The Treatment Administration Record (TAR), dated (MONTH) 2019, documented R111's treatments to the left heel were not completed as ordered on 03/05, 03/12, 03/14, 03/19, 03/22, 03/26, 03/27 and 03/28. The TAR dated (MONTH) 2019, documented R111's treatments were not completed as ordered on 04/02, 04/07 and 04/09. On 03/17/19, a nurse's note documented the initial observation by staff of the left buttock pressure ulcer that was draining green fluid. It documented the physician was notified, calcium alginate and foam dressing were applied, and the wound physician will assess on Tuesday. The TAR for (MONTH) 2019, had no documentation of a treatment being done on the left buttock on 03/17, 03/18, 03/19 or 03/20. The TAR documented treatment for [REDACTED]. There was no documentation that the treatments were completed on 03/22-day shift, 03/25/19 evening shift. There were no orders for antibiotics for the green discharge. There was no documentation that there were treatment orders for the left buttock on 03/26/19 through 03/30/19. There was no documentation indicating treatments were done during this period. The TAR for (MONTH) 2019 documented treatments for the left buttock was not completed on 04/02, 04/03-day shift, 04/05 evening shift and no treatments from 04/06 to 04/09. There were no nursing notes or TAR notes indicating R111 refused any of these treatments. The MDS, dated [DATE], documented R111 was cognitively intact with a BIMS of 14 and required extensive assist of two for bed mobility, transfers and toileting. The care plan, dated 04/01/19, documented R111 had a pressure ulcer to the left heel and left buttock. The interventions, in part as, administer treatments as ordered and monitor for effectiveness. Follow facility policies and protocols for the prevention/treatment of [REDACTED]. The Pressure Ulcer Prevention, dated 11/28/12, documented under Purpose: To prevent and treat pressure sores/pressure injury. Guidelines: 2. Inspect skin several times daily during bathing, hygiene and repositioning measures. Then 5. Turn dependent resident approximately every two hours or as needed . 3. The MDS dated [DATE] documents R14 to have severe cognitive impairment with a BIMS score of 2. The MDS documents R14 is dependent on 2 staff for all mobility. The (MONTH) 2019 physician's orders [REDACTED]. The order also, include an order for [REDACTED]. A Skin Assessment 3/19/19 for R14 identifies healed areas on her butt along with surface areas x2 (times two) pink in centers protective cream as ordered but includes no assessment of the wound status such as measurements, wound bed, drainage, color and/or odor if any. A Progress Note dated 3/22/2019 at 1:14pm, documents a new order reading cleanse areas on r and l buttocks apply protective foam drsgs daily and prn in the evening for wound care tx (treatment) applied today. A Skin Assessment 3/24/19, documents R14 to have a 1.4cm (centimeter) [MEDICAL CONDITION] cm open area l inner buttock pink center new open area inner buttock but has no measurements on the new area. A Weekly Skin assessment dated [DATE] identifies no wounds or skin issues at all even though R14 is currently being treated for [REDACTED]. A Weekly Skin Assessment 4/02/19, documents R14 to have 2 areas r inner buttock area left buttock pink/red centers tx as ordered with no measurements documented on the assessment. On 4/04/19 02:03 PM, R14 was up in her wheelchair at 10:26 am. V14 stated she had just gotten her up in the wheelchair and won't go back down to bed until after lunch as she is a full body mechanical lift. R14 was observed to remain in her wheelchair until 1:20 pm when she was transferred to bed using the lift by V14 and V15 CNA. R14 had deep white/red creases across hips/buttocks and upper thighs which lingered until the observation ended. R14 has a urinary catheter and had no evidence of barrier cream on when rolled to her side. R14 had two dressing in place, one on each side of the inner buttock. R14 had dressing on both inner buttocks which were loose on the top edge. The care plan dated 4/08/19 documents R14 to have a potential for impairment to skin integrity d/t (due to) poor skin turgor [MEDICAL CONDITIONS]. mobility, [MEDICAL CONDITIONS] and I am at risk for pressure injury. I have an area to my coccyx that the wound Dr. will see. The goal is to not develop alteration in skin integrity with interventions to include: pressure reducing mattress, geriatric chair, minimize pressure over bony prominence's, Protective skin barrier cream as ordered, provide diet as ordered and monitor nutritional status and dietary needs, and Report pertinent changes in skin status to Physician. There is nothing in the care plan addressing timely repositioning to redistribute weight or the need for checking/changing for incontinence to ensure skin is kept clean/dry. 4. According to R33's MDS dated [DATE], R33 was originally admitted to the facility on [DATE] and depends on staff for most activities of daily living. The MDS also indicates a Brief Interview Mental Status score of 15 cognitively intact. On 4/03/19 at 12:25 PM R33 was rolled onto her left side a rolled up Duoderm on coccyx no date or initials, the medicated Santyl had fallen out of the wound onto the bed from the stage IV pressure ulcer. A strong odor was noted. R33's right buttocks and upper leg was a large bloody red area with white slough macerated edges. A large bloody drainage stain was observed on incontinent pad. V13 Licensed Practical Nurse (LPN) stated that the wound doctor was advised but wanted to see the wound before ordering a treatment. V13 also stated that yesterday the wound doctor was here but R33 was sitting in a wheelchair so wound was not seen. V13 stated we are only putting barrier cream on wound.

Based on interview, observations and record review, the facility failed to provide adequate services for range of motion (ROM) to maintain and/or improve function including an assessment of degrees of limitations for 5 of 15 residents (R14, R33, R90, R108, R119) reviewed for Range of Motion in a sample of 65. This failure resulted in a decline in range of motion from no upper extremity limitations to limitations of both upper extremities for R90. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] documents R90 has ROM deficits, bilaterally upper extremities and one side lower extremities with no services provided. The MDS dated [DATE], documents a decline as R90's ROM limitations were identified as, no limitations of upper extremities and one-sided lower extremities. The MDS identifies R90 to have a left Below Knee Amputation (BKA). The most recent MDS, also documents R90 as having no cognitive impairment with a Brief Interview of Mental Status (BIMS) score of 15. The care plan dated 2/20/19 fails to reflect ROM deficits and/or services addressing this need. On 4/04/19 at 12:30pm, R90 stated, he doesn't get any exercises from staff, but looks forward to going to therapy to use the bike. R90 stated, he just recently had a BKA on left and getting fitted for a prosthetic. R90 stated, he would appreciate some exercises being done. A Restorative Observation/assessment dated [DATE] (the most recent provided) was completed prior to R90's BKA and no assessment had been done since his decline, this was documented on the MDS dated [DATE]. R90's assessment dated [DATE] does not specifically identify any limitations but does have limitations in voluntary movement/ROM checked. The facility Assessment for Range of Motion included measurements, as being appropriate, and R90 is not receiving services. The assessment does not address whether the resident had previously received treatment and services for ROM and whether he maintained his ROM, whether the ROM declined, and why the treatment/services were stopped. On 4/10/19 at 1:14pm, V31 Physical Therapist (PT) stated they recommended R90 to have ROM services and that they are waiting for his prosthetic to come in to restart therapy. V31 stated R90 is cognitively intact and would benefit from ROM twice daily 7 days a week. V31 stated a yearly measurement assessment would give residents a baseline in which to determine improvement or lack of. 2. The MDS dated [DATE] documents R14 has limitations one side upper and lower extremities and receives Passive ROM 6 days a week. The care plan dated 4/08/19 documents R14's problem as I have an ADL self-care performance deficit r/t (related to)[MEDICAL CONDITION] with [MEDICAL CONDITION] to right side, Dysphagia with a goal to improve current level of function in ADLs through the review date. Interventions include: PROM to right side daily X 10 repetitions daily. R14's Restorative Progress notes dated 2/07/19 documents R14 has limitations in voluntary movement/ROM with the right shoulder, right wrist, and right hip and severe < (less than) 50% of normal for right elbow, right knee, right ankle and right foot. On 4/10/19 at 1:14pm, V31, Physical Therapist (PT), stated R14 would be appropriate for PROMS and does have limitations. V31 agreed that range of motion should be twice daily 7 days/week. V31 stated they recommended that for R14. On 4/10/19 at 1:45pm, V33, CNA, stated they only do range of motion on R14's left side due to her having a stroke on her right. V33 stated she does 5-10 repetitions on R14's left side and only do it on her right as they dress her. V33 was observed doing range of motion and failed to complete the following: Horizontal abduction/adduction, Internal/external rotation and hyperextension of the shoulder joint, flexion/extension and supination/pronation of the elbow joint, abduction/adduction of the finger joints, flexion/extension, a=opposition of the thumb joint, internal/external rotation and hyperextension of the hip joint, and inversion/eversion of the ankle joint with no range of motion for the toe joint. 3. R108's MDS dated [DATE] documents her to have limitations bilateral lower extremities with no services provided. The MDS documented R108 to have short/long term memory deficits. On 4/03/19 and 4/04/19 throughout the day when up in her wheelchair, R108 was noted to sit with her left leg off the leg rest and right leg to cross over. On 4/04/19 at 11:14 AM, R108 was transferred to her bed. V14, CNA, stated they do range of motion on her. V14 was observed to do incomplete range of motion as she only verbally asked R108 to raise her arms, straighten her legs stating she cues her to the exercises. R108 was unable to straighten left knee with right being less limited. A Restorative Observation assessment dated [DATE] documents no limitations for R108 at the time. On 4/10/19 at 1:14pm, V31, Physical Therapist (PT), stated they hadn't seen R108 for a while, but would be appropriate for PROMs. V31 states they do not necessarily measure degrees of limitations. A Therapy note dated 11/30/18 documents R108 to be within normal limits. The care plan dated 3/13/19 documents a decline in transfer ability with no information regarding R108's identified limitations and her need for range of motion services. 4. The MDS dated [DATE] identifies R119 to have no cognitive impairment with a BIMS score of 15. The MDS documents R119 has no limitation upper extremities with limitations bilaterally lower extremities with no services provided. On 4/03/19 at 12:25pm, R119 stated the staff doesn't do exercises with her, but she's supposed to go back to therapy when my butt heals. R119 stated I don't get up at all right now. The Care Plan dated 3/15/19 documents nothing about R119's ROM limitations on the care plan. The Restorative Nurse Program policy/procedure dated 11/28/12 documents the purpose as to promote each resident's ability to maintain or regain the highest degree of independence as safely as possible and documents A functional program may include range of motion provided during routine daily care such as dressing, grooming/hygiene, eating, transfers, bathing, etc. It continues Range of motion programs may include active assisted range of motion, active range of motion, or Passive range of motion. Under definitions, it documents Passive range of motion (or PROM) - staff or equipment moves the joint through the range of motion with no effort from the resident. ·

Based on interview and record review, the facility failed to identify dangerously low blood glucose levels, failed to assess/monitor for adverse reactions following changes of insulin and fluctuating glucose levels, failed to assess and monitor risk factors of [MEDICAL CONDITION] and failed to provide coordination/continuity of care by medical professionals to maintain residents highest practical physical well-being for 2 of 11 residents (R4) reviewed for quality of care in the sample of 11. These failures resulted in R4 having an acute episode of [DIAGNOSES REDACTED], which resulted in respiratory/[MEDICAL CONDITION] and subsequent death, and R2 being admitted to the hospital [MEDICAL CONDITION] on [DATE] and [DATE]. Findings include: 1. Electronic Health Record (EHR) Admission Note documents R4 as a [AGE] year old male admitted to the facility from another long term care facility on [DATE] with [DIAGNOSES REDACTED]. Admitting orders from the prior placement included: 1) (Finger stick blood glucose monitoring) Call MD (medical doctor) if blood sugar is less than 70 or greater than 450 before meals and at bedtime 2) Humalog (fast acting) U-100 Insulin Sliding scale with special instructions Call MD if blood sugar is less than 70 or greater than 450 - (Blood Sugars in range of:) ,[DATE]=0 units, ,[DATE]= 3 units, ,[DATE]=5 units, ,[DATE]=7 units, ,[DATE]=10 units, ,[DATE]=15 units, >450 call MD before meals 7:00 AM-9:00 AM, 11:00 AM-1:00 PM, 4:00 PM-6:00 PM. Orders also included: 1) Humalog 10 units subcutaneous (subq) three times a day 8 AM, 12 noon and 5 PM, 2) [MEDICATION NAME] ([MEDICATION NAME]) (long acting insulin) U-100, 18 units subq at hs (bedtime.) 3) Glucose chewable tablets 2 tabs daily PRN (as needed) - give if blood sugar is less than 70. R4's orders included diet orders for a LCS (low concentrated sweets/Regular diet and an HS (bedtime) snack offer sandwich, yogurt, cottage cheese, etc. at (10 PM). The care plan, dated [DATE], identifies a focus area, I have Diabetes Mellitus and am insulin dependent. with a goal to have minimal complications related to diabetes through out the review date. Interventions include: Medication as ordered, monitor/document for side effects and effectiveness, fasting serum blood sugar as ordered by physician, monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of [MEDICAL CONDITION]; increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd (abdominal) pain, Kussmaul (deep labored) breathing, [MEDICATION NAME] breath (smells fruity), stupor, coma, Monitor/document/report PRN any s/sx of [DIAGNOSES REDACTED]; sweating, tremor, increased heart rate ([MEDICAL CONDITION], pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait and offer substitutes for food uneaten in part. The Minimum Data Set ((MDS) dated [DATE] documents R4 to be cognitively intact with a Brief Interview of Mental Status (BIMS) score of 14. On [DATE], following admission, a new order for sliding scale (s/s) insulin was given by V24, R4's Attending Physician, which was as follows: ,[DATE]=0 units, ,[DATE]=3 units, ,[DATE]=5 units, ,[DATE]=7 units, ,[DATE]=10 units, ,[DATE]=12 units, ,[DATE]=15 units, subq before meals. This was different for ,[DATE] and ,[DATE]. There is no information as to why this would have been changed at the time and no documentation as to why the new order was obtained. A new order to increase the [MEDICATION NAME] Solution 18 units to twice daily at 8 am and 8 PM was given in addition to the 10 units of Humalog at 8 am, 12 noon and 5 PM. This was an increase of the [MEDICATION NAME] from 18 units once a day to 18 units twice a day. V24, physician, documents his only visit to see R4 as a Late Entry dated [DATE] at 1:42 PM that reads rounds were made with the presence of the nursing staff. Questions were answered to the presence of her patient. Medical Record was reviewed nurse's notes recommendations were made for updated on immunization recommending following the policy for the CDC (Centers for Disease Control) on opioid use and stewardship of antibiotics. The note finishes with CKD ([MEDICAL CONDITION]) Diabetes but identifies no concerns with R4's blood sugars at the time. The (MONTH) (YEAR) Medication Administration Record (MAR), documents R4 receiving sliding scale insulin occasionally with the routine Humalog 10 units at 8 am, 12 noon, and 5 PM and 18 Units of [MEDICATION NAME] at 8 am and 8 PM. An Order Detail dated [DATE] at 9:22 PM documents the [MEDICATION NAME] ([MEDICATION NAME]) Solution 100 units/ml (milliliter) 45 units subcutaneously every day and 35 unit at bedtime was ordered by V23, Nurse Practitioner (NP). This was an increase of the [MEDICATION NAME] from 18 units every AM to 45 units every AM and from 18 units at HS to 35 units at HS. New orders received from V23, NP, on [DATE] at 9:16 PM with a start date of [DATE] documents a new sliding scale as follows for the Humalog 100 unit/ml (milliliter): ,[DATE] =3 units, ,[DATE] = 6 units, 201- 250 = 9 units, 251 - 300 units = 14 units, 301 - 350 = 18 units, 351 - 450 = 22 units, > (greater than) 450 call MD (medical doctor) for orders, subcutaneously with meals for DM (diabetes mellitus.) There was also an order [REDACTED]. Neither orders were signed until [DATE]. There are no progress notes documented as to why V23 would order a new sliding scale and one that included 3 units for bloods sugars of ,[DATE] for which previously none would be given. There are no progress notes written by V23, NP, on [DATE] indicating that he had seen him. The (YEAR) (MONTH) MAR documents an order dated [DATE] for 45 units of [MEDICATION NAME] ([MEDICATION NAME]) Solution once daily given at 8 am on [DATE]. R4's blood glucose was documented as 79 at 8 am. There are no progress notes or physician/nurse practitioner notes written at the time to explain why this 45 units was ordered on ,[DATE] and not given until 8 am on [DATE] when R4's Blood sugars were documented as 300 at 8 am with 10 units of Humalog given per sliding scale and a 450 at noon with 15 units documented as given per sliding scale. R4's blood sugar recorded at 5 PM on [DATE] is 241 with 5 units Humalog given and at HS, R4's blood sugar was recorded as 88. No additional insulin was given on [DATE] besides what was already ordered. V23's note dated [DATE] documents [AGE] year old caucasian male resident seen today for a follow up to his type 2 diabetes and elevated blood glucose with c/o (complaints of) generalized pain and weakness. V23 documented the plan as Discontinue all current diabetes regimen and start the new regime stated in progress notes. Get A1C (blood test that reflects average glucose levels over prior ,[DATE] weeks) in am and repeat in 3 mos (months). There is no evidence that R4's attending physician was aware of these changes. On [DATE] at 8 am, the MAR records R4's blood sugar as 79 with the 45 units of [MEDICATION NAME] given in addition to 3 units according to the new sliding scale order received from V23, NP on [DATE]. R4 was also recorded as receiving the [MEDICATION NAME] 500 mg. R4's blood sugar at noon recorded on the MAR was 70 with 3 units of Humalog documented as given and at 5 PM, R4's blood sugars was recorded as 57 with 3 units of Humalog documented, but a 15 or no insulin required according to the MAR legend. R4's blood sugar recorded on the MAR for 8 PM on [DATE] is recorded as 230 on the old sliding scale with no sliding scale Humalog given. A Concern/Compliment Form dated [DATE] submitted by R4 to V4, Social Service Designee (SSD), documents R4 complained about having blood in his urine. Progress notes fail to document any follow up to this complaint. On [DATE] at 8 am, R4's blood sugar was documented as 81 with 3 unit of Humalog giving per sliding scale from NP along with 45 units of [MEDICATION NAME] Solution and the [MEDICATION NAME]. At 12 noon, R4's blood sugar was recorded as 297 with 9 units of Humalog given per sliding scale with a progress note written by V31, Registered Nurse (RN), which reflected the same sliding scale from V23 dated [DATE] with a statement at the end of redundant order. At 5 PM, R4's blood sugar was 88 with 3 units given along with the [MEDICATION NAME]. At 8 PM, R4's blood sugar was 230 with insulin documented as refused by R4 with no explanation. A Concern/Compliment Form submitted by R4 to V4, Social Service Designee (SSD), dated [DATE] documents R4 sometimes does not get his HS (bedtime snacks.) The form does not document any corrective action to R4's concerns and no follow up is evident. On [DATE], V23 documented another note (no time) which read male resident seen today per nurse's request for a hypoglycemic episode and c/o lethargy. The plan was to decrease [MEDICATION NAME] ([MEDICATION NAME]) to 30 unit subq q (every) am and repeat A1C in 3 months. This was a decrease from 45 units. There is no indication that R4's attending physician was notified of the multiple changes made by V23, NP. A physician order [REDACTED].= 0 units, ,[DATE] = 3 units, ,[DATE] = 5 units, ,[DATE] = 7 units, ,[DATE] = 10 units, 350 - 400 = 12 units, 401 - 450 = 15 units, subcutaneously before meals and at 9 PM, a new order from V24 for [MEDICATION NAME] Solution 100 units/ml In ject 35 units subcutaneously at bedtime and inject 30 units subcutaneously one time a day for diabetes. The order was signed [DATE]. The MAR following the new orders from V24 reflects both sliding scale orders with the nurse documenting on both simultaneously. The MAR documents R4's blood sugar at 8 am on [DATE] as 233 with 9 units of Humalog given according to the sliding scale from V23, NP not V24, physician's orders [REDACTED]. At noon on [DATE], R4's blood sugar was recorded as 88 with 3 units given and at 5 PM, R4 was given 3 units of Humalog for a blood sugar of 116 according to the sliding scale from V23, NP not V24, physician, which would have been for none to be given. R4 received the [MEDICATION NAME] 500 mg at 5 PM. R4 was given 35 units of [MEDICATION NAME] ([MEDICATION NAME]) at 8 PM with his blood sugar recorded as 267. On [DATE], the MAR documents R4's blood sugar as 70 and was again given 3 units according to the sliding scale ordered by V23, NP, which should have been none given per V24's sliding scale. The MAR also documents R4 receiving 30 units of [MEDICATION NAME] and the [MEDICATION NAME] 500 mg. At noon, R4's blood sugar was recorded as 160 and was given 6 units according to V23's sliding scale, which should have been 3 units given per V24's sliding scale. At 5 PM, the MAR records R4's blood sugar as 86 with 3 units of insulin recorded as given by V20, License practical Nurse (LPN), which should have been none given per V24's sliding scale. R4 received 35 units of Humalog at bedtime with a blood glucose of 80. Progress notes entered between [DATE] and [DATE] when R4 was sent out reflects only one entry regarding R4's blood sugars and that was on [DATE] at 12:14 PM entered by V31, Registered Nurse (RN.) The entry documents the sliding scale ordered by V23, NP, and ends with the statement Redundant order. There is no evidence the facility nurses were monitoring R4's response to the change in insulin orders, his fluctuating and repeated low glucose level and his food intake in an effort to determine the cause of the fluctuations. On [DATE] at 12:30 PM, V2, Director of Nurses (DON), was asked to provide V24's standing orders and stating she'd try to find some. At 1:00 PM, V2 provided a copy of the standing orders that had just been faxed from V25's office at 12:43 PM on [DATE]. The standing orders document, When patient's blood sugar is < (less than) 80 and patient has symptoms, patient should be treated with a dose of [MEDICATION NAME] followed by a meal that is substantial and the blood sugar should be checked every 15 minutes x 2 and then every hour until stable oral hypoglycemic events should be reported immediately and the root cause corrected. There is no evidence the facility nurses had V24's standing orders or that they follow his orders for a low blood sugar. On [DATE], notes documented by V23 NP indicate R4 had swelling and tenderness to the index finger of his left hand. A note dated [DATE] written by V23 documents he ordered Keflex 750 mg (milligrams) twice daily times 7 days for an infection. Meal Intake records for R4's stay from [DATE] through [DATE] documents he ate ,[DATE]% of most meals except supper on [DATE] when he was documented as eating ,[DATE]%. The facility was unable to provide intake records for HS snacks as evidence of monitoring his intake. EHR progress notes dated [DATE] at 9:22 am entered by V30 LPN documents under narrative Resident v/s (vital signs) ,[DATE], 45, 96.1, 12 blood sugar read low resident unresponsive [MEDICATION NAME] shot given. Resident still unresponsive 911 called another [MEDICATION NAME] shot given blood sugar up to 51 resident not responding EMT's (emergency medical technician) here working on resident. EMT stated resident is coding CPR (cardiopulmonary resuscitation) initiated by EMT. Resident left facility with EMT's continuing CPR going to ER (Emergency Department). (V23) NP aware and (V2) DON (Director of Nurses) Resident own POA (power of attorney) and no other contacts available. Hospital Emergency Department notes documents R4 presented in full respiratory and [MEDICAL CONDITION] on arrival. History and Physical notes dated [DATE] at 11:16 AM documents under impression Acute hypoxic/hypercapneic [MEDICAL CONDITION] ,[DATE] (secondary) severe [DIAGNOSES REDACTED] requiring mechanical ventilation and Asystolic s/p (status [REDACTED]. R4 expired following family consent to remove ventilator. On [DATE] at 8:50 am, V30, LPN, stated the incident occurred before 7 am on [DATE] when she went in to do treatments on R4's feet. V30 stated she noticed that he wasn't himself, unresponsive. On [DATE] at 1:35 PM, V23, Nurse Practitioner, stated he had seen R4 several times and wrote notes on him on his computer and stated he didn't know the dates off hand and hadn't given the notes to the facility yet. He recalled R4 as being tall, thin and fragile. V23 stated he knew R4's blood sugars were running high, running low, and didn't know if he snacked a lot or if his family brought food in for him. V23 stated one minute it would be ,[DATE] then bottom out. When asked what he meant by bottoming out, V23 stated a blood sugar of ,[DATE]. V23 was asked if he was aware that R4 already had sliding scale insulin ordered when he ordered one on [DATE] and stated yes, but couldn't state why he reordered one. V23 stated the facility nurse had texted him at the time. V23 was asked if he specifically ordered the blood sugar of ,[DATE] = 3 units on the sliding scale dated [DATE], stated yes and when asked why, could not say. V23 repeatedly stated he needed to check his notes in his computers. Asked why the facility didn't have access to his notes, V23 stated they are just in the processes of setting him up to the printer so he can print out his notes when he does them. V23 stated he would not typically order ,[DATE] =3 units so he was thinking an error occurred, but stated even if he did, the nurses should have held the insulin if his blood sugars were under ,[DATE]. The orders dated [DATE] for the sliding scale were signed by V23 on [DATE], after R4 had expired. V23 stated it would be the nurses discretion to give or not to give the insulin with a low sugar, but he would expect them to hold it, stating they should have known better. V23 stated he was not notified about the low blood sugars R4 was consistently having after [DATE] even though he had seen him on ,[DATE] and [DATE]. V23 agreed that infections can cause a fluctuation in blood glucose levels. On [DATE] at 10:30 am, V31, RN, recalled R4 well describing him as alert and oriented times three. V31 stated she remembered R4 as having really low blood sugars that V23, NP, changed his insulin drastically for. V31 was asked about a progress note dated [DATE] at 12:14 PM where a new sliding scale which started out with ,[DATE] = 3 units was ordered by V23 and V31 stated V23 was in the building when she printed out the blood sugars for him. V31 stated V23 reviewed them before giving her the new orders for the sliding scale. V31 stated V23 actually gave her the numbers for the sliding scale which included the ,[DATE] = 3 units. V31 was asked why she documented redundant when the new sliding scale was different from the old, stated because R4 already had an order for [REDACTED]. V31 stated R4 always wanted to know what his blood sugar was and how much insulin he was getting as he was very aware of what he needed. When asked if she ever held R4's insulin due to his blood sugar being too low, stating I never considered holding his insulin and if I had, I would have documented it as being held. V31 was asked about R4's eating habits and stated he had a lot of snacks in his room and sometimes he ate, and sometimes he did not. V31 stated he also had [MEDICAL CONDITION] of his finger at the end which could have also caused his blood sugars to fluctuate. V31 stated she did not document any assessment towards R4's adjustment to the insulin at the time as she didn't see any difference. V31 stated she was here the morning he crashed and stated she heard V30, LPN, yelling for her to come down. V31 stated she ran down to get the [MEDICATION NAME] injection then ran down to get the printed information to send with him to the ER (emergency room ). V31 stated V30 gave the injection and 911 was called. V31 stated she understood that he didn't crash until the paramedics got here. On [DATE] at 11:40 am, V24, R4's attending Physician/Medical Director, stated he didn't immediately recall R4, but that he was unaware that V23, NP, gave multiple insulin orders for R4 in the week following his hospitalization . V24 explained that V23 works for a different company than his so he is not privy to any information from V23 unless the facility informs him or provides it which they did not. V24 stated the facility nurses call V23 often and V23 is there every day, but they don't always let V24 know what's going on. V24 stated he recently had a major meeting with the facility over this problem as he sent his nurse down to the facility and she was denied access to the medical records of V24's patients. V24 stated he also makes rounds with a nurse at the facility who isn't actually the nurse taking care of the residents and she doesn't know if there are any changes that have occurred or if there is anything going on with the resident at that time. V24 stated he would expect to be called with any condition change including any time there is a hypoglycemic episode that's symptomatic. V24 stated he doesn't like sliding scale insulin as it tends to over correct a resident causing more problems. V24 stated he likes to keep the am blood sugar 140 or below and would expect them to recheck a blood sugar 2 hours after they eat and let me know the results. V24 stated he has standing orders for everything including diabetes, but facility nurses do not follow them. When asked about the sliding scale from V23 with the ,[DATE] = 3 units, V24 repeated he was unaware of that and would have expected his standing orders to be followed. V24 stated he would also expect them to monitor the resident after insulin changes for adverse reactions. V24 was asked about when to contact him, stating he would expect them to contact him whenever a resident has a hypoglycemic episode and during a significant condition change. V24 stated he does not want them contacting V23 instead. When asked about the nurses giving insulin with low blood sugars, V24 stated the nurses don't follow standards of practice. V24 stated they have agency nurses sometimes who aren't familiar with the residents at all stating continuity of care is a problem. On [DATE] at 10:45 am, V43, R4's family member, stated R4 told family members that he was getting too much insulin and that he had diabetes for over [AGE] years and was well aware of what he needed. V43 stated that she was told by R4 that he'd refused it a couple of times, but that the nurses did not really assess the insulin situation well. The facility's policy entitled [MEDICAL CONDITION] (undated) but faxed [DATE] documents Resident will be monitored for s&s (signs and symptoms) of Diabetic coma (also known as [MEDICAL CONDITION] condition that occurs in diabetic residents when they do not receive enough insulin to metabolize carbohydrates, when there is increased stress, or infection. The onset is gradual. Under Procedure, the policy documents Should you observe a diabetic resident, or should a diabetic resident complainn of any of the following symptoms an accu-check will (should any symptoms exist, the accu-check would reveal a high blood sugar > (greater than) 300.) Report all changes in the diabetic resident to the physician IMMEDIATELY. The symptoms include: breathing difficulties and increased respirations, sweet or fruity breath, flushed skin, loss of appetite, nausea and/or vomiting, increased thirst and dry tongue, dry skin, increased urination, senses are dulled, complaints of aches, loss of consciousness. The facility's policy/procedure entitled [DIAGNOSES REDACTED] (undated) but faxed [DATE] documents It is appropriate at the time of admission to request an order for [REDACTED]. Diabetic residents who exhibit signs/symptoms of [DIAGNOSES REDACTED]/Insulin reactions to determine the blood sugar level. Fingerstick blood sugar monitoring may be performed when a change in status is observed and hypo or hyper glycemia is suspected. The signs/symptoms of [DIAGNOSES REDACTED] includes: generalized muscular weakness, sweating, nervous instability, trembling, faintness, hunger pangs in epigastrium, headaches, numbness or tingling of tongue or lips, rapid heart action, confusion, double vision, and unsteady gait. The policy continues to document Give some form of glucose if resident is conscious. A) Mild reaction - small amount of food - ,[DATE] gm carbohydrates (such as orange juice, 6 oz of regular soda, 8 oz of 2% skim milk) repeat in ,[DATE] minutes as needed. B) Moderate reaction - (drowsy, profuse perspiration, blood glucose ,[DATE] below normal) . The policy documents contact Physician if blood sugar is below 60 unless there are specific call parameters. The policy also documents Document findings, interventions, and MD contact in resident's clinical record. 2. On [DATE] at 11:01 AM, R2 stated she is incontinent and does need assistance with incontinent care and has a history of Urinary Tract Infections [MEDICAL CONDITION]. R2 further stated she woke up in the hospital back in October, (YEAR) and when she woke up incoherent and next thing I know I'm in ICU. R2 felt the facility failed to identify her UTI, which subsequently lead to her [MEDICAL CONDITION]. R2 stated she is not sure that her Primary Care Physician (V24) is notified of her condition changes, and that only Nurse Practitioner (NP), V23 is notified. R2's MDS, dated [DATE], documents R2 having a BIMS score of 15, indicating intact cognition and occasionally incontinent of urine. R2's Care Plan dated [DATE] and revised on [DATE] documents, R2 being rejective of cares, and having an Activities of Daily Living (ADL) self-care performance deficit, having limited physical mobility, being at risk for fall/injury from weakness and tiredness. The Care Plan does not list what ADL self-care performance deficit R2 has, nor does the Care Plan reflect which areas of care R2 is resistive to. Nurse's Notes dated [DATE] at 9:50 AM documents, R2 reported feeling nauseous this am and when asked by V46, LPN, when her symptoms began, R2 stated late last night. The Nurses Note further documents R2 had no emesis at the time and V23, NP, was notified. There is no documentation that R2's primary physician was notified. Nurse's Notes dated [DATE] at 10:57 AM, documents in part, Writer went into resident's room (R2) to give medicine at this time because she was unable to take medicine earlier and had fallen back to sleep. Writer had assessed temp this am it read at 98.8. Temperature was 100.6 upon reassessing. Skin warm to the touch. Left leg is slightly more red than the right one. No emesis but still feeling nauseated. (V23, Nurse Practitioner) notified. Orders to send to ER (sic) for evaluation requested. The Nurse's Note do not reflect R2's physician was notified. Hospital History and Physical dated [DATE] documents R2 having Severe Septic Shock, and having UTI and lower extremity [MEDICAL CONDITION]. Hospital Summary dated [DATE], documents R2 [MEDICAL CONDITION] secondary to E. Coli (Escherichia coli) in urine. Hospital History and Physical dated [DATE] documents R2 being admitted for septic shock secondary to UTI. On [DATE] at 1:20 PM, V2, Director of Nursing (DON), stated it is the expectation for nursing assessment to be done anytime there is a change of condition. Facility Policy entitled Assessment of Resident, dated [DATE] and revised on [DATE], documents in part, To gather comprehensive information as a basis for identifying resident problems/needs. The policy further documents in part, 8. If reassessing resident, review previous nursing progress notes, physician's orders [REDACTED]. 10. Notify the attending physician of significant findings and request necessary change in orders. The Policy also identifies assessments are to be performed when the resident's past or current history indicates the need/problem is present, and/or as observed or deemed necessary.

Based on interview, observation, and record review, the facility failed to promptly identify, assess, treat and monitor pressure ulcers to prevent deterioration and failed to ensure timely repositioning for 2 of 4 residents (R3, R4) reviewed for pressure ulcers in a sample of 11. This failure resulted in deterioration of R4's pressure ulcers per physician's assessment. Findings include: 1. The Admission Record documented R4 as a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R4's Physician/Discharge Orders, dated 10/19/18 from discharging facility , documented Cleanse stage 2 pressure injury to right heel and stage 3 pressure injury to left heel with wound cleanser and pat dry. Apply Allevyn dressing every other day. The Minimum Data Set, MDS, dated [DATE], documented R4 to be cognitively intact with a Brief Interview of Mental Status (BIMS) score of 14. The MDS documents R4 requires extensive assist of one staff for bed/transfers. The Care Plan dated 10/21/18 documents R4 to have pressure ulcers to his left/right heels. The goal was for the ulcers to show signs of healing and remain free of infection. Interventions include in part: Administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing, measure length, width, and dept where possible, Report improvements/deterioration to MD (medical doctor), monitor dressing to ensure it is intact and adhering, report loose dressings to nurse, and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. The Treatment Administration Orders (TAR) for (MONTH) (YEAR) documents the right heel stage II pressure ulcer treatment was initialed as done on 10/20, 10/22, 10/28 and 10/30/18 and was ordered to be done every other day but reflects no treatments done for the left heel. The weekly skin observations dated 10/22/18 identifies R4's right/left heel ulcers but includes no measurements. This form identified the ulcers as being present on admission. A Concern/Compliment submitted by R4 dated 11/6/18 documents that his dressing on his R (Right arm) and heels haven't been changed as scheduled. On 11/15/18 at 3:00 PM, V3, Licensed Practical Nurse, LPN provided the first wound assessment for R4's feet and is dated 10/26/18, 7 days after admission. The Wound Assessment provided by V3 dated 10/26/18 documents R4's left heel pressure ulcer as having slough/eschar measuring 0.7 cm (centimeter) x (by) 1.2 x 0.8. The right heel was documented as same with measurements documented as 1.4cm x 1.6cm x 1.1cm. The first entry into the Electronic Health Record (EHR) is on 10/29/17 at 8:01PM entered by V20 Licensed Practical Nurse (LPN) documents WEEKLY SKIN OBSERVATIONS GENERAL SKIN OBSERVATIONS: Weekly skin observation completed for (R4) Skin is warm, dry, within normal limits. Skin turgor is fair. SKIN CONCERNS: Skin intact, no concerns noted. FOOT OBSERVATIONS/CARE: No foot concerns noted. The Electronic Progress Record (EHR) dated 10/30/18 documents R4 was seen be the Wound Specialist, V21. V21's Initial Wound Evaluation & Management Summary dated 10/30/18 documents R4 to have an unstageable (due to necrosis) of the left heel measuring 0.6cm x 0.5 x not measurable with 50% necrotic tissue and 50% granulation. The report documents R4's right heel measures 1.3cm x 1 x not measurable with 100% necrosis. The order for these wounds was Alginaid calcium apply once daily. The (MONTH) (YEAR) TAR/MAR (Medication Administration Record) failed to document V21's orders given on 10/30/18. The (MONTH) (MAR) documents R4's Left heel treatment ordered every other day was only documented as done on 10/20, 10/22, 10/26, 10/28 and 10/30/18 missing the treatment on 10/24/18. R4's right heel treatment documented on the TAR also ordered every other day was documented as done only on 10/20, 10/22, 10/25, 10/28 and 10/30/18 with none being documented as done on 10/24 and 10/26/18. A Weekly Skin Observation, dated 11/5/18, completed by V25, LPN, documents R4 to have no foot concerns with skin intact even though R4 has unstageable ulcers on both heels. V21's, Wound Specialist, Wound Evaluation & Management Summary dated 11/6/18 documents decline in the left heel with measurements as 1.5cm x 1.5cm x not measurable with 100% necrosis. R4's left heel pressure ulcer also documented decline with measurements as 1.5cm x 1.7cm x not measureable with 50% necrosis and 50% granulation. V21 documented for both left heel and right heel that the deterioration was due to [MEDICAL CONDITION] and ordered dressing not in place. The (MONTH) (YEAR) TAR or MAR fails to include any treatment orders for either of R4's heels therefore none are documented as done. 2. R3's Admission Record, undated, documented she had [DIAGNOSES REDACTED]. R3's MDS's, dated 10/23/18 and 10/31/18, document R3 required extensive assistance from staff for bed mobility, toilet use and personal hygiene. R3's MDS documented she required total assistance from staff with transfers. R3's Skin Assessment, dated 11/13/18, documents R3 scoring a 16 on the Braden Observation Assessment, indicating being at risk for skin breakdown. Physician Wound Evaluation authored by V21, Wound Specialist, dated 11/13/18, documents R3 had a pressure ulcer to her buttock which was Resolved. On 11/16/18 8:15 AM R3 was lying in bed on her left side with 2 pillows underneath her head and 2 incontinent pads underneath her buttocks. R3 had an opened pressure ulcer on her right buttock that was beefy red in color. There was no dressing on R3's pressure ulcer. V11, Certified Nursing Assistant (CNA), stated, I just creamed it (buttocks), and further stated she hadn't informed the nurse of the open area to R3's right buttock. On 11/16/18 at 11:10 AM, R3 was up in the chair at bedside. R3 stated her butt was hurting. At 12:14 PM, R3 remained up in her chair in the therapy room. At 1:15 PM, R3 remained up in the wheelchair in her room, and stated she had been up since this morning. R3's TAR dated 11/1/18 through 11/30/18 did not list a treatment for [REDACTED]. The (MONTH) (YEAR) TAR or MAR fails to include any treatment orders for R3's right buttock. R3's Care Plan dated 8/30/2018 and revised on 10/17/2018 did not document anything regarding a pressure ulcer to R3's right buttock. R3's Care Plan further documents R3 having potential for impairment to skin integrity related to fragile skin, impaired mobility, incontinence, having a [DIAGNOSES REDACTED]. On 12/3/18 at 8:30 AM, V2, DON, stated she had just went and assessed R3's buttock and found it to be closed now. V2 further stated she cannot determine when the wound was closed, could not verify the measurements at the time of initial findings of R3's open wound, and that there was not a treatment for [REDACTED]. V2 further stated she would have expected the CNA to report any skin changes to the nurse and for the nurse to notify the physician and seek treatment orders, and to have the Care Plan updated with the pressure ulcer included to R3's right buttock. On 11/28/18 at 11:40 AM, V24, R3's attending Physician/Medical Director stated in part, the facility nurses call V23, Nurse Practitioner (NP) and he is there every day but they don't always let him know what's going on. He stated he recently had a major meeting with the facility over this problem as he sent his nurse down to the facility and she was denied access to medical records. V24 said the other problem is that he makes rounds with a nurse who isn't actually the nurse taking care of the residents and she doesn't know if there has been any changes or what's going on with the resident at that time. V24 states he would expect to be called with any condition changes. V24 further stated he has standing orders for everything, which they do not follow. V24 asked about when he expected the nurses to contact him, stated he would expect them to contact him whenever a resident has a significant condition change. V24 stated he does not want them contacting V23 instead. V24 stated there is no continuity of care. The facility's policy/procedure entitled Pressure Injury and Skin Condition assessment dated [DATE] identifies the purpose as: To establish guidelines, monitoring and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implementing and Pressure and other ulcers will be assessed and measured at least every seven (7) days by licensed nurse, and documented in the resident's clinical record. The policy documents A skin condition assessment and pressure ulcer risk assessment will be completed at the time of admission/readmission and a wound assessment will be initiated and documented in the resident chart when pressure and/or other ulcers are identified by licensed nurse. The policy documents wound assessment will include site location, size, stage, odor, drainage, description and date/initial of individual performing the assessment. The policy documents a license nurse shall observe condition of wound incision daily or with dressing changes as ordered with notation documented in the nurse's notes. Facility Policy dated 11/28/12, and revised on 11/17/18, entitled Pressure Injury and Skin Condition Assessment, documents in part, Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented. The Policy documented 3. A wound assessment will be initiated and documented in the resident chart when pressure and/or other ulcers are identified by licensed nurse. The Policy continued to document 6. Care givers are responsible for promptly notifying the charge nurse of skin breakdown. It continued 16. The licensed nurse is responsible for notifying the attending physician, Director of Nursing and legal representative. 17. The resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches and goals for care. 18. Physician ordered treatments shall be initiated by the staff.

Based on observation, interview, and record review the facility failed to monitor and assess signs and symptoms of Urinary Tract Infections [MEDICAL CONDITION], perform complete incontinent care, indwelling urinary catheter care and [MEDICATION NAME] care and timely toileting for 5 or 5 residents (R1, R4, R5, R6, and R7), reviewed for in a sample of 11. This failure resulted in R4 being sent to hospital with partial [DIAGNOSES REDACTED]. Findings include: 1. R4's Minimum Data Set, MDS, dated [DATE] documents R4 to be cognitively intact with a BIMS score of 14. The MDS documents R4 to have a catheter on admission and be frequently incontinent of bowel. The MDS also documents R4 requires extensive assist of one staff for transfers. physician's orders [REDACTED]. R4's Care Plan dated [DATE] documented R4 to have a Focus area Catheter r/t (related to) [MEDICAL CONDITION] and [MEDICAL CONDITIONS]. The goals documented I will show no signs or symptoms of Urinary infection through review date with interventions as follows: Check tubing for kinks each shift, Monitor and document intake and output as per facility policy, Monitor for s/sx (signs/symptoms) of discomfort on urination and frequency, Monitor/document for pain/discomfort due to catheter, Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns and Position catheter bag and tubing below the level of the bladder and away from entrance room door. The (MONTH) (YEAR) Treatment Administration Record (TAR) documents R4's catheter on [DATE]. A Concern/Compliment Form dated [DATE] documents R4 submitted concerns to the facility stating He has been telling the nurse for the last couple of days that his catheter has blood and nurse stated it is due to be changed on the 24th. On [DATE], A Concern/Compliment Form submitted by R4 documents He stated sometimes sat on toilet over weekend for an hour + (and) half s (without) anyone coming. Neither Form has any summary to pertinent findings on these voiced concerns and neither has any corrective actions documented as being taken. On [DATE] at 1:30pm, V4 Social Service Designee (SSD) stated she gave a copy of R4's concerns to nursing and didn't know how they resolved the blood in the catheter. V4 stated they did check on the sitting on the toilet for a long time complaint and couldn't tell by the video's if staff left him or not. On [DATE] at 1:40 PM, V2 Director of Nurses (DON) stated she was unaware of R4's complaints of blood in his catheter therefore has no documentation to show the facility followed up on this complaint. The Electronic Health Record (EHR) progress notes from R4's admission to his discharge to the hospital on [DATE] fail to document any concerns and/or information at all on R4's catheter and/or the status of his urine. Hospital Emergency Department notes documents R4 presented in full respiratory and [MEDICAL CONDITION] on arrival. History and Physical notes dated [DATE] at 11:16 documents under impression Acute hypoxic/hypercapneic [MEDICAL CONDITION] ,[DATE] (secondary) severe [DIAGNOSES REDACTED] requiring mechanical ventilation and Asystolic s/p (status [REDACTED]. R4 expired following family consent to remove ventilator. There is no evidence any nurses followed up to R4's complaints about blood in his catheter on [DATE] or the days prior. Facility Policy entitled Incontinence Care, dated [DATE] and revised on [DATE], documents in part, Guidelines: Incontinent resident will be checked periodically in accordance with the assessed incontinent episodes or every two hours. Facility Policy entitled [MEDICATION NAME] CARE, dated [DATE], documents in part, A. POLICY [MEDICATION NAME] care will be given by RN (Registered Nurse) or LPN (Licensed Practical Nurse), to prevent excoriation and infection. Facility Policy entitled Urinary Catheter Care, dated [DATE] and revised on [DATE], documents in part, Urinary Catheter Care. 12. Catheter drainage bags shall be emptied one time on each shift or as needed, using a separate collecting container for each resident's drainage bag. 2. On [DATE] at 9:52AM, R1 sat in her wheelchair in the library room on 2nd floor with her upper torso leaning forward onto her lap. A strong urine odor was noted. V11 and V14, Certified Nursing Assistants (C.N.A.), stated they were going to take R1 back to her room to perform hygiene. V14 removed R1's incontinent brief which was saturated with urine, and R1 having a large brown ring around the perimeter of her white pants beginning at the top of her bilateral hips, extending down to her bilateral mid thighs. R1's pants were urine soaked. Also present on R1was bilateral deep creases to R1 buttocks extending down to her bilateral thighs. Surveyor asked V11 if the incontinent brief was urine soaked. V11, CNA, replied: Yes, I would say! As V11, CNA, performed incontinence care on R1, but failed to perform incontinence care to R1's entire right side of her body. R1's Care Plan dated [DATE], document R1 requiring extensive assistance with toileting, and has impaired cognitive thought processes related to dementia. R1's Minimum Data Set ((MDS) dated [DATE] documents R1 being incontinent of bowel and bladder and having functional limitations to her lower bilateral extremities and requires extensive assistance for toileting and hygiene. R1's MDS further documents R1 having severely impaired cognition. Hospital Emergency Department (ED) progress notes dated [DATE], documents R1 being admitted for UTI (urinary tract infection), GI (Gastrointestinal) Bleed, and Pneumonitis. 3. R5's MDS dated [DATE], documents R5 had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. The MDS also documented R5's required total dependence on staff for personal hygiene and toileting. The MDs documents R5 was incontinent of bowel. R5's MDS further documents R5 having the following Diagnoses: [REDACTED]. R5's physician's orders [REDACTED]. R5's Medication Administration Record [REDACTED]. The MAR further documents R5 not having received ostomy care on the evening shift on [DATE]. R5's MAR indicated [REDACTED]. R5's Care Plan revised on [DATE] documents in part R5 having the [MEDICAL CONDITION] Susceptible Staphylococcus Aureus (MRSA) infection and having alteration in urinary elimination related to her [MEDICATION NAME]. The Care Plan also documents intervention to empty urine drainage bag every shift and to monitor for signs and symptoms of Urinary Tract Infection [MEDICAL CONDITION], changes in color or clarity of urine. The Care Plan further documents R5 having an Activities of Daily Living (ADL) self-care performance deficit. On [DATE] at 4:10PM, R5 stated in part, she cannot change her [MEDICATION NAME] independently. R5 further stated It ([MEDICATION NAME]) a lot of times it doesn't get changed. 4. R6's MDS dated [DATE] documented R6 had a BIMS score of 12, indicating moderately impaired cognition. The MDS also documented R6 required extensive assistance with personal hygiene and toileting, and being frequently incontinent of bowel. The MDS further documented R6 having a history of [MEDICAL CONDITION] (MDRO), Diabetes Mellitus (DM), Retention of Urine, and Portal Hypertension. R6's Care Plan initiated on [DATE] and revised on [DATE], with a resolved date of [DATE], documents in and requiring extensive assistance with toileting. R6's Care Plan also documents R6 having in part, the following Diagnoses: [REDACTED]. R6's Care Plan with initiation date of [DATE] documented he had an indwelling urinary catheter related to [MEDICAL CONDITION]. This care plan did not document when and how often R6 should be receiving catheter care. R6's Care Plan with initiation date of [DATE] stated that he had Urinary Tract infection with Vancomyacin Resistant [MEDICATION NAME] (VRE). The Interventions listed were Monitor use of catheter and not characteristics of urine. On [DATE] at 4:03 PM R6 was lying on his back with his left leg hanging off the side of his bed. As V26, Certified Nursing Assistant (CNA), removed R6's blanket, R6's leg collection urine bag appeared to be wet on the outside of the bag, which was full of dark amber urine. V26, CNA, noted 1000 milliliters (ml)/cubic centimeters (cc) of dark amber urine in the bag when she measured R6's urine output. V26 stated (R6) is supposed to have a catheter bag not a leg bag when in bed. On [DATE] at 4:12PM, R6 stated (Staff) don't do catheter care every day, let alone on multiple times a day. I'm lucky if they do it every 2 days. They never empty the bag (urine) like they should either. Progress Notes dated [DATE] through [DATE] 16 reflects the following [DIAGNOSES REDACTED]. R6's MAR, dated [DATE] through [DATE], documents in part, (Indwelling urinary) cath (catheter) care q (every) shift. The MAR further documents R6 not receiving (indwelling urinary) catheter care on the following dates and shifts: [DATE] (days), [DATE] (evenings), [DATE] (evenings), [DATE] (nights), [DATE] (days), [DATE] (days), [DATE] (days), [DATE] (days), and [DATE] (nights). R6's MAR indicated [REDACTED]. Nurse's Notes dated [DATE] at 1:00AM, documents in part, POA (Power of Attorney) Update on residents (R6) condition given. POA requesting UA (urinalysis) C&S (culture and sensitivity). Also stated she did not want resident sent to hospital at this time. Nurse's Notes dated [DATE] at 4:00AM, documents in part, Resident (R6) being sent to (hospital) d/t (due to) critical potassium of 6.1 and critical platelet of 12. Hospital Report dated [DATE] documents in part, R6 being sent to the Emergency Department (ED) for an evaluation. The Emergency Medical Services (EMS) brought R6 to the ED from the facility for evaluation [MEDICAL CONDITION] criteria. The Report also documents in part, Septic Shock present: YES - Lactic Acid >=(greater than/equal to)4.[MEDICAL CONDITION] Diagnosis: [REDACTED]. The Hospital Report further documents (R6) has a history of UTI with an indwelling (indwelling urinary) catheter, and a history of [MEDICATION NAME]-Resistant [MEDICATION NAME] (VRE) organism in his urine. On [DATE] at 1:55PM, V3, Assistant Director of Nursing (ADON), stated There should not have been a leg bag on him when he (R6) was put to bed. Also, there should never be 1000 cc of urine in any bag when it is emptied. It should have been emptied long before that. 5. R7's MDS dated [DATE], documents R7 is cognitively intact with a BIMS score of 15. The MDS documented R7 required extensive assistance for personal hygiene and toileting. R7's MDS further documents R7 having in part the following Diagnoses: [REDACTED]. physician's orders [REDACTED]. R7's MAR indicated [REDACTED]. R7's Care Plan initiated on [DATE] documents R7 having a catheter. The Care Plan does not list any interventions for R7 to receive catheter care. On [DATE] at 4:20PM, R7 stated in part when asked about catheter care, No, no, not do the cleaning for me, the staff just get me the supplies; I don't get catheter care at all. R7 further stated he empties his own urine out of his catheter bag. On [DATE] at 1:20PM V2, Director of Nursing (DON) stated she would expect staff to perform complete incontinent care, (indwelling urinary) catheter care, and [MEDICATION NAME] care as ordered as well as on an as needed basis.

Based on interviews and record reviews that facility failed to accurately identify, assess, evaluate, provide timely care and monitor for signs and symptoms of infection for 1 out of 3 residents (R2) resulting in R2 calling 911(ambulance) for himself and being transferred to hospital where R2 succumb to illness. Findings include: 1. R2's Electronic Medical Record (EMR) documents in part, R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2's Minimum Data Set (MDS), dated [DATE], documents Brief interview for Mental Status (BIMS) score of 15, cognitively intact. On 10/11/2018 at 11:50 AM, V7, Licensed Practical Nurse (LPN), stated that R2 had right leg surgery and he wore a leg brace and when she removed leg brace R2 had a scarred heeled incision, [MEDICAL CONDITION] in both legs. V7 also stated that R2 would complain of pain in his legs and back and had scheduled pain medication. On 10/11/2018 at 12:10 pm, V6, LPN, stated that R2 didn't have any open wounds and R2 would complain of pain and had swelling in both legs. V6 stated that at one time R2's knee had been a holy terror and was getting bandage changes. V6 stated that she heard that R2 was running a fever and was concerned about it and he had called 911. V6 stated that on 9/30/2018, V25, LPN, called her and she (V6) stated if he (R2) is his own POA (Power of Attorney) then he can go out to the hospital. On 10/12/2018 at 09:00 AM, V28, Lifestar (EMT), stated that on 9/30/2018 was dispatched to facility on a 911 call. V28 stated that R2 was in bed with a gown on. V28 stated that V25 (LPN) stated to him, You can't take (R2) without a doctor's order. V28 (EMT) stated he told her, Yes we are. V28 (EMT) stated that (R2) in the hospital ER (emergency room ) stated that he had been trying to go to hospital for a week. The EMT patient care report, dated 09/30/2018, documents in part; Skin Temp=Hot, Respiratory 32, Pulse 120 and temp [MEDICAL CONDITION] is considered. V29's ED (Emergency Department) Physician Notes, dated 9/30/2018 at 11:30, documents in part R2's O2 (oxygen) Saturation resting is 56% (Normal range 95 to 100). Per ED nurse, (R2) called 911 himself because his nurse at NH (nursing home) would not call for him after asking for 1 week. When EMS arrived, the nurse told them they were not allowed to take him. EMS stated patient was A&Ox 3 (alert and oriented) and they would bring him to the ED. R2's History & Physical from hospital, dated 9/30/2018, documents in part, (R2) stated his shortness of breath and fever started 3-4 days ago. On admission, (R2) has elevated WBC count 12.3 and is requiring 10 L of oxygen. (R2) stated that his right knee is larger in size than his left knee and has been hurting since the past month. (R2) stated he had a fever of around 103 degree at home. Chest x-ray shows bilateral interstitial and airspace opacities likely representing infiltrate. admitted for [MEDICAL CONDITION] due to infection, possible PNA vs. acute or chronic R knee infection, worsening respiratory status in IMC. R2's facility 9/2018 Treatment Administration Record documents in part; Cleanse right knee and lower leg incisions with wound cleanser, cover knee with xeroform and wrap in kerlix and secure ace wrap applied loosely from the base of toes to thigh, knee immobilizer to be worn at all times, every night shift. The following dates 9/3-9/13 resident refused treatment, 9/16-9/20 resident refused or was not at facility, 9/22/18 is blank, 9/23/-9/25 resident refused, 9/27-9/28 resident refused and 9/29/18 is blank. R2's care plan dated 9/26/2018 documents in part; Focus (R2) has surgical incision to right knee. Interventions monitor site for s/s of infection. On 10/25/2018 at 12:20 PM, V26, Certified Nurses Aide (CNA), stated that R2 was alert and oriented and made his needs known. V26 stated that R2 was well liked and spent a lot of time in his room. On 10/25/2018 at 12:25 PM, V7, LPN, stated,Temperature, redness, warmth are all signs of infection. On 10/25/2018 at 1:38 PM, V25, LPN, stated that R2 was laying in bed and stated to her on 9/30/2018 that he was really really cold with chills. V25 stated that she would turn up the heat for R2 if he wanted. V25 stated she took (R2's) vitals and temp and assessed R2 then charted a change of condition. V25 also stated the only thing stated to EMT's was that to let her get paperwork ready before they left. V25 also stated, elevated temperture, warmth, not feeling well and chills are signs and symptoms of infection. R2's assessment documented on interact transfer form V4.1 Discharge to hospital V25's vitals for R2 are the following; Blood pressure 130/78, pulse 82, respirations 18, temperature 97.6 axillary, 02 Saturation 97% on room air and Blood glucose 243. On 10/25/2018 at 2:15 PM, V2, Director of Nursing (DON), stated you can't go by the assessment charted in transfer form V4.1 because it's not accurate, due to if the nurse doesn't clear the last vital the system will pull the latest vital and that's what will be displayed. Health Status Note dated 9/30/2018 at 10:18 AM Note Text: Resident c/o not feeling well this am and having cold chills. Aide took temperature and it read at 101.3. Writer administered 500 mg [MEDICATION NAME] and contacted NP (Nurse Practitioner) for further orders regarding this concern. Resident is currently on [MEDICATION NAME] 100 mg BID [MEDICATION NAME] for infection prevention. R2's Orders - Administration Note dated 9/30/2018 Note Text: [MEDICATION NAME] Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for Elevated Temperature;Pain - Mild elevated temp of 101.3 and mild pain R2's Medication Administration Record, [REDACTED]. On 10/25/2018, V2 stated, I will find the [MEDICATION NAME] order. V2 returned with Facility's Medication Review report that documents [MEDICATION NAME] 325mg give 2 tablets q 6 hour prn (as needed) start date 7/20/2018. V2 unable to provide a MAR indicated [REDACTED] Nurses Note 9/30/2018 at 10:58 AM Narrative: Writer called out to Dr. Resident is adamant about getting sent out to the ER. Awaiting a return call from Dr. Nurses Note 9/30/2018 at 11:03 AM Narrative: Resident has called paramedics himself from his personal cell phone. Paramedics arrived at 11:03. Writer advised paramedics that currently no orders are in place for resident to be sent out. Writer spoke with house supervisor. Resident is his own POA and can be sent out to ER per his own wishes. On 10/25/2018 at 3:00 PM, V10, LPN, stated, It would have to be serious for (R2) to want to go to hospital. V10 stated that R2 was alert and oriented, he worked with insurance claims. On 10/16/2018 at 3:19 pm, V31, County Coroner, stated, What's going on with this facility? Have you read the medical records? I called and spoke to the hospital doctor and he stated that if (R2) had come into the hospital a week earlier he may have not perished. Facility's Change in Condition policy and procedure dated 11-17-17 documents in part; The facility will inform the resident; consult with the resident's physician; and if known notify resident's legal representatve or an interested family member when there is: B. A significant change in the resident's physical, mental, or psychosocial status. Facilty's Abuse Prevention and Reporting policy and procedure dated 11-28-16 documents in part; The resident has the right to be free from abuse, neglect, misappropriatiion of resident property Supervisors will monitor the ability of the staff to meet the needs of residents, including that assigned staff have knowledge of individual resident care needs.

Based on interview, observation and record review, the facility failed to provide timely incontinent care, assess/monitor for a urinary tract infection (UTIs), and failed to follow physician orders [REDACTED]. This failure resulted in discomfort from the catheter voiced by R7 and repeated UTI's. Findings include: 1. The Admission Record documents R7 to be a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE] and 9/14/18, identify R7 to require extensive assist of one staff for hygiene and total assist of two staff for bathing. The MDS documents R7 to have moderate cogntivie impairment with a Brief Interview of Mental Status score of 12. Progress Notes reviewed from 8/5/18 to 8/10/18 document no significant changes for R7. There are no entries between 8/5/18 - 8/8/18 and between 8/8/18 - 8/11/18. Progress notes dated 8/11/18 at 6:54am entered by V22, Licensed Practical Nurse (LPN), documents only that R7 was showered off schedule. At 9:44am, V22 documented in the progress notes weekly skin observations. The next entry into the progress notes was on 8/13/18 at 11:22am when V22 documented in the progress notes that unable to assess bm (bowel movement) res (resident) in hosp (hospital) since 8/11 (8/11/18.) There is no indication as to why or what occurred that sent R7 to the hospital recorded in the progress notes. An eInteract Transfer Form, dated 7/8/18 entered by V21, LPN, documents SBAR (Situation, Background, Assessment, Recommendations) Acute Change in Condition Note Included with vitals recorded as blood pressure 215/120, Pulse 75, Respirations 20, Temperature 97.5, O2 Sat (oxygen saturation) 97 room air. The form does not include an assessment of R7's status or current condition prior to his discharge via ambulance to the hospital. The form documents V24, Nurse Practitioner, was notified along with R7's POA (Power of Attorney), but not the attending physician. A Nursing Home to Hospital Transfer Form dated 8/11/18 documents the same vitals as the eInteract Transfer Form, but documents the reason for Transfer as Altered Mental Status. On 10/26/18 at 3pm, V21, LPN stated she probably should have done a progress note on 8/11/18, but did complete an eInteract form which is a standard form. V21 stated she knew R7 was making inappropriate sexual advances while he said he was allowed to so she knew something was up with him. V21 stated she mentioned his behavior to the daughter who said that was out of character for him, he probably has a UTI (urinary tract infection). V21 stated the daughter insisted he may be having focal [MEDICAL CONDITION] and sent him due to her request. V21 stated she did not do an assessment of him at the time, but just sent him out. Emergency Department (ED) notes, dated 8/11/18 under Physical Exam, documents He is well-developed, well-nourished, and in no distress. Staring into space, but eventually does respond to you. Did not look at me when I asked him questions. Just stared ahead and his lower lip and tongue was twitching. Then all of a sudden he would say soemthing that was related to the topic. Under History of present illness, it documents (R7) is a [AGE] year old male with past medical history significant for [MEDICAL CONDITION], hx (history) [MEDICAL CONDITION], DM,[MEDICAL CONDITION](Hypertension,) [DIAGNOSES REDACTED], and [MEDICAL CONDITION] disorder who since yesterday was not himself, more disoriented than usual and unable to speak. He was at his baseline early in the week which includes holding a full conversation, playing chess and eating well. However, he then started to act inappropriately by groping staff members and NH (nursing home) residents. Today they noticed he was starring into space and had strange tongue movements that they had never noticed before. He has hx of UTI's (last CX had ESBL (Extended spectrum beta-lactamases) proteus) which have made him confused in the past. Additionally, he has also had subclinical that would improve his mental status by receiving [MEDICATION NAME]. The ED (Emergency Department) note documents UTI in past had ESBL proteus, again now, had hematuria. The note documents under clinical Impression: urinary tract infection (primary), Altered mental status, [DIAGNOSES REDACTED], and [MEDICAL CONDITION] disorder. The note document Pt (patient) with confusion and significant UTI. Due to [MEDICAL CONDITION] pt admitted to hospital for IV (intraveneous) antibiotics and continued monitoring. No signs of [MEDICAL CONDITION]/shock. Discharge Instructions, dated 8/17/18, include remove (catheter) and voiding trials, periodic checks PVRs (Post Void Residual Urine tests.) Re-Admission Observations, dated 8/23/18 (6 days after readmission), entered by V6, LPN, documents R7 as always continent, with a indwelling urianry catheter. V6 documents [MEDICAL CONDITION] that causes persistent overflow as the reason for the catheter. R7's care plan, dated 7/9/18 with a target dated of 12/13/18, failed to include any focused areas for urinary incontinence prior to R7's hospitalization and/or R7's repeated history of urinary tract infections including his most recent hospitalization . Nor does it reflect the discharge orders to do voiding trials and/or post void residual urine tests. Progress Notes, dated 8/17/18 19:36 (7:36pm), documents incontinent of bladder. Resident has a catheter. Indwelling/catheter in place. Catheter patent/draining. Catheter care provided. Urine characteristics: amber. Resident uses bedpan. Resident uses toilet/commode. Resident uses pads/briefs, check and change. Progress Notes documented following R7's readmission from the hospital fail to include any assessment toward removing the catheter as ordered on the discharge record dated 8/17/18. A 8/28/2018 15:40 (3:40pm) physician progress notes [REDACTED]. Progress Notes dated 8/27/2018 at 7:00Pm entered by V23, LPN, documents Nurses Note Narrative: Writer spoke with eldest daughter regarding catheter. Family is concerned that catheter is not getting emptied out. Writer assured the daughter that catheter will be emptied out by writer and that she should call back if any further concerns come up. Also she expressed that she wonders if he even needs the catheter since it was put in while he was hospitalized . Writer contacted V24, (Nurse Practitioner) regarding this matter. A Progress Note entered on 8/29/2018 at 6:00am, documents a Neurologist Note: UA (urinalysis) C&S (culture and sensitivity) obtained at 0600 am and sent to the lab. Light yellow urine with sediment noted. Fluids encouraged. V15 (R7's Power of Attorney) aware. The (MONTH) (YEAR) Physician order [REDACTED]. Other Active on 9/2/2018. Lab results of a UA collected 8/29/18 with resultes reported 8/31/18 document a UTI of >100,000CFU/ML (colony forming units/milliliter) Proteus Mirabilis. The results document V24, Nurse Practitioner (NP) for V23 was notified on 9/3/18, 3 days later of R7's UTI and lab results. V24 ordered [MEDICATION NAME] 875mg by mouth twice daily (BID.) The (MONTH) (YEAR) POS documents an order to dc foley cath No directions specified for order dated 9/5/2018. The Progress Notes dated 9/5/18 at 1:29pm, documents R7 to be incontinent of bladder. has catheter. There is no progress note that documents when R7's was actually discontinued. Treatment Administration Records (TAR) and Medication Administration Records (MAR) for (MONTH) and (MONTH) (YEAR) fail to reflect any care provided to R7's catheter ie catheter care, recorded output and changes. The facility's policy/procedure entitiled Urinary Catheter Care dated 1/17/17 documents the purpose of the policy is to establish guidelines to reduce the risk of, or prevent infections in resident with an indwelling catheter. The Guidelines document Routine Hygiene (e.g. cleansing of the meatal surface during daily bathing or showering in appropriate. and The date of the catheter insertion shall be documented in the nurses notes and treatment record. Progress notes dated 10/18/2018 at 14:20 (2:20pm) documents Note Narrative: Resident refused multiple times to staff that he would not get up and take a shower. Resident did give into taking a bed bath. Resident was up for about 30 minutes before he starting yelling about getting into bed. Family requested for UA & CS to be done and to straight cath if needed. Labs results document the urine specimen was collected 10/22/18, 4 days after V15 requested it, with results given on 10/25/18. The note documents R7 was started [MEDICATION NAME] daily for a UTI on 10/24/18. The C&S results identify the source as 10,000-50,000CFU/ML of Proteus Mirabilis which is resistent to Cipro. On 10/25/18 at 4:48pm, V2 DON stated the nurses already identified the resistence and contacted the nurse practitioner who changed the order to Bactrim. On 10/23/18 at 10:10am, R7 was his wheeldchair fully dressed at bedside. R7 was asleep, leaning to the left. R7 remained asleep at bedside and was observed to eat lunch while in his wheelchair at bedside. At 1:45pm, R7 was still in his wheelchair at bedside. At 2:30pm, R7 remained asleep in his wheelchair. At 2:45pm, he was in his wheelchair when V18 and V20 Certified Nurse Aides (CNAs) entered the room to transfer him. V20 had to go to another floor to get a partial mechanical lift (Sit to stand.) R7 was transferred to bed. and his pants removed. R7 had deep red/white creases throughout his abdomen, hips, buttocks, upper posterior thighs and buttocks. R7 had been incontinent of bowel and blader. Incontinent care was provided but no barrier cream was applied. R7's deep creases remained throughout the care which ended 3:15pm. R7's left elbow, which he had been leaning on his wheelchair armrest with, had an oval deep red area that did not seem to blanch. R7 was left on his back in bed, no preventitive measures taken with his heels which rested on the matress. On 10/23/18 at 3:29pm, V15, R7's Power of Attorney (POA) stated R7 was transfered to this facilty from another long term care facility when it closed. V15 stated R7 had a history of [REDACTED]. V15 stated each time he's had a UTI, including the time he went to the hospital, she's had to tell them. V15 stated she visits in the evening in August, she had asked for a UA C&S which took days to get. The day he went into the hospital 8/11/18, she told the nurses he was not right around 10am and he declined until she finally convinced them to send him into the hospital. V15 stated R7 ended up staying in the hospital for a week. V15 stated when he returned, he had a catheter which she kept asking about removing. V15 stated he developed another UTI before they got it out. V15 stated she was just called last night and told he had another UTI. V15 stated she had requested days before for them to get another UA because he was not acting himself. V15 described his UTI symptoms as lethargic, touching staff inappropriately, refusing to get out of bed, not talking, etc and that they just don't pay attention. The facility's policy entitled Incontinence Care dated 1/16/18 documents the purpose as: to prevent excoriation and skin breakdown, discomfort and maintain dignity. Under Guidelines, the policy documents Incontinent residents will be checked periodically in accordance withthe assessed incontinent every two hours and provided perneal and genital care after each episode.

Based on observation, interview and record review the facility failed to implement effective interventions and provide supervision to prevent falls for 2 of 3 residents (R1, R2) reviewed for falls in the sample of 8. This failure resulted in R2 having 4 falls with injuries requiring her to be sent to emergency room (ER) for treatment. Findings include: 1. On 9/20/18 at 9:35 AM, R2 was sitting in her wheelchair in the hallway outside of her room. R2's foot pedals were on her wheelchair while R2's feet were on the ground. R2 was moving her bottom forward in the seat, trying to stand up while the foot pedals were down. No staff were in the area to supervise her. On 9/20/18 at 10:10 AM, R2 was sitting in her wheelchair. R2 was propelling the wheelchair with her arms. R2 left the activity room and went as far as she could go on the carpet until she came to the strip on the carpet leading to the wood floor. R2 was unable to get the wheelchair across the strip on the floor. R2 put her feet on the floor and the foot pedals were down, trying to push her over the strip while she is leaning forward. V2 Director of Nurses (DON) walked past R2 and didn't see her struggling to move the wheelchair or that the foot pedals were down with her feet on the floor. R2's Electronic Medical Record documents in part, R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2's Minimum Data Set ((MDS) dated [DATE] documents, R2's Brief Interview of Mental Status (BIMS) score was10, indicating moderately impaired cognition. R2's MDS documented she required extensive assistance from two staff persons for transfers. The MDS documented she required extensive assistance from one staff person with locomotion on and off unit and walking. The facility's fall log from (MONTH) (YEAR) through (MONTH) (YEAR) documented R2 had fallen eleven times in the past six months. R2 has had 4 falls with injuries. The Log documented on 9/14/18 she sustained a laceration to her forehead. The Log documented on 8/25/18 she sustained a laceration to her forehead. The Log documented on 4/23/18 she sustained a laceration to her face and on 4/20/18 a laceration to her head. R2's Fall Occurrence note dated 4/20/18 documents in part, Resident was found by maintenance director on floor, resident was laying on right side with approximate 15-30 cc (cubic centimeters) of frank red blood around head. Resident was assessed for injury to lower and upper extremity. No injury noted. No complaints of neck pain, only head pain. Resident is very uncooperative with assessment and neuro checks. Injuries observed, Laceration to right forehead approximate 2 cm (centimeters). Approximate 15-20 cc blood loss, pressure was applied. Bleeding was stopped easily. Actions taken Sent to local ER (emergency room ) for evaluation of head trauma from fall. Intervention: resident is uncooperative and will not usually redirect. R2's Progress notes dated 4/23/18 at 7:00 AM, documents, Narrative: lab tech informed writer that res had dried blood all over floor and on hosp (hospital) gown writer went in room at 0609 res (resident) sitting in w/c (wheelchair) by bathroom in clean clothes no blood on hands dried blood noted on lips small amt (amount) active bleeding to laceration under lower lip and deep laceration under chin oral cavity with dried blood and dk (dark) areas posterior teeth and roof of mouth Hosp gown on bathroom floor with mod (moderate) amt (amount) dried blood and areas of dried blood on bedroom floor. Immediate Action Taken, Description: All areas assessed, noted need for sutures to laceration on chin, to ER for evaluation. The facilities Root Cause Analysis of R2's fall on 4/23/18, Standing up in room. Intervention and care plan updated, Environmental check of the room around closet. R2's Progress notes dated 8/25/18 documents in part, Resident observed to be on the floor. Resident mildly responsive to tactile stimulus. Resident states 'I was in my wheelchair when I fell to floor. States 'I am not hurt'. Resident has small laceration to lateral lobe of head. Laceration treated via paramedics, called post fall. Unable to complete vital sign capacity due to resident physical composition at this time. Resident is side lying with limp stance and mildly responsive. Resident responsible party notified. Resident transported via EMS to local emergency room for evaluation. The facilities Root Cause Analysis of R2's fall on 8/25/18 which was dated 8/27/18 documents, Root cause of the fall fell out of wheel chair onto the floor. Interventions and care plan updated: Monitor laceration till healed, offer to lay down after every meal. R2's Progress Note dated 9/14/18 at 12:07 PM, documented, Resident lying in the hallway at 11:20 AM. Legs were stuck under the wheelchair with the wheels up in the air. Resident has a large laceration to her forehead/scalp on the left side. Resident was helped out of the wheelchair and pressure was put to her forehead. Resident had complained of pain to both knees and lots of pain to her right hip area. Ambulance service was called right away. They arrived at 11:30. resident left the facility with them at 11:55 AM. Power of Attorney (POA) was notified. R2's emergency room Final Report, dated 9/14/18, documented Physical Exam includes Head: 3 cm jagged laceration to left forehead repaired with sutures. Plan: Hospitalist admitted resident due to altered mental status, confusion, (she thinks its 1978). Resident discharged back to facility on 9/17/18. The facilities Root Cause Analysis of R2's fall on 9/14 18, which was dated 9/17/18 documents. Leaning forward, fell out of wheel chair. Interventions and care plan updated with, Med review, lay her down when she is leaning forward, have her evaluated for psych facility upon return. R2's Care Plan dated 7/2/18 documents in part. Focus: I am at risk for fall/injury related to wandering/poor safety awareness, [MEDICAL CONDITION], anxiety disorder, [MEDICAL CONDITION], Bi-Polar, History of falls and hypertension. I will put myself on the floor at times. Interventions: 12/26/17 Call light within reach and area free from clutter. Draw labs as per MD orders. Keep personal items within reach. Observe for any signs and symptoms of any drugs that can cause gait disturbance, orthostatic [MEDICAL CONDITION], weakness, sedation, lightheadedness, dizziness, change in mental status. 1/15/18 Offer me painting, I like to paint. Lowered rod in closet and removed my summer clothing. 2/12/18 Dycem replaced in wheel chair. 2/7/18 Report all behaviors to behavioral care and for them to evaluate. 2/22/18 Increased staff supervision and refer for psych eval (evaluation) and possible inpatient stay. 3/16/18 Environmental check and behaviors evaluated. 3/27/18 Encourage me to wear shoes, I do not care for the grippy socks due to the feel of them. 4/9/18 Low bed put into place. 4/20/18 Environmental check of the room and around the closet. 5/23/18 Staff to increase offering me to toilet more frequently. 6/15/18 Offer to lay me down after lunch. 6/25/18 Dycem in wheelchair. 8/20/18 Behavioral Care to see at next visit. 8/21/18 Speech Therapy to evaluate. 8/27/18 Offer to lay me down after breakfast and supper. 9/10/18 Therapy to screen. 9/27/18 Medication review, offer to lie me down when I am leaning forward in the wheelchair and evaluation for placement in psych facility upon my return. R2's Care plan does not document anything about removing foot pedals to R2's wheelchair when she propels herself. On 9/20/18 at 12:35 PM, V5 Licensed Practical Nurse (LPN) stated, R2's fall was not witnessed by staff, R2's foot pedals were on the wheelchair when she fell on [DATE], she was on the floor in the hallway, her knees were on each foot pedal, her feet were under the wheelchair, she had a laceration to her forehead and was bleeding. V5 stated, I wondered why (R2) had foot pedals on her wheelchair when she was propelling herself. On 9/20/18 at 2:40 PM, V13 Occupational Therapist stated, Foot pedals should not be on the wheelchair if the resident propels herself. (R2) is a special case, some days she propels herself all around, other days she doesn't propel herself at all. The staff should take the foot pedals off when she is alert and propelling herself. On 9/20/18 at 3:05 PM, V14 Certified Nurse Aide (CNA) stated, No one has trained me about when to use the foot pedals with (R2). The facility Policy and Procedure for Fall Prevention Program dated 11/28/12, revised 11/21/17, documents in part, Purpose: To assure the safety of all residents in the facility, when possible. The program will include me which determine the individual needs of each resident by assessing the risk of falls and implement appropriate interventions to provide necessary supervision and assistive devices are utilized as Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Guidelines: The Fall Prevention Program includes the following components: *Methods to identify risk factors *Use and Implementation of Professional Standards of Practice *Communication with direct staff members *Adherence to manufacturer's recommendation in use of alarm and medical devices and equipment *Care Plan incorporates: *Identification of all risk/issue *Interventions are changed with each fall, as appropriate and Preventative measures. 2. The MDS dated [DATE] documents R1 to be cognitively intact with a BIMS score of 15. The MDS documents R1 to require extensive assist of two staff for transfers and extensive assist of one staff for locomotion on and off unit. The MDS identifies R1's balance as not steady, only able to stabilize with staff assistance for seated to standing, turning around, on/off toilet and surface to surface transfers. The Care Plan dated 8/16/18 documents R1 to be at risk for falls due to hypertension, [MEDICAL CONDITIONS], obesity and left knee pain in part. The goal documents R1 will sustain no serious injury from falls until next review with interventions for staff to remind her to lock her wheeled walker prior to sitting down (4/18/18), anticipate and meet needs, be sure call light is in reach and encourage to use it for assistance, and ensure appropriate foot wear On 9/20/18, the Incident/Accident log has documented 6 falls for R1 since 7/13/18. R1's Progress Note dated 7/13/18 document R1 slid out of her recliner as she was reaching for something and had a pillow behind her that cut down on sitting space in the chair. There was no revision made to the care plan as a result of this fall. On 7/16/18 at 4:17 AM, R1 Progress Note documented R1 slid out of bed trying to get up to go to the bathroom. The root cause was identified and an intervention dated 7/17/18 was added to the care plan for staff to encourage not placing pillow in recliner and offering non-skid socks. An Occupational evaluation was also recommended. This fall occurred from the bed not the recliner chair as the intervention suggests and there is no information as to whether or not she had appropriate foot wear on as is included in her care plan. On 7/18/18 at 12:10, R1's Progress Note documented again sliding from her easy chair onto the floor. There was a note that R1 had grippy socks on. There was no new revisions and/or interventions added into the falls prevention plan following this fall and no information as to whether R1 had the pillow to her back at the time or not. On 7/25/18 at 11:00 AM, R1's Progress Note documented R1 to be on the floor in front of her chair with the wheeled walker next to her in an unwitnessed fall. The note documents R1 was trying to get something out of the refrigerator. The note documents staff applied shoes. The root cause was identified as attempted self transfer but fails to address whether she had on shoes or not at the time of the fall. A Fall Interdisciplinary note dated 7/26/18 documents the cause of the fall to be attempted self transfer with the intervention being to put up reminder signs in the room to call, don't fall. However, it doesn't address the fact that she again had no shoes on and doesn't indicate whether or not she had grippy socks on at the time of the fall as is listed as an intervention in her care plan. On 9/4/18 at 1:00 PM, R1 was documented in the progress notes as being up and ambulating without staff assistance when she fell and slid to the floor. The intervention is to make sure she has staff with her when ambulation. The root cause was identified as an attempted self transfer. The care plan documents an intervention to do Orthostatic blood pressure times 3 days 9/4/18 since the Falls - Initial Occurrence Note dated 9/4/18 documents R1 stated when she stood up she got light headed and dizzy and slid down to the floor. On 9/10/18 at 9:15 AM, the progress notes document R1 attempted to go to the bathroom and fell . The care plan reflects a new intervention dated 9/11/18 that reads remind her of signs in room to call, don't fall, medication review and encourage to ask for assistance. No new interventions were implemented as a result of this fall. On 9/25/18 at 8:45am, R1 was sitting on the edge of her recliner which was positioned against the wall in her room. She had a pillow to her back and had worn grippy socks on. There was a cloth incontinent pad under her covering the cloth recliner seat. R1's wheeled walker was in front of her. The television was adjacent to her, right against the wall in the corner causing her to sit crooked in the recliner in order to see the television. R1 did not have a call light within reach as it was on the bed across the room. R1 stated she is able to ambulate about her room by herself without assistance of staff and acknowledged that her television was a little difficult to see from where her chair is located. R1 stated she does get into her refrigerator for sodas which are located under her television.

Based on observation, record review and interview, the facility failed to provide the physician ordered treatment for [REDACTED]. This failure resulted in R2's coccyx pressure ulcer deteriorating. Findings include: The Facility's Pressure Ulcer Recommended Treatment Protocols undated states All residents with pressure ulcers will be treated with consistent treatment protocols to aid in the healing process. Stage IV: Treatment 2. Obtain MD order for proper treatment option. The Facility's Physician Orders-Entering and Processing policy dated 8/22/17, states To provide general guidelines when receiving, entering, and confirming physician or prescriber's orders. Verbal and telephone order will be documented as such in the Electronic Medical Records. A MDS (Minimum Data Set) assessment dated [DATE], documents in Section C (Cognitive Patterns), R2 scored a 15 out of 15 on the Brief Interview for Mental Status, indicating R2 is cognitively intact. According to the admission records, R2 was re-admitted to the facility on [DATE] with a Stage IV pressure ulcer to her coccyx. R2's current care plan documents R2 has a Stage IV pressure ulcer to coccyx and to administer treatments as ordered and monitor for effectiveness. A wound evaluation and management summary dated 7/24/18 by V6 Physician, documents that R2 has a Stage IV pressure ulcer on their coccyx, measuring 4 centimeters (cm) in length x 4 cm in width x 2.5 cm in depth with undermining and deteriorating with the ordered individualized treatment plan and dressing is to add negative pressure (wound vac) for three times a week for 30 days and discontinue the current treatment alginate silver foam. A wound evaluation and management summary dated 7/31/18 by V6 Physician, documents that R2's Stage IV pressure ulcer on R2's coccyx has deteriorated measuring 4.5 cm in length x 3.7 cm in width x 2.5 cm in depth with the ordered individualized treatment plan is a negative pressure wound vac three times a week for 23 days. On 8/7/18 at 9:40 a.m., R2 was resting in bed on right side. R2 did not have a wound vac in use. R2 stated: I am supposed to have a wound vac and no one seems to be in a hurry to get it. On 8/7/18 at 11:40 a.m., V4 Wound Nurse stated that on 7/24/18, V6 Physician ordered a wound vac for R2's Stage IV pressure ulcer to her coccyx. V4 stated This was ordered by (V6 Physician) and until the wound vac arrives, to continue the current dressing. V4 also stated that the the wound vac is ordered through central supply and that V6 or V4 was never made aware that the wound vac had not been ordered and that V6 was wanting the wound vac to prevent the wound from deteriorating. On 8/7/18 at 2:10 p.m., V3 Licensed Practical Nurse stated she remembers being in the room with (V6 Physician) and (V4 Wound Nurse) but that she was never given an actual order, only told verbally by (V6 Physician) to place a wound vac order and V3 further stated that she did go to central supply and told V7 (Central Supply) to let V5 (CNA) know that they were probably going to need a wound vac for R2 and that she never followed up on this request. V3 also stated that she did not chart or document the wound vac order in the electronic medical records. On 8/7/18 at 2:00 p.m., V5 CNA/Central Supply stated that on 7/24/18 she was told by (V3 LPN) to order a wound vac for R2. V5(CNA) stated that she informed (V3) she needed a face sheet and measurements but never received the information from (V3). V5 stated that she did not follow up on the wound vac order and somewhere the communication was lost and R2 has not had a wound vac as ordered by the physician for approximately 13 days. V5 stated that the wound vac can usually be obtained in one day. V5 also stated that the wound vac was ordered as a Stat order today (8/7/18). A facility document dated 8/7/18 at 10:09 a.m., from V5 CNA/Central Supply to a local supplier company documents a Stat order for vac (wound vac) and supplies for R2 along with a facility order form signed by V5 on 8/7/18 documenting a negative pressure wound therapy is needed ASAP. A delivery receipt dated 8/7/18 from a local supplier documents a wound vac pump with supplies was received by the facility on 8/7/18. On 8/8/18 at 11:10 a.m., V2 Director of Nursing stated: There was obviously a lack of communication and no one followed through to order R2's wound vac as ordered by (V6) the physician on 7/24/18.

Based on observation, interview and record review the facility failed to prevent a resident from developing a stage 4 pressure ulcer, failed to follow physician orders [REDACTED]. Findings include: 1. R81 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility wound report dated 5/8/18 documents R81 developed a facility acquired pressure ulcer on 4/24/18 to her right heel, Stage 4 with measurements of 1.3 X 0.7 X unable to determine (UTD). 50% necrotic, 50% granulation. V23's Wound Doctor, wound care specialist evaluation record dated, 4/24/18 documents in part, Stage 4 pressure wound of the right heel-Initial evaluation, Recommendations: Off load wound, float heels in bed. R81's Physician order [REDACTED]. R81's care plan dated 6/26/18 does not document off loading wound and float heels in bed or heel boots to bilateral lower extremities at all times. On 7/9/18 2:59 PM, V22 Licensed Practical Nurse (LPN), removed the blankets on R81's legs, the right heel is on the bed, the foam floater is on the top of her leg, V22 stated, Yes, her heel should be floating, her left leg has the heel boot and that should be on the right leg as well. The floater should have been under her leg to float her heel. I don't know why she does not have the heel boot on her right heel, it should be on all the time. On 7/10/18 at 10:00 AM, R81 is resting in bed, both right and left heel boots are on the roommates dresser, not on R81's heels. On 7/10/18 at 2:40 PM, V23 Wound Doctor, stated R81 Should have the heel boots on all the time to off load the heels. The facility Policy and Procedure for Pressure Injury and Skin Condition assessment dated , 11/28/12, revised 1/17/18 documents in part, Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented. #17. The resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches and goals for care. 2. R90's Minimum Data Set (MDS), dated [DATE] documented R90 with two unstageable deep tissue injury's. The MDS further documents in part, R90 at risk for pressure ulcers. R90's Wound care special evaluation dated 5/15/18 documented a wound to right posterior thigh resolved. R90's Care Plan last review dated 6/27/18, documented in part, Potential for impairment to skin integrity related to decreased mobility, fragile skin, incontinence, Spinal Stenosis and [MEDICAL CONDITION], the same care plan interventions documented in part, Turn and Reposition with care: Every two hours and PRN (as needed). On 7/10/18 at 9:05 AM, R90 was transferred to a wheeled high back chair. R90 was observed from 9:05 AM through 11:46 AM, with 15 minute intervals, R90 remained in the room and in his chair. 3. R79's MDS, dated [DATE], documented in part, always incontinent of bowel, at risk for pressure ulcers. R79's Braden Assessment, dated 4/26/18, documented in part, R79 is occassonial moist and chairfast reflected in a score of 15, indicating At Risk. On 7/10/18 at 8:55 AM, R79 was transferred to wheeled high back chair by a full mechanical lift. R79 was observed from 8:55 AM through 11:45 AM, with 15 minute intervals, R79 remained in the room in chair. On 7/11/18 at 2:25 PM, V2 stated she had asked staff to assure residents were turned and repositioned Facility Policy revision dated 1/15/18, entitled Pressure Ulcer Prevention, documents in part, Purpose: To prevent and treat pressure sores/pressure injury. 5. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protecting bony prominence's as indicated. 11. Use positioning devices or pillows, rolled blankets, etc. to reduce pressure and friction/shearing from heels, toes and malleoli as indicated.

Based on observation, interview, and record review, the facility failed to identify and assess potential hazards/risks and develop interventions to reduce the potential for accidents for 2 of 4 residents (R1, R4) reviewed for accident prevention in a sample of 13. This failure resulted in R1 receiving two second [MEDICAL CONDITION] her right breast and one second Degree burn to her right arm. Findings include: 1. R1's Minimum Data Set ((MDS) dated [DATE] documents in part, R1 having a Brief Interview of Mental Status score of 15, indicating cognition intact. The MDS documents R1 required extensive assistance of one staff person with eating. Facility Incident Report dated 4/7/2018 at 11:35 AM, documents in part, (R1) was yelling and upon entry into room writer (V14, Licensed Practical Nurse/LPN) observed resident had reddened area to Right breast and Right upper arm. Resident stated she burned herself with oatmeal and it hurts really bad. Report further documents R1 sustained a burn to her right upper arm which measured 4 by 6 centimeters (cm) and a burn to her right breast area that measured 11.5 cm by 10 cm. There is no depth documented. The report also documents R1 to be alert and oriented but being drowsy. The Report documents Resident has predisposing condition where she has jerking movements. Resident sleeps completely naked and had no clothes on while eating breakfast (this is a normal thing for this resident). The Report did not document staff were assisting R1 eating but did document staff entered the room after hearing her yell out. R1's Nurse's Note dated 4/7/18 at 9:37 AM, documents R1 received a burn to her Chest - Right breast - 11.5 x (by) 10 cm; Reddened and painful to touch; peeling. The note further documents physician was notified and ordered pain medication and the treatment ordered was [MEDICATION NAME] cream to areas BID (twice daily) until healed. The report further documents in part, no change to the Care Plan. Nurse's Note dated 4/7/2018 at 6:37PM documents in part, No blistering present at burn site. On 4/18/18 at 12:15 PM, R1 stated she was in her room and [MEDICAL CONDITION] her right chest and right arm because oatmeal was spilled on her during breakfast. R1 further stated she didn't have a shirt on and she typically sleeps in the nude when she is in bed and was not wearing a shirt when the oatmeal was spilled. R1 confirmed her chest was exposed to the oatmeal and did not have on protective clothing at the time. At the time of the interview, R1 had 2 small burn areas to her right breast, but nothing was noted to her right upper extremity. Care Plan dated 1/5/2018 and revised on 4/5/2018, documents in part, R1 receiving a regular diet, needing extensive assistance with one person physical assistance with eating and having the following Diagnoses: [REDACTED]. The Care Plan also documents on 4/9/18 R1 had a burn to her right breast and right upper arm. The intervention listed is to seek medical attention if skin becomes bloody or infected. The Care Plan did not address R1's eating meals in bed while naked and how staff should address this to prevent risk of injury. There is no documentation in R1's medical record the facility assess risks versus benefits of R1 eating in bed naked as she has Frederick's Ataxia ( a neuro-muscular disorder). There was no documentation in R1's medical record that the facility attempted to discuss these risks with R1. On 4/18/18 at 1:08 PM, V14, Licensed Practical Nurse (LPN), stated she was the nurse caring for R1 on the date of the incident whereby R1 received [MEDICAL CONDITION] her right breast and one to her right upper arm. She stated R1 was in her room lying in bed waiting for her breakfast (asked to have it later than scheduled), and R1 prefers her bedside table to be positioned to the left of her body aligned with the bed. V14 also stated R1 holds her plate and/or bowls on her chest area, while lying in bed, and does not wear clothing when in bed. V14 stated on the day of the incident she heard R1 yelling and went to her room and noticed R1 rubbing her bare chested area of her breast that was reddened. She stated the affected area was from where the nipple starts and across entire right breast leading up to top of chest, and that R1 was trying to wipe off the oatmeal from her chest area. On 4/18/18 at 1:50PM, V25, CNA, stated she was working on the date of incident involving R1. She stated she took R1's tray into her room and she was awake and she placed the bowl of oatmeal on R1's sternum area as per R1's request. She stated a few minutes later she heard screaming down hallway. V25 stated usually R1 doesn't immediately eat when the tray is served to her, as she may take some time before she begins to eat. V25 stated on that day R1 wanted to eat her breakfast as soon as she got her tray. On 4/19/18 at 9:40AM, R1 was lying in her bed with her bedside table to the left side of her body. Her breasts were exposed 2 circular open areas were noted to the upper part of her right breast. The rest of her body is covered by a blanket. V31, CNA, offered R1 her breakfast which consisted of a bowl of oatmeal, hot chocolate, fruit loop cereal, an English muffin with butter and jelly. R1 stated she did not want the oatmeal or the hot chocolate, but requested for V31 to get her 2 bowls of Rice Krispies. V31 stated she would go get her the cereal she requested. When leaving the room, V31 stated she had a towel to cover up R1 while eating, but stated she hadn't provided R1 a clothing protector not before today. On 4/19/18 at 9:57AM, V10, LPN, stated R1 is known to sleep and eat in her bed in the nude and that is her normal routine. On 4/20/18 at 8:05AM, V15, Certified Nursing Assistant (CNA), stated R1 always eats in the nude while eating in her room. On 4/20/18 at 8:07 AM, V17, Licensed Practical Nurse (LPN), stated R1 always eats in the nude while in her room and has done this since her first day of admission to the facility. R1's Electronic Face Sheet documents R1 was admitted to the facility on [DATE]. On 4/20/18 at 8:10AM, V24, CNA, stated R1 eats in the nude while in her room, but now since she had the burn, she is allowing the use of a clothing protector. On 4/20/18 at 8:20AM, V26, CNA, stated R1 does eat nude in her bed when she is in her room, but is now willing to allow for a clothing protector over her chest. According to Merck Manual website www.merckmanuals.com/burns on 4/20/18, documents Second-[MEDICAL CONDITION](also called partial-thickness burns) extend into the middle layer of skin (dermis). Second-[MEDICAL CONDITION] sometimes further described as superficial (involving the more superficial part of the dermis) or deep (involving both the superficial and the deep parts of the dermis). Facility Policy entitled Burns: Emergency Procedures Guidelines, undated, documents in part: All residents experiencing a burn will be assessed and treated immediately. 4. Assess the burn site to determine the severity and degree of burns. [MEDICAL CONDITION] quickly as possible with sterile dressing or a clean cloth. 6. Call paramedics and transfer to hospital. 8. Treat for emotional and physical pain and discomfort. Medicate for pain as ordered by the physician. 2. The MDS dated [DATE] documents R4 to be cognitively intact and requires total to extensive assist for all activities of daily living. The Care Plan dated 3/17/18 no abnormal behaviors from R4 on admission 3/16/18. On 3/29/18 at 7:05 PM an entry into the Electronic Health Record (EHR) Nurse Notes by V10 LPN (licensed Practical Nurse) document It was reported to writer by staff member resident had bottle of medication in jacket pocket. Writer spoke with resident and stated needed to look in jacket related to resident having medication. Resident became very upset and angry at writer. Yelled at writer 'That's mine you can't take it from me.' Writer removed bottle marked [MEDICATION NAME] 100 mg cap however contents of bottle is [MEDICATION NAME] and [MEDICATION NAME]. Writer stated to resident with staff member present that it was against facility policy for a resident to have any medications prescribed or over the counter while at the facility. Resident continued to be argumentative with staff. Writer notified (V2) DON (Director of Nurses.) Call placed to V13's MD (Physician) office. V35 (MD on call for V13) paged and returned call. Made aware. R4's Nurse's Notes, dated 4/2/18 at 1:11 PM , written by V10 (LPN) documents V22 (V13's office Nurse), called and reiterated that (V13) MD had not written narcotic prescriptions in months for resident due to drug screens done at his office. On 4/17/18 at 3:00 PM, V10 LPN stated she understood that R4's primary physician, V13 MD, refused to order Narcotics for R4 due to past history of having negative drug screens when requesting more [MEDICATION NAME] and [MEDICATION NAME]. V10 stated R4 was a drug seeker which they were unaware of until V13 (MD) informed them after this incident. V10 stated the drugs found in the [MEDICATION NAME] bottle on 3/29/18 were [MEDICATION NAME] and [MEDICATION NAME] which she determined by checking the imprint of the medications. V10 stated the [MEDICATION NAME] was not the same as what was ordered for R4 at the facility and R4 never had an order for [REDACTED]. On 4/17/18 at 3:20 PM, V21 Nurse Practitioner (NP) stated R4 was taking [MEDICATION NAME] before he was admitted to the facility and he ordered the [MEDICATION NAME] and [MEDICATION NAME] for him on 3/16/18, the afternoon of admission to the facility. V21 stated he was unaware of R's narcotics history or any problems prior to that. On 4/18/18 at 8:30 AM, V13 MD stated he has been caring for R4 for the past [AGE] years and knows him well. V13 stated R4 had been calling office asking for stronger pain medications and on 4/6/18, the facility called to tell them they would no longer prescribe Narcotics for him as he had been sneaking [MEDICATION NAME] into his room. V13 stated R4, on two separate occasions over the past two years, has had negative drug screens done for [MEDICATION NAME] and [MEDICATION NAME], both of which he had been filling on a routine basis for him. V13 stated he was unsure where the [MEDICATION NAME] and [MEDICATION NAME] went but assumed he wasn't taking it himself since his screen came back negative. V13 stated he has been able to treat R4's pain with non-narcotic medications and would not order any narcotics for him at this time due to that history unless they could assure him that R4 is actually consuming the medication and not getting drugs elsewhere. On 4/17/17, V1, Administrator, was unable to provide an investigation on the narcotics in the [MEDICATION NAME] bottle found in R4's coat pocket on 3/29/18 and was unable to say where R4 got the [MEDICATION NAME] and [MEDICATION NAME]. V1 was also unable to provide a plan to prevent future occurrences of drug seeking and obtaining medication from outside the building. V3 stated the prior DON, V34, took care of the drugs. V3 provided text messages copied from V34 which included a picture of the drugs in the bottle found on R4 and read these are what we suspected were [MEDICATION NAME] and [MEDICATION NAME]. These are what were destroyed. and There was no narcotic sheet these were his illegally obtained meds (medications). On 4/18/18 at 3:00 PM, V3, Assistant Director of Nursing (ADON) stated the facility did not notify their pharmacy and no toxicology tests were done on R4. V3 stated they assumed he got the drugs from an outside source but was unsure as to who it would have been or how they were obtained. R4's Care Plan, dated 3/17/18, documents a concern dated 3/30/18 of I am med seeking. I am verbally aggressive. I at times will threaten staff. I fabricate stories. Cares in pairs when giving cares with the goal being I will have fewer episodes of behavior through the next review dated (6/14/18.) Interventions documented Administer medications as ordered and Anticipate and meet the resident's needs. The care plan was not revised with interventions to address R4 from obtaining medications that are not his and how staff should address this issue. Facility Policy entitled Incident/Accident Reports, undated, documents in part, Policy: The Incident/Accident Report is completed for all accidents or incidents. NOTE: For all medication-related incidents, use Medication Incident Report. 1. An incident/accident report is to include: b. Full written statement and possible cause of incident, physical assessment, injuries noted, vital signs, treatment rendered, and notification of appropriate parties.

Based on observation, interview, and record review, the facility failed to ensure appropriately trained competent staff performed reinsertion of gastrostomy tube for 1 of 1 resident (R2) reviewed for gastrostomy tube reinsertion in the sample of 9. This failure resulted in R2 sustaining a bowel obstruction and perforation secondary to insertion of urinary catheter for gastrostomy tube. Findings Include: R2's Electronic Health Record (EHR), dated 1/30/18, documents in part, Enteral Feeding, [MEDICATION NAME] 1.5 milliliters (ml) per hour, via Percutaneous Endoscopic Gastrostomy (PEG) tube, continuous 6:00 PM through 6:00 AM. R2's Electronic Nurses Notes, dated 1/28/18 at 6:30 PM by V9, Licensed Practical Nurse (LPN), documents in part, Narrative: CNA (Certified Nurses Assistant) reported to nurse that resident (R2) PEG/[DEVICE](gastrostomy) came out of resident's abdomen. NP (Nurse Practitioner) and DON (Director of Nursing) aware of tube coming out. (Urinary catheter) (20FR{french} 20 cc) inserted. New ordered received per (NP) to hold flushes and feedings until appropriate tube is re-inserted and position verified. Will address tomorrow in AM. POA (Power of Attorney) aware. On 2/16/18 at 2:20 PM, V15, LPN, stated he hadn't received any specific training for peg/g tubes, not for a long time. V15 denies ever being inserviced on peg/g tubes. On 2/16/18 at 2:40 PM, V9, LPN, stated on 1/28/18 at about 6:00 PM, V25 and V26, CNAs, came to let him know about R2's peg/g tube was out. He stated he got a hold of V14, Nurse Practitioner, and was given an order to put in a (urinary catheter) in place of R2's peg/g tube. He stated he wasn't sure of the (urinary catheter) size he put in, and stated he had put in (urinary catheter for G tube) into other residents in previous employment. He stated he has been employed at the facility for about 1 1/2 years, and denies ever having any training at the facility on peg/g tube placement or enteral feedings. V9 stated he only checked for placement at first, and has not had any one-on-one training on any peg/g tubes here at the facility. V9 denied R2 being sent for an x-ray to check for placement after inserting the (urinary catheter). V9 further stated he didn't go back to check the (urinary catheter) for patency because (R2) was doing fine and eating by mouth. V9 further stated R2 had no complaints of pain, and that the facility has a BM (bowel movement) protocol. V9 couldn't recall if R2 had any bowel movements during his shift. On 2/16/18 at 12:35 PM, V14, Nurse Practitioner (NP), stated he re-called the date R2's [DEVICE] became dislodged. He stated he received a call from V9, LPN, and he discussed with V9 prior to V9 placing the (urinary catheter) into R2's stomach to keep the site patent, if V9 was comfortable placing the (urinary catheter). V14 stated V9 told him he was comfortable doing the procedure. On 3/1/18 at 4:22 PM, V14, NP, stated he would expect V9 to have been trained by the facility prior to putting the catheter in R2 when the [DEVICE] came dislodged. On 2/16/18 at 1:40 PM, V7, LPN, stated she has only been employed at the facility for about 3 weeks, and part of her orientation has not included peg/g tube training and/or enteral training. V7 further stated she would not insert any catheter or [DEVICE] should a [DEVICE] become dislodged, because she hasn't been trained to do it. On 2/16/18 at 12:30 PM, V10, LPN, stated she doesn't recall any training on [DEVICE] replacement, but did have [MEDICAL CONDITION] training just day prior. She stated she wouldn't replace any [DEVICE]s of any kind because she has been told that for a long time. Why we have to send out (R1- another resident), when any thing happens to her [DEVICE]. On 2/16/18 at 10:15 AM, V6, LPN, stated it has been a long time since she has had to replace a [DEVICE] (with a urinary catheter) when one is dislodged, and admits to that being many years ago. V6 further stated she would send any resident that had their feeding tube come out to the hospital for replacement. On 2/16/18 at 2:35 PM, V5, Assistant Administrator, stated the facility has not done training with regard to enteral feedings and/or placing (urinary catheter) to keep a peg/g tube site patent. V5 further also stated the facility hasn't had any training in (YEAR) nor up to present date. V5 further stated the nurses were currently being trained as becoming aware of the lack of training on this date. Training Schedule, dated (YEAR) provided by the facility, does not list any training and/or inservicing for PEG/[DEVICE], including placement for nurses. The facility failed to provide documentation of training for (YEAR) up to and including date of entrance on 2/16/18. The facility also failed to provide documentation of PEG/[DEVICE] training for V9, Licensed Practical Nurse (LPN). The Facility's undated Gastrostomy or Jejunostomy Feedings policy and procedure documents in part, *Gastrostomy tube can pass through the pyloric sphincter into the small bowel. In addition, you may draw 10-20 cc of air into the syringe. Using stethoscope over mid-gastric region inject air and listen for 'whooshing' sound. The Facility's undated Tube Feeding - Infusion Pump Method (Closed Container System) policy documents in part, 8. Checking for Tube Placement: a. Draw 5-10 cc of air into syringe. b. Place stethoscope on the abdomen just above the waist. c. Insert barrel of syringe into [DEVICE]. d. Unclamp tube. e. Gently inject air into port and listen to the stomach for gurgling or growing sound. f. If gurgling or growling is observed, continue with tube feeding as ordered. g. If no gurgling or growling is observed, notify physician. DO NOT PR[NAME]EED with feeding. The policy further documents in part, that auscultation should not be solely relied upon to check for placement, but to observe for signs and symptoms of misplacement, including d. If there is a suspicion of feeding tube misplacement NOTIFY PHYSICIAN to request an x-ray to confirm feeding tube placement. R2's Electronic Nurses Notes, dated 1/30/18 at 3:15 PM, documents in part, New order received per (V14, NP). Send (R2) to Memorial Medical Center ER (emergency room ) for PEG tube placement. R2's H&P electronically signed on 2/6/18, documents in part, 01/30/2018 1813 (6:13 PM), Radiology, states pt (patient) has the tube extended into jejunum - There is a 4 cm (centimeter) balloon blocking the jejunum. R2's H&P, dated 1/30/18, documents in part, (R2) presented with complaints of increasing abdominal distention, constipation for 1 week and general feeling of malaise and diaphoresis. (R2) has not had a bowel movement in over one week. (R2) states he has been sweating since his abdomen was noted to get bigger. The H&P further documents in part, Abdominal pain: All quadrants, The severity is moderate, Characterized as (Cramping/colicky, Continuous). Diagnosis & Plan: Small bowel obstruction/obstipation. (R2) was noted to have a small bowel obstruction in his jejunum secondary to (urinary catheter tubing) catheter insertion. R2's H&P, dated 2/1/18, documents in part, (R2) underwent J-Tube (jejunostomy) placement 2 weeks ago in (metropolitan city), surgically. At ECF (extended care facility) has had worsening abdominal pain and constipation. His J tube was noted out 1/28/18 and was replaced with a (urinary catheter tubing). The (urinary catheter tubing) balloon was inflated and left in place. After this patient had worsening abdominal distention and pain and was brought to ED 1/30/18. CT (Computed Tomography) revealed over distention of the balloon in the jejunum causing proximal bowel and stomach dilation. He was admitted to the hospital following this. After multiple enemas and manual disimpaction, he had 4 large BM's (bowel movements). R2's Operative Report, dated 2/2/18, documents in part, Postoperative Diagnosis: [REDACTED]. R2's H&P electronically signed on 2/3/18, documents in part, (R2) had worsening abdominal pain and distention and was brought to the Emergency Department, which revealed over distention of the balloon in the jejunum causing bowel and stomach dilatation. R2's H&P electronically signed on 2/4/18, documents in part, (R2) transferred to Intermediate Care Unit (ICU). R2's H&P electronically signed on 2/5/18 document in part, On 1/28/18 his PEG tube became dislodged and was replaced at nursing home. However, the tip was placed into the jejunum and with inflation created small bowel obstruction which caused diaphoresis with eating. Patient was brought to Emergency Department (ED) on 30 (MONTH) (YEAR) and had PEG tube replaced. (R2) was also found to be significantly constipated and was given fleets enema and suppositories with minimal response. Surgery with J tube placement. He underwent second Exploratory laparotomy on 2/2/18 to look for a perforated viscus and Esophagogastroduodenoscopy (EGD) which showed a gastric perforation from prior PEG tube.

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding to 2 of 3 residents (R2, R3) reviewed for tube feedings. This failure resulted in R2 sustaining a small bowel obstruction secondary to (urinary catheter tubing) insertion into the jejunum at the facility and R3 having a 10 pound weight loss from 2/5/18 to 2/15/18. Findings Include: 1. R2's Minimum Data Set (MDS), dated [DATE], documents R2's Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. The MDS further documented R2 being totally dependent on staff for Activities of Daily Living (ADLs). R2's Electronic Health Record (EHR), dated 1/25/18, documents in part, R2 having the following Diagnoses: [REDACTED]. R2's EHR, dated 1/30/18, documents in part, Enteral Feeding, [MEDICATION NAME] 1.5 milliliters (ml) at 90 cc(cubic centimeters) per hour, via Percutaneous Endoscopic Gastrostomy (PEG) tube, continuous 6:00 PM through 6:00 AM. EHR further documents R2 to receive 200 cc of water every six hours via peg/g (gastrostomy)-tube. R2's Medication Review Report (MMR), dated 1/25/18, documents in part, R2's Enteral Feed Order is to run continuous for 12 hours, may come off tube feeding for ADLs. Feeding is to run 6 PM to 6 AM. The EHR further documents for the tube feeding to be flushed twice daily with 60 cc (cubic centimeters) of water on the day and afternoon shifts. The report further documents to flush the tube feeding with 20 to 30 cc of water before starting tube feeding and upon completion. R2's Care Plan, dated 1/27/18, documents in part, R2 having ADL self-care performance deficits, having limited physical mobility related to [MEDICAL CONDITION], having decreased cardiac input, with the interventions being to administer medications as ordered. The Care Plan also documents R2 having an alteration in gastro-intestinal status, having poor oral intake, with difficulty swallowing and chewing. The Care Plan further documents R2 having a nutrition problem related to poor appetite, history of weight loss, and new peg tube placement. R2's Admission Record, dated 3/1/18, documents R2 was admitted to the facility on [DATE] and discharged to Memorial Medical Center on 1/30/18. R2's Nurses Notes, dated 1/28/18 at 1:00 PM, documents in part, Bowel sounds sluggish. R2's Electronic Nurses Notes, dated 1/28/18 at 6:30 PM by V9, Licensed Practical Nurse (LPN), documents in part, Narrative: CNA (Certified Nurses Assistant) reported to nurse that resident (R2) PEG/[DEVICE] came out of resident's abdomen. NP (Nurse Practitioner) and DON (Director of Nursing) aware of tube coming out. (urinary catheter tubing) (20FR{french} 20 cc) inserted. New ordered received per (NP) to hold flushes and feedings until appropriate tube is re-inserted and position verified. Will address tomorrow in AM. POA (Power of Attorney) aware. R2's Electronic Nurses Notes, dated 1/30/18 at 3:15 PM, documents in part, New order received per (V14, NP). Send (R2) to Memorial Medical Center ER(emergency room ) for PEG tube placement. Nurses Notes, dated 1/30/18 at 3:20 PM document in part, that (local) Ambulance called for transport from facility. Nurses Notes, dated 1/30/18 at 3:35 PM, documents in part, (Local) Ambulance here to transport resident to (hospital). Resident left facility via stretcher to hospital. R2's History and Physical (H&P), dated 1/23/18, documents in part, Discussed options with the patient and mother and caregivers their desire to proceed with PEG tube placement. Desired to proceed. (R2) will require inpatient care postoperatively to arrange for appropriate feedings. R2's H&P, dated 1/30/18, documents in part, (R2) past medical history significant for [MEDICAL CONDITIONS] secondary to [MEDICAL CONDITION], anxiety, muscle spasms who presented with complaints of increasing abdominal distention, constipation for 1 week and general feeling of malaise and diaphoresis. (R2) has not had a bowel movement in over one week. (R2) states he has been sweating since his abdomen was noted to get bigger. The H&P also documents R2 being alert and oriented times four. The H&P further documents in part, Abdominal pain: All quadrants, The severity is moderate, Characterized as (Cramping/colicky, Continuous). Diagnosis & Plan: Small bowel obstruction/obstipation. (R2) was noted to have a small bowel obstruction in his jejunum secondary to (urinary catheter tubing) catheter insertion. R2's H&P, dated 2/1/18, documents in part, (R2) underwent J-Tube (jejunostomy) placement 2 weeks ago in (metropolitan city), surgically. At ECF (extended care facility) has had worsening abdominal pain and constipation. His J tube was noted out 1/28/18 and was replaced with a (urinary catheter tubing). The (urinary catheter tubing) balloon was inflated and left in place. After this patient had worsening abdominal distention and pain and was brought to ED 1/30/18. CT (Computed Tomography) revealed over distention of the balloon in the jejunum causing proximal bowel and stomach dilation. He was admitted to the hospital following this. After multiple enemas and manual disimpaction, he had 4 large BM's (bowel movements). R2's Operative Report, dated 2/2/18, documents in part, Postoperative Diagnosis: [REDACTED]. R2's H&P electronically signed on 2/3/18, documents in part, (R2) had worsening abdominal pain and distention and was brought to the Emergency Department, which revealed over distention of the balloon in the jejunum causing bowel and stomach dilatation. R2's H&P electronically signed on 2/4/18, documents in part, (R2) transferred to Intermediate Care Unit (ICU). R2's H&P electronically signed on 2/5/18 document in part, (R2) underwent PEG tube placement in (metropolitan city) approximately 2 weeks ago and was transferred to nursing home for his feeding tube feeds. On 1/28/18 his PEG tube became dislodged and was replaced at nursing home. However, the tip was placed into the jejunum and with inflation created small bowel obstruction which caused diaphoresis with eating. Patient was brought to Emergency Department (ED) on 30 (MONTH) (YEAR) and had PEG tube replaced. (R2) was found to be dehydrated and was fluid resuscitated in the ED. (R2) was also found to be significantly constipated and was given fleets enema and suppositories with minimal response. Surgery with J tube placement. He underwent second Exploratory laparotomy on 2/2/18 to look for a perforated viscus and Esophagogastroduodenoscopy (EGD) which showed a gastric perforation from prior PEG tube. R2's H&P electronically signed on 2/6/18, documents in part, 01/30/2018 1813(6:13PM), Radiology, states pt (patient) has the tube extended into jejunum - There is a 4 cm (centimeter) balloon blocking the jejunum. On 2/16/18, V25, Certified Nursing Assistant (CNA), stated she and V26, CNA, were on the unit when R2's peg/g tube became dislodged. V25 stated she and V26 were getting ready to transfer R2 from the wheelchair to his bed using the full mechanical lift. She stated he had a t-shirt on and she went to remove the t-shirt off from his back and V26 was removing the t-shirt from the front. She stated as V26 was pulling the t-shirt up from his abdomen, his g/peg tube popped out of his stomach. V25 stated there was some blood near the insertion site, so she put a towel over it, and she was panicked and went to immediately inform V9, LPN, and he came to assess R2. V25 further stated while R2 was on a feeding tube, the CNAs would assist R2 in the dining room with eating. On 3/1/18 at 4:10 PM, V26, CNA, stated she was working on the day that R2's peg/[DEVICE] became dislodged and came out. She stated she believed when his t-shirt was removed the peg/[DEVICE] came out. She further stated the [DEVICE] was not secured and was ''hanging loose.'' V26 further stated she had seen R2 tug at it (peg tube). She stated she and another CNA informed V9, LPN, at the time the tube was dislodged. On 2/16/18 at 2:40 PM, V9, LPN, stated on 1/28/18 at about 6:00 PM, V25 and V26, CNAs came to let him know about R2's peg/g tube was out. He stated he got a hold of V14, NP, and was given an order to put in a (urinary catheter) in place of R2's peg/g tube. He stated he wasn't sure of the (urinary catheter) size he put in, and stated he had put in (urinary catheter) into other residents in previous employment, but not at this facility. He stated he has been employed at the facility for about 1 1/2 years, and denies ever having any training, including one-on-one demonstration at the facility on peg/g tube placement and/or enteral feedings. V9 denied after inserting the (urinary catheter)checking for placement nor having R2 sent for an x-ray to check for placement. V9 further stated he didn't go back to check the (urinary catheter) for patency because (R2) was doing fine and eating by mouth. V9 further stated R2 had no complaints of pain, and that the facility has a BM (bowel movement) protocol. V9 couldn't recall if R2 had any bowel movements during his shift. On 2/16/18 at 1:00 PM, V15, LPN, stated on 1/29/18 when she came to work, she was told R2's peg/g tube had came out and because R2 was eating and everything was fine, the facility was trying to get him sent out to get a [DEVICE] placement. She stated R2 was eating by mouth, and she would crush his pills and he would take them by mouth. She further stated R2 was on thickened fluids. V15 stated she called the hospital to see when R2 could get a [DEVICE] placement scheduled, and she was told R2 had to go to the hospital where his initial peg/g tube was placed. V15 stated she has not had any training on replacing a peg/g tube with a (urinary catheter) nor any training on enteral feedings. On 2/16/18 at 2:20 PM, V15, LPN, stated he hadn't received any specific training for peg/g tubes, not for a long time. V15 denies ever being inserviced on peg/g tubes. On 2/16/18 at 12:35 PM, V14, Nurse Practitioner (NP), stated he called the date R2's [DEVICE] became dislodged. He stated he received a call from V9, LPN, and he discussed with V9 prior to V9 placing the (urinary catheter) into R2's stomach to keep the site patent, if V9 was comfortable placing the (urinary catheter). V14 stated V9 told him he was comfortable doing the procedure. On 3/1/18 at 4:22 PM, V14, NP, stated he would expect V9 to have been trained by the facility prior to putting the catheter in R2 when the [DEVICE] came dislodged. On 2/16/18 at 1:40 PM, V7, LPN, stated she has only been employed at the facility for about 3 weeks, and part of her orientation has not included peg/g tube training and/or enteral training. V7 further stated she would not insert any catheter or [DEVICE] should a [DEVICE] become dislodged, because she hasn't been trained to do it. On 2/16/18 at 12:30 PM, V10, LPN, stated she doesn't recall any training on [DEVICE] replacement, but did have [MEDICAL CONDITION] training just day prior. She stated she wouldn't replace any [DEVICE]s of any kind because she has been told that for a long time. Why we have to send out (R1), when any thing happens to her [DEVICE]. On 2/16/18 at 10:15 AM, V6, LPN, stated it has been a long time since she has had to replace a [DEVICE] (foley catheter) when one is dislodged, and admits to that being many years ago. V6 further stated she would send any resident that had their feeding tube come out to the hospital for replacement. On 2/16/18 at 2:35 PM, V5, Assistant Administrator, stated the facility has not done training with regard to enteral feedings and/or placing (urinary catheter) catheters to keep a peg/g tube site patent. V5 further also stated the facility hasn't had any training in (YEAR) nor up to present date with regard to g/peg tube placement nor enteral feedings. V5 further stated the nurses were currently being trained as becoming aware of the lack of training on this date, and going forward no nurse will be allowed to place a (urinary catheter) when any tube comes out, the resident will be sent directly to ER. On 3/2/18 at 10:10 AM, V5, Assistant Administrator, stated he had obtained R2's hospital records and is aware of a perforated bowel due to an over-inflated bulb. V5 further stated in part, he would expect any nurse to only have put in a catheter if he had been trained by the facility on [DEVICE]s, and he hadn't until after the issue came up and (surveyor) came in on this complaint. V5 also stated he would have expected the [DEVICE] to have been secured to prevent it from dislodging. On 3/2/18 at 1:59 PM, V5, Assistant Administrator, stated in part, I'm aware of bowel obstruction and him (R2) being on a vent. 2. The Admission Record identifies R3 as being admitted to the facility following a PEG (Percutaneous endoscopic gastrostomy) tube placement on 2/5/18 with the [DIAGNOSES REDACTED]. The MDS, dated [DATE], documents R3 to have severe cognitive impairment with a BIMS score of 7. Admitting orders from the hospital, dated 2/5/18, includes no order for the PEG tube feeding. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. The MAR fails to reflect a ML (Milliter) per hour, but does reflect initials at 3 AM, 2 PM and 8 PM for each shift. The EMR or MAR indicated [REDACTED]. The Progress Notes or EMR (electronic medical record) entries written in the the days following R3's admission to the facility fail to document any monitoring and/or assessment of R3's tolerance of the tube and/or feeding given that he had a newly placed PEG tube and entries into the EMR from 2/5/18 through 2/15/18 are as follows: An EMR dated 2/6/2018 at 6:28 AM documents Glucerna 1.5 Cal Liquid - Give 1 unit via [DEVICE] 21 hours for NPO for 12 Months. The next entry entered by V17, LPN, refers to R3's tube feeding on 2/8/18 at 7:37 AM and documents Receives tube feeding. Bowel sounds active. The next entry was on 2/10/18 at 4:51 PM and documents Receives tube feeding. No gastric residual written by V22, LPN. An EMR, dated 2/15/17 entered by V16, RN at 15:48:05 (3:38 PM), documents a Note Text: Enteral Feed Order every 4 hours for Nutritional Supplement Flush [DEVICE] with 200 ml (milliliter) water. V16, RN, documents in the EMR on 2/15/2018 at 5:02 PM Narrative: Resident's feeding tube has hole in it, is leaking. Writer assessed tube and found that it needs changed. (Local hospital) GI (gastrointestinal) dept called, they indicated that res (resident) should be sent to ER (emergency room .) Writer will call non emergent ambulance line for transport. Resident is own responsible party. Onsite provider aware. JW every 4 hours for Nutritional Supplement Flush [DEVICE] with 200 mL water. Feeding tube compromised, resident being sent out for evaluation. An EMR, dated 2/15/18 at 3:25 AM, shows V17 also documented Note Text: Enteral Feed Order every 4 hours for Nutritional Supplement Flush [DEVICE] with 200 mL water All meds, feeding, et flushes on hold until peg tube replaced. On 3/2/18 at 8:55 AM, V18, RN, stated she was a new employee and worked orientation with V17, LPN, the night of 2/15/18. V18 stated V17 told her general information and stated V17 told her she was unsure what rate R3's tube was to be running. V18 stated she looked back thru R3's chart and did not see an order that included the rate to run or the amount of Glucerna R3's was suppose to get but did find it in the Dietary Assessment. V18 stated she noted that the rate R3's tube feeding was running on 2/15/18 was higher than recommended by the Dietician. V18 stated she wrote a clarifying order to include the tube feeding rate based on the dietician's recommendation. V18's statement on 3/2/18 was confirmed by a EMR dated 2/15/18 at 2344 (11:44 PM) when V18, RN, documented Glucerna 1.5 Cal Liquid (Nutritional Supplements) Give 1 unit via [DEVICE] 21 hours for NPO for 12 Months Rate 85 cc/hr x 21 hours total 1785 mls. Weight record documents R3's weight on 2/5/18 at 168.9 pounds with a repeat weight at 168.9 pounds on 2/6/18. On 2/15/18, the weight record documents a weight loss of 10.5 pounds or 6.2% in just two weeks for R3. On 3/2/18 at 3:30 PM, V2, DON, was asked to provide any evidence as to how much Glucerna R3 was receiving from 2/5/18 through 2/15/18 to ensure he was receiving adequate formula to prevent weight loss and adequate care to prevent aspiration. As of 3/6/18 at 4:45 PM, no information/ documentation was provided. The EMR for R3 also fails to consistently document on R3's condition and/or assessment of R3's tube placement after the damage tube was identified except to document that all medications were being held until the tube was replaced as Note Text: Hold all medications and feeding until new g tube placed. every shift until 02/16/2018 23:59 [DEVICE] nonfunctional. On 2/16/2018 at 9:43 PM, an EMR entry written by V23, LPN, documents [DEVICE] placed and verified for placement, but the EMR notes fail to document any other information as to whether he was transferred out or the placement took place in the facility. A Change in Condition Form, dated 2/15/18, documents R3's peg tube was displaced or blocked and pt (patient) is hungry. On 2/16/18 at 22:37 (10:37 PM), an EMR entry documents Note Text: Hold all medications and feeding until new g tube placed every shift until 02/16/2018 23:59 [DEVICE] nonfunctional. Peg tube replaced and medications, feedings, et (and) flushes given per [DEVICE]. Residual and placement verified. On 2/17/2018 at 2:19 AM, the EMR documents an Order - Administration Note Text: Glucerna 1.5 Cal Liquid Give 1 unit via [DEVICE] 21 hours for NPO for 12 Months Rate 85 cc/hr x 21 hours total 1785 mls. At 2048 (8:48 PM) on 2/18/18, an EMR entry documents Narrative: (1330) Writer notified facility NP of change of condition. New orders received to obtain STAT CBC, CMP, Ammonia level, and lipid panel. Also STAT chest x-rays ordered. Writer called Gamma Lab and ordered STAT labs. Biotech X-ray called for STAT chest x-rays. (1830) Received results from Biotech. Facility NP notified and awaiting return call. (2005) Lab results received from (lab). Facility NP notified. Awaiting return call with any new orders. Family made aware. An EMR entry, dated 2/18/18 at 8:54 PM, documents, Resident is alert. Oriented to person. Evidence of an acute change in mental status from the resident's baseline noted, Resident lethargic, Has shortness of breath or difficulty breathing when sitting at rest. Shortness of breath or difficulty breathing when lying flat. Lung Assessment: Lung sounds diminished. Has a non-productive cough. Receives oxygen therapy; # liter per minute: 3 Oxygen via nasal cannula. Resident breathing appears labored with new orders received for an Antibiotic. The note continues to identify right lower lobe infiltrate/atelectasis. There is no indication the nurses considered aspiration when assessing R3. On 2/18/18 at 10:30 PM, the EMR documents R3 is being treated for [REDACTED]. An EMR entry dated 2/19/2018 at 2:24 PM written by Dietary documents Note Text: REVIEWED FOR NPO STATUS AND TUBE FEEDING. RECENT READMISSION AND NEW WT (weight) SUGGESTS WT LOSS OF 10# SINCE READMIT. TUBE RECENTLY REPLACED DUE TO LEAKAGE AND TF IS RUNNING AS REQUESTED. KCAL NEEDS ESTIMATED AT 2500, FLUID NEEDS AT 2200 CC, PROTEIN AT 86 GMS (grams) DAILY. TF PROVIDES 2678 KCALS, 1355 CC FREE H20 PLUS 1200 CC IN ROUTINE FLUSHES, 147 GMS PROTEIN. BS RUN GREATER THAN 200, LIKELY DUE TO PNEUMONIA DX, ON ABT CURRENTLY. NPO STATUS TO CONTINUE FOR NOW. WILL CONTINUE CURRENT FEEDING AS IT IS ADEQUATE TO PROMOTE WT GAIN TO BMI ABOVE 23. WILL FOLLOW UP PRN (as needed) FOR NEED TO MODIFY NUTRITION. There is no evidence Dietary considered the fact that R3 had just had his tube placed in (MONTH) when calculating his caloric needs to his need for continued monitoring for tolerance of the tube and feeding/flushes. On 2/19/18 at 17:26 (5:26 PM) document a Change in Condition with a transfer sheet at 17:42 documenting R3 was sent to the hospital for a respiratory infection. A Transfer sheet documents R3 returned to the facility on [DATE] and the Hospital Note documents History of Present Illness as This is a [AGE] year old gentleman who is a nurse home resident. He was brought in by EMS (emergency medical services) after being found more lethargic and hypoxic. He has been treated with PO (by mouth) antibiotics for presumed aspiration pneumonia but has become progressively worse. He was lethargic for GCS and failing to protect his airway on arrival. He is on a nonrebreather to maintain oxygen saturations over 90. He was intubated after conversation with the power of attorney over healthcare. An EMR entry dated 2/28/2018 at 1:19 PM documents an order Enteral Feed Order one time a day Tube Feeding: Give 1 unit Glucerna 1.5 via Gtube for NPO. 85 cc/hr (hour) x 21 hrs for total of 1785 ml. On at 1400 and off at 1100 No order for tube feeding upon readmission from hospital yesterday. On 3/6/18 at 11:15 am, V5, Assistant Administrator, stated R3 returned from the facility on comfort measures with a regular diet order so the tube feeding order was discontinued except the flushes. V5 stated R3 only receives flushes via his PEG tube now. On 2/16/18 AT 1:40 PM, V7, LPN, brought in the 100 ml/1 Liter (milliliter) bottle of tube feeding of Glucerna. She documented the residents name, room, date, time and rate on the bottle (85 cc/hour) for R3. She crushed two 325 mg Tylenol (650 mg total) and poured greater than 200 milliliters of water into the graduate. V7 then disposed of the Tylenol with water in the toilet, and stated she was starting over. She left the room, came back with a stethoscope, washed her hands, and donned gloves. V7 then listened for placement and to aspirated stomach contents and confirmed there was 40 cc of residual. V7 then removed the syringe from R3's tubing and took the stomach contents and dumps the contents into the toilet. V7 then opened up hub of feeding tube, placed the syringe in the tubing, and instilled 150 cc of water via gravity into the tube. V7 failed to wipe the hub of the feeding tube, nor did she replace the gastric residual back to the resident. Training Schedule dated (YEAR) provided by the facility does not list any training and/or inservicing for PEG/[DEVICE], including placement for nurses. The facility failed to provide documentation of training for (YEAR) up to and including date of entrance on 2/16/18. The facility also failed to provide documentation of PEG/[DEVICE] training for V9, Licensed Practical Nurse (LPN). The Facility's Gastrointestinal Tube Re-Insertion policy and procedure, dated 11/28/12 and revised 1/11/18, documents in part, Purpose: To establish route for the administration of medications, fluids, or nutrients into the gastrointestinal tract when the gastrointestinal tube becomes dislodged. Equipment: Gastrointestinal tube or (urinary catheter) catheter (type and size as ordered by the physician). The Facility's undated Tube Feeding - Infusion Pump Method (Closed Container System) policy and procedure documents in part, Policy: To provide nutrients, fluids and medications, as per physician orders, to residents requiring feeding through an artificial opening into the stomach. It continues, 6. Position resident on his/her back with head elevated to minimal 30 degrees and preferable 45 degrees. and further documents, 8. Clean each tubing connection with an alcohol swab whenever accessing the hub. Checking for Tube Placement: a. Draw 5-10 cc of air into syringe. b. Place stethoscope on the abdomen just above the waist. c. Insert barrel of syringe into [DEVICE]. d. Unclamp tube. e. Gently inject air into port and listen to the stomach for gurgling or growing sound. f. If gurgling or growling is observed, continue with tube feeding as ordered. g. If no gurgling or growling is observed, notify physician. DO NOT PR[NAME]EED with feeding. The policy further documents in part, that auscultation should not be solely relied upon to check for placement, but to observe for signs and symptoms of misplacement, including d. If there is a suspicion of feeding tube misplacement NOTIFY PHYSICIAN to request an x-ray to confirm feeding tube placement. Checking for Gastric Residual: and continues, 3. Aspirate all of stomach contents. 4. Measure the amount aspirated. Replace gastric residual.

A. Based on interview, observation, and record review, the facility failed to provide pain management for a gangrenous leg for 1 of 8 residents (R20) reviewed for pain in the sample of 24. This failure resulted in R20 being in severe pain during treatments of a gangrenous foot and during general movement exhibited by grimacing/wincing and moaning. Findings include: The Minimum Data Set (MDS), dated [DATE], identifies R20 to have a Brief Interview for Mental Status (BIMS) score of 12 identifying moderate cognitive impairment. The MDS documents R20 requires extensive assist of two staff for most activities of daily living (ADL's). On 9/26/17 during initial tour of the building at 9:30 AM, R20 was identified to have gangrenous ulcers on bilateral feet. On 9/27/17 at 10:25 AM, E12, Registered Nurse (RN)/Wound Nurse entered R20's room to change the dressing on R20's right foot. R20 was sitting in the wheelchair and E12 had laid a disposable incontinent pad under her feet. E12 cut the gauze dressing off R20's right foot with a scissors and removed the dressing. R12 flinched, and repeatedly stated, Ow, Ow as E12 continued. R20 would take a deep breath and sigh, grimacing as a gauze pad was removed from between her 4th and 5th toe. R20's 4th toe was completely black with her other toes darkened. R20's left foot had darkened areas on the dorsal surface. E12 stated R20 had just gotten pain medication a while ago and asked R20 if she was okay. During this time, E12 also stated that R20 flinches sometimes before she even touches R20. E12 then added that R20 can be dramatic. On 9/27/17 at 10:45 AM, E27, Licensed Practical Nurse (LPN), stated she had given R20 her scheduled pain medication, [MEDICATION NAME], around 9 AM or so. E27 stated R20 gets routine [MEDICATION NAME] at 8 AM, 12 noon, 4 PM and 8 PM. R20's September 2017 physician's orders [REDACTED]. R20's September 2017 Medication Administration Record [REDACTED]. The Care Plan, dated 9/11/17, documents R20 has an active infection ([MEDICAL CONDITION] and wounds to right and left foot), but fails to identify R20's gangrenous feet. The Care Plan also documents Pain as has a potential for pain related to generalized pain, [MEDICAL CONDITION] of right lower limb, hx (history of) [MEDICAL CONDITION] ([MEDICAL CONDITION],) Hypertension, [MEDICAL CONDITION], Gout, hx of hip and lower back pain, hx of UTI (urinary tract infection), and depression. The Interventions document assess and monitor for non-verbal indicators of pain (facial grimacing, moaning, clenched teeth, crying, whining, grasping, wincing, wrinkled forehead), monitor and report to nurse signs/symptoms of pain or worsening pain, administer and monitor for effectiveness and for possible side effects of medication (see MAR) and assist with repositioning. Neither section of the Care Plan addresses pain management during treatments and/or breakthrough pain. The Nursing Monthly Evaluation, dated 9/11/17, documents R20 hurts a little with non-verbal sound like crying, whining, at times when feet are touched. The September 2017 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On 9/27/17 at 10:30 AM, R38, R20's room mate, stated during the group meeting that R20 cries during care and treatments and she is concerned that they are not giving her pain medication as they should. R38 is identified by the facility as being cognitively intact. On 9/28/17 at 8:30 AM, R20 was sitting at the dining room table asleep. R20 ate only bites of food from her breakfast tray before taken back to her room. Progress Notes from 9/15/17 through 9/28/17 include no reference to pain or any assessment, but does document she tolerates foot treatments. Progress notes, dated 9/18/17 (no time), documents R20 was out for an appointment and refuses amputation as recommended. Weight records show R20 weighed 195 pounds on 8/14/17 and 181 pounds on 9/8/17. Pain Rating tool, dated 9/11/17, documents R20 to have pain, chronic, intensity a 2, worst pain gets 9, and best pain gets 3 described as ache, and anxious at times. The assessment documents moving of feet causes pain, how long is blank as is anything else about pain. The assessment, dated 6/19/17, documents pain when someone touches feet. Both assessments have refer to care plan checked. On 9/28/17 at 11:10 AM, E27 was asked about R20 not getting her dose at 4 PM on 9/27/17 stated R20 was out of [MEDICATION NAME] but agreed that the medication would have been available from the convenience box. E27 stated the pharmacy delivered R20's [MEDICATION NAME] the evening of 9/27/17. On 9/28/17 at 11:13 AM, R20 was lying in bed awake. R20 was asked if she rated her pain at the worst during the day on a scale of 1-10 with 10 being the worse, what would it be. R20 shook her head and stated I really can't say, I'm sorry, I can't think about it now. When asked if she was comfortable at the time, stated I would like to be comfortable. On 9/28/17 at 4 PM, E2, Director of Nurses, stated R20's physician and vascular physician have recommended R20 have an above knee amputation due to vascular insufficiency, but R20 has refused. E2 stated R20 has a state guardian and due to the process, they are waiting for permission to put her on Hospice and make her a Do Not Resuscitate. E2 agreed the nurses should be pre-medicating prior to treatments. When asked about R20's pain medication being ordered without any given between 8 PM and 8 AM, E2 stated they need to look at that. E2 stated R20 has definitely had an overall decline including weight loss in the past several months. On 9/29/17 at 9:00 AM, E1, Administrator, stated R20's physician was contacted for additional pain medication. The facility's policy/procedure entitled Pain Management documents it's purpose as to help staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. The policy documents the pain management program is based on a facility wide commitment to resident comfort with Pain Management being defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his/her clinical condition and established treatment goals. The policy includes the interdisciplinary care process to include the following: assessing the potential for pain, effectively recognizing the presence of pain, identifying the characteristics of pain, addressing the underlying causes of pain, developing and implementing approaches to pain management, identifying and using specific strategies for different levels and sources of pain, monitoring for effectiveness of interventions, and modifying the approaches as necessary. The policy documents a comprehensive pain assessment will be done upon admission to the facility, at the quarterly review, whenever there is a significant change in condition and when there is onset of new pain or worsening of existing pain. The policy also documents the nurses are to assess the resident's pain and consequences of pain at least every shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. The possible behavioral signs of pain are identified by the policy as: verbal expressions such as groaning, crying, screaming, facial expressions such as grimacing, frowning, clenching of the jaw, etc, changes in gait, skin color and vital signs, behaviors such as resisting care, irritability, depression, decreased participation in usual activities and limitations in his/her level of activity due to the presence of pain. For assessing actual pain, the policy documents staff should be documenting intensity (as measured on a standardized pain scale), descriptors of pain, pattern of pain, location and [MEDICAL CONDITION] of pain, frequency and strategies that reduce pain. On 9/27/17 at 10:30 AM, R38, R20's room mate stated R20 cries during care and treatments. On 9/29/17 at 11:30 AM, E30, Nurse Practitioner (NP), stated he is familiar with R20 and agrees she has pain. E30 stated he last saw R20 on 9/28/17 during a dressing change. E30 acknowledged that she had a lot of pain and that it does cause her to not participate in activities, eating well, etc and that with the [DIAGNOSES REDACTED]. E30 stated he expects the nurses to assess for pain both verbally and non-verbally throughout the day and notify him if the current medication regime is not effective. When asked why the nurses would mark no pain for all three shifts for the month of September on the shift to shift pain assessment, E30 stated he had no idea since she obviously has pain and staff should be able to anticipate it given her diagnosis. E30 stated he changed R20's pain medication yesterday (9/28/17) which included changing her [MEDICATION NAME] to every 8 hours PRN (as needed) and [MEDICATION NAME] ([MEDICATION NAME]) every 4 hours. B. Based on interview, observation, and record review, the facility failed to identify, monitor and treat excoriation timely for 2 of 4 residents (R10, R20) reviewed for wounds in the sample of 24. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], identifies R20 to have a Brief Interview for Mental Status (BIMS) score of 12, identifying moderate cognitive impairment. The MDS documents R20 requires extensive assist of two staff for most activities of daily living (ADL's) including bathing and hygiene. The MDS documents R20 is frequently incontinent of bowel and bladder. On 10/27/17 at 10:45 AM, R20 was transferred to bed via a full body mechanical lift by E24 and E25, Certified Nurses Aides (CNA). R20 had a dry disposable brief on. R20 had excoriation throughout inner buttocks, perineal area and an open area inner right thigh. R20 cringed and stated, ow as the CNA's wiped barrier cream on her buttocks. R20 stated, it's tender, when asked if it hurts. The progress notes, dated 9/11/17 through 9/28/17, fail to reflect R20's excoriation. The facility's Wound care policy, dated 10/2010, documents the purpose as providing guidelines for the care of wounds to promote healing, but fails to reflect any information regarding assessments. 2. The MDS, dated [DATE], documents R10 as being cognitively intact, but requiring total assist of one to two staff for mobility, hygiene and bathing. The MDS documents R10 to always be incontinent of urine. On 9/26/17 at 1:45 PM, E8 and E7, CNA's, transferred R10 to bed via a full body mechanical lift. According to E8, R10 was up in his wheelchair at 7 AM when they came on shift. E11, LPN, was present and stated she toileted R10 at 10:30 AM. R10 had a bright red rash across both buttocks, rectal area and perineal area with petechiae present. When E8 wiped R10's buttocks, he complained of discomfort. E8 failed to cleanse all areas which were wet with urine, then applied barrier cream. R10's progress notes, dated 9/23/17 through 9/28/17, fail to reflect R10's buttocks/coccyx rash. A progress note, dated 9/28/17 (no time), documented by E12, RN/Wound Nurse, documents R10 noted to have excoriation to bil (bilateral) inner thighs + peri area. Appears to be shearing from incontinence briefs. Res (resident) c/o (complains of) area feeling 'uncomfortable.' N.O. (new order) obtained for zinx oxide to area. C. Based on interview, observation, and record review facility failed to assess, identify, and implement behavior interventions for residents with dementia related behaviors for one of 5 residents (R17) reviewed for dementia care in the sample of 24. Findings include: On 9/26/17 at 12:50 PM during the noon meal, R18 attempted to move her wheelchair around the table bumping into R17's walker. R17 then struck R18 on her left arm with his hand. E19, CNA, then stood up from her chair and pushed R18 out from the table into the hallway. On 9/27/17 at 10:50 AM, R17 stopped walking in the hallway in front of the nurses station and waited for R30 to move into his personal space as she was propelling her wheelchair down the hallway. R17 then turned his walker, lifted his right arm and struck R30 in the hallway. E22, Registered Nurse (RN), and E20, CNA, immediately separated the residents. E22 stated she would expect staff to report incident to E1, Administrator, and check the victim for injuries. R17's MDS, dated [DATE], documents R17 was admitted to the facility on [DATE] with a diagnoses, in part, of Dementia. The MDS also documents R17 rejected care that is necessary to achieve the residents goals for health and well-being. On 9/28/2017 at 8:35 AM, E16, RN Manager, stated that he knew R17 has had altercations. E16 provided an undated Preliminary 24 hour incident investigation report that documented R17 made contact with his roommate's right shoulder twice with his hand which was witnessed by staff on 7/11/17 at 2 PM in their room on the 4th floor. On 9/28/17 at 12:20 PM, E16 stated that he knew about this incident and gave no reason why R17's Care Plan or Behavior Tracking didn't reflect these behaviors. E16 also acknowledged that R17 has a tendency to target two individuals in particular and both are female. The two residents identified by E16 are R30 and R18. On 9/28/17 at 3:11 PM, E3, Social Services, stated that R17 was moderately impaired with cognitive skills for daily decision making. R17's Care Plan, dated 8/9/2017, documents, in part, Problems R17 can be verbally aggressive at times, will threaten others, likes to 'shadow box' as they walk by, and acts like he's going to hit staff, but doesn't when he is in activities. R17's Care Plan does not reflect his physical aggression. The interventions fail to address what to do when R17 becomes physically aggressive and his focus on R18 and R30. R17's Behavior/Intervention for September 2017 documents: Will threaten others and 'shadow boxes' with others as they walk by. On 9/28/17 at 8:57 AM, E18, LPN, stated she has never really seen R17 hit anyone. E18 stated that R17 likes to 'shadow box' and takes things. On 9\28\17 at 9:05 am, E20, CNA, stated I have never seen R17 hit anyone, I usually jump in before it gets that far. On 9/28/2017 at 9:50 AM, E21, LPN, stated I have seen R17 'shadow box', but R17 is easily redirected, I have not personally seen R17 hit anyone. R17 is easily agitated.

Based on observation, record review, and interview, the facility failed to ensure staff use safe transfer techniques for 2 of 3 residents (R2 and R3) reviewed for mechanical lift transfers in a sample of 5. This resulted in R2 and R3 sustaining fractures during an improper transfer. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], documents R3 has [DIAGNOSES REDACTED]. The MDS documents R3 to be severely cognitively impaired and totally dependent on staff for all activities of daily living. The MDS documents R3 requires total assist of two staff for all transfers. On 7/13/16, the facility provided a list of residents requiring mechanical lifts for transfers. R3 is identified on a list of residents requiring mechanical lift for transfers. The Care Plan, dated 5/10/16, documents R3 to have self care deficits and requires to be transferred with a mechanical lift and 2 staff. R3's Kardex for CNA care documents R3 requires a mechanical lift for transfers with 2 staff assistance. An Episode Note, dated 7/4/16, at 7:08 PM, written by E4, Licensed Practical Nurse (LPN) documents Nurse called stating that patient has left knee swelling after CNA's (Certified Nurse's Aides) were attempting to dress her for bed. The patient states that she accidentally bumped her left knee on the chair while moving. She denies any other trauma or falls. The treatment plan documents R3's knee appeared slightly swollen, unsure of the extent of the injury. The physician was called and an order to X-ray was given. A Situational Background Assessment Recommendation, SBAR form, dated 7/4/16, completed by E11, LPN, documents a large bruise was noted to R3's left knee measuring 8 centimeters (cm) x 4 cm, and R3 was tearful and stating her knee hurts. E11 documents Resident stated she hit her knee on the wheelchair. The X-ray report, dated 7/4/16, documents under Impressions: Horizontal fracture of the patella, with proximal distraction of the superior fracture fragment. This fracture appears acute. Impacted fracture of the proximal tibia, which is age indeterminate but maybe chronic. Correlate with previous radiographs. On 7/13/16 at 8:55 AM, E2, Director of Nurses (DON) identified E8, CNA, as being R3's CNA on 7/4/16. E2 stated after watching the tapes of activities going on in and out of R3's room on 7/4/16, E2 determined that R3 did not always have two assist to transfer. E2 stated E8 and E5 CNA were observed going into R3's room after breakfast and E4 LPN going into R3's room before lunch to do a treatment but didn't see any other incidents when staff entered R3's room to assist E8 in transferring R3. E2 identified E9 and E6 CNA's as also working on 4th floor 7/4/16. E2 stated there is a Kardex on each floor in front of the CNA documentation book that is updated daily that identifies the type of transfer each resident is to have and how many staff are to assist. E2 stated it is the policy of the facility that the mechanical lift have 2 staff present when used. On 7/13/16 at 11:00 AM, E4 stated E8 was R3's primary aide on 7/4/16. E4 stated R3's normal behavior is sometimes to cry but she noticed that afternoon, it was continuous. E4 stated R3 does talk but only to people she knows and trusts, those most likely to take care of her the most. E4 stated after lunch, she asked R3 if she was okay and she shook her head no. E4 stated after they found her knee swollen, she asked E8 if she used the mechanical lift to transfer and E8 told her she lifted her and did not use the machine. On 7/13/16 at 11:30 AM, E5, CNA, stated that she recalled R3's incident on 7/4/16 and stated she helped E8 with only one transfer that day and it was after breakfast. E5 stated R3 normally cries and whines but doesn't usually complain of pain. E5 identified E9 and E6 as also working 4th floor on 7/4/16. On 7/13/16 at 11:35 AM, E6, CNA, stated she worked 4th floor on 7/4/16 but did not assist E8 with any transfers for R3. On 7/13/16 at 12:20 PM, E9, CNA, stated she worked 4th floor on 7/4/16 and did not assist E8 with any transfers for R3. E9 stated people think R3 doesn't know what's going on but she does and can talk when she wants to. On 7/13/16 at 1:30 PM , E8, CNA stated 7/4/16 was an average day for R3 and when asked who helped her transfer R3 throughout the day, identified only E5 helping her around 11:30 AM. E8 was asked who helped her the other times, stated she used the mechanical lift. On 7/13/16 at 1:58 PM, Z2, R3's Power of Attorney stated she questioned how R3 could bump her knee and sustain a fractured knee. Z2 stated she visits weekly and has seen numerous transfers where staff lift R3 into bed and has never seen a mechanical lift used. Z2 stated R3 told her at the hospital that she hit her knee during a transfer but couldn't recall what time it was and didn't want to identify the CNA for fear of getting her into trouble. Disciplinary reports dated 7/13/16 for R3's incident of 7/4/16 documents E8 was given a formal warning for failure to have two staff for a (mechanical lift) transfer. The facility's policy and procedure entitled Safe lifting and movement, dated 4/2016, documents the policy is to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents. The policy documents staff are to follow procedural guidelines for whatever type of transfer assistance is identified. 2. Admission Sheet for R2 documents [DIAGNOSES REDACTED]. The MDS dated [DATE] documents R2 has severe cognitive impairment and is totally dependent on two staff for all transfers. The Care Plan did not document what type of transfer R2 requires. The facility's list for Mechanical lifts, provided on 7/13/16, identified R2 as requiring a mechanical lift. R2's Kardex documents she is to be a 2 person assist with mechanical lift. A SBAR dated 6/20/16 written by E11, LPN, documents CNA called writer into room. Upon entering, res (resident) noted to have RT (right) foot/ankle caught in between bed frame railing/mattress area. Mattress lifted by staff + res foot freed from railing/mattress area. Head to Toe assessment completed. Rt ankle swollen c (with) reddish purple discoloration. Res also had slight grimacing. The SBAR documents an X-ray was done at 2240 (10:40 PM). An incident report completed by E11, dated 6/20/16 at 1855 (6:55 PM) documents Res (R) (right) foot R ankle was caught in bed frame railing/mattress area. CNA notified Nurse. The CNA was identified as E10. The report documents R2's ankle to be swollen with some discoloration (Purple/reddish.) The incident investigation worksheet dated 6/20/16 documents that the only witness was E10 and R2 did not fall. The Investigation documents E10 stated R2 was shaking/having anxiety during care and transfers resulting in R foot getting stuck in railing mattress area. The X-ray report dated 6/20/16 documents a Medial and lateral malleolus fracture which are essentially non-displaced. E2 stated on 7/13/16, at 3:30 PM, that E10 stated did not use a mechanical lift as required by R2. The discipline report documents E10 stated she lifted R2 by herself and did not use a gait belt. As the result, R2 sustained a fracture during transfer. On 7/13/16 at 11:20 AM, R2 was in bed. Her bed had a head board and foot board but no railings.

Based on record review and interview the facility failed to identify/assess and monitor condition changes for 1 of 5 residents (R5) reviewed for change of condition in a sample of 19. This failure resulted in R5's hospitalization . Findings include: R5's Minimum Data Set (MDS), dated [DATE], documents that R5 is cognitively impaired, requires extensive assist of two for bed mobility and transfer, R5 does not ambulate, mobility per wheelchair. R5's MDS also documents that R5 is at high risk for falls, and pressure ulcers. R5's hospital discharge record, dated 3/22/16, documents that R5 had a right leg above the knee amputation on 3/16/16 due to Vascular disease and, a right fourth and fifth toe dry, gangrene, and non healing extremity arterial ulcers. It also documents that R5 was discharged back to the facility on [DATE] with orders for dressing changes daily and follow up appointments with Z3, Surgeon. R5's hospital record documents that R5 has a history of pressure ulcers. R5's facility records lack any documentation of gangrene on the right toes. On 5/4/16 at 9:00 AM, E12 and E13, Wound Nurses, stated, (R5) had no gangrene on the right toes when (R5) left here on 3/13/16 to be admitted to the hospital. R5's Communication Form and Progress Note, dated 3/22/16, documents in part that R5 was readmitted to facility with a right above the knee amputation surgical site. No notable open areas. R5's Nurses Notes, dated 4/11/16 at 10:15 PM and signed by E15, Licensed Practical Nurse (LPN), documents in part that R5 fell out of bed and was found on floor, lying on (R5's) right side on the floor. Head to toe assessment done. This Nurses Note lacked any documentation of the right stump surgical site. R5's Incident Report, dated 4/11/16 and signed by E15, documents that R5 fell out of bed and was found lying on R5's right side at 10:15 PM. The Incident Report documents that R5 sustained a raised area on the right forehead. The Incident Report documents that facility was unable to call R5's Physician so the on call service for the facility was notified. The Incident Report documents, Assessed for injuries. R5's on call service Episode Note, dated 4/12/16 at 12:25 AM, documents in part, Evaluation of the patient after a fall. RN (E14, LPN) reports that fall was minimal. The patient had localized swelling to the right forehead. No other complaints reported. The patient rolled out of bed. Neuro checks per facility protocol. The Episode Note lacked any documentation of the right stump surgical site. R5's Nurses Note, dated 4/12/16 at 11:10 AM, documents in part, that during a dressing change, it was noted that, (R5's) right stump surgical site had a dehisce area (surgical site had opened up) about 1.3 cm (centimeters) by 3.0 cm by 0.4 cm. The Nurses Note also documents that (R5's) physician was notified. R5's Nurses Note, dated 4/12/16 at 1:45 PM, documents in part, that Z4, Z3's Nurse, stated R5's incision must have opened up with the fall last night and Z3 would have expected the surgical site to be assessed at the time of R5's fall on 4/11/16. R5's Nurse Notes, dated 4/11/16-4/14/16 day shift notes, document that R5's right stump surgical site was healing, clean, and intact. The facility's Wound History Note, dated 4/7/16, lacks any documentation of R5's surgical site dehiscing. No drainage and healing. Z3's Progress Note, dated 4/15/16, documents, (R5's) Right above the knee stump is now open. On 4/26/16 at 2:00 PM, E12, Wound Nurse/LPN, stated I would expect the staff to do a head to toe assessment, including the right stump surgical site. On 4/27/16 at 3:05 PM, E15 stated I didn't do (R5's) assessment after the fall on 4/11/16. (E14, LPN) did the assessment and called the physician on call services. I just documented the incident in the Nurse Notes. On 4/27/16 at 3:10 PM, E14 stated I haven't assessed any falls for (R5) since (R5) returned from the hospital from having the right leg amputated (3/22/16). I never took any dressing off of (R5's) right leg stump and assessed the surgical wound after any falls. On 4/27/16 at 3:25 PM, E15 stated, I guess I did the assessment after I returned to the floor after (R5's) fall on the 4/11/16. I did a head to toe assessment. I did not take the dressing off and assess the right stump surgical site. On 4/27/16 at 11:00 AM-11:15 AM, Z4 stated, (Z3) said (Z3) would have expected the facility to remove the right stump dressing and assess the surgical site at time of the 4/11/16 fall. R5's Daily Skilled Nurse Note for 4/15/16, 11:00 PM-7:00 AM, has no documentation of R5 having a fever, abdominal pain, vomiting, poor appetite, or acting sleepy. R5's Daily Skilled Nurse Note for 4/16/16 10:00 AM documents that pain medication was given and right stump dressing change done and right stump felt warm. The Note lacks any documentation of R5 having a fever, abdominal pain, vomiting, poor appetite, or acting sleepy. The facility's Daily Assignment Sheet, dated 4/16/16 for the 7:00 AM-3:00 PM shift (no specific time documented), documents that R5's vital signs were 153/69, pulse=62, respirations=26 and temperature=103.8. Over those readings in a different type marker is written pulse=62, respirations=26 and temperature=99.8. R5's Nurses Note, dated 4/16/16 1:20 PM, documents that family reported that R5 was not acting right and did not seem responsive. The Note documents Vital signs were Blood Pressure=136/72 Pulse=76, Respirations=22, and Temperature=99.8 R5's Nurses Note, dated 4/16/16 1:50 PM, documents that the facility received orders to send R5 to the hospital for evaluation for possible wound infection and to insert a access line for antibiotics. The Note also documents R5 was sent to the hospital Emergency Department. R5's on call service Episode Note, dated 4/16/16 at 2:43 PM, documents in part, Patient has a open area at Above the Knee Amputation (right leg stump). Today has poor appetite and fever, earlier to 103.8 and now 99.8. Patient sleepy. Wound stump on right is warm. Wound infection. Plan to start [MEDICATION NAME] (intravenous antibiotic) Will send to Emergency Department for access line. R5's Hospital admission records, dated 4/16/16, document in part, Patient presented to Emergency Department with abdominal pain and lethargy. Patient was admitted with acute [MEDICATION NAME] (inflammation or infection of the gall bladder), pancreatitis (inflammation or infection of the pancreas), and [MEDICAL CONDITION] (body/blood infection). On 4/27/16 at 11:00 AM, E16, Certified Nurses Aide (CNA), stated I got (R5) up in the morning of 4/16/16. (R5) looked sleepy and did not look like (R5) felt well. (R5) didn't eat anything at breakfast and (R5) was laying (R5's) head on the dining room table. I told (E2, Director of Nursing) that (R5) did not look well, wasn't eating, and had what looked and smelled like vomit on the floor mat next to (R5's) bed when I got (R5) up. (E2) said to lay (R5) down. I also told all this to (E17, LPN) when (E17) came in to relieve (E2) later that morning. On 4/27/16 at 11:30 AM, E17 stated that, I did not know anything was wrong with (R5) on 4/16/16 until the family told me that afternoon. I was told nothing about a fever, lethargy, or vomiting On 4/27/16 at 3:00 PM, E2 stated, I was aware that (R5) didn't feel good that day. (R5) was not eating and was laying (R5's) head on the table during breakfast. I saw the floor mat that morning, but was not sure it was vomit. The 103 temperature that was written under the other vital signs on the Daily Assignment Sheet was from that morning, but I did not think that was accurate so they took it again and it was around 99 degrees. I had no report from the night shift that (R5) had vomited during the night. I did give report to (E17). I did not chart the incident or call the physician. The facility's policy titled, Change In Condition or Status Notification (Revised March 2016) documents in part, If a significant change in the residents physical condition occurs, a comprehensive assessment of the residents condition will be conducted.

Based on observation, interview and record review, the facility failed to implement preventative measures, timely identify, assess and treat pressure ulcers for 3 of 4 residents (R1, R2, R3) reviewed for pressure ulcers in the sample of 19. This failure resulted in R3 developing unstageable pressure ulcers in the coccyx, sacrum and heel within 12 days of admission. Findings include: 1. On 4/26/16 from 9:15 AM-9:30 AM, based on continuous observation, R3 was in the 300 hall dining room. R3 was sitting in a wheelchair with lower half of his buttocks hanging off the wheelchair's seat. R3's pants were bunched up around the groin and coccyx area. E19, Certified Nurses Aide (CNA), was in the 300 hall dining room and E19, Registered Nurse (RN), was approximately 20 feet from R3 outside of the 300 hall dining room area. E18 and E19 were within viewing area of R3. On 4/26/16 from 10:15 AM-10:30 AM, based on continuous observation, R3 was sitting in his wheelchair, in the 300 hallway, within 20 feet of the 300 hall Nurses Station. R3 was sitting in wheelchair with the lower half of his buttocks hanging off the wheelchair's seat. E19 walked by R3 at least twice without repositioning R3 during that time frame. On 4/27/16 at 1:30 PM, R3 was lying in bed with both heels, buttocks, and back in contact with the mattress. R3 had a large adhesive bandage on the left heel. R3 lacked any elbow or heel protectors. On 4/28/16 at 7:20 AM, R3 was in bed with no dressing on the left heel area, and R3's sacral dressing was unattached to his sacral area and saturated with red and yellow drainage. R3 lacked any sponge boots on feet, and elbow or heel protectors. On 4/28/16 at 8:10 AM, R3's pressure areas were measured by E12, Wound Nurse, and E13, Wound Nurse as left heel area: 2.5 Centimeters (cm) by 2.2 cm, Sacrum area: 4 cm by 6 cm, Coccyx area: 3 cm by 1.5 cm. The sacrum area was excoriated, red and had layers of skin missing with in the area. The 4 cm by 6 cm sacral area contained 4 open areas within the 4 cm by 6 cm sacrum area. The Sacrum dressing was saturated with a large amount of red and yellow drainage. E12 and E13 did not measure the 4 open areas on the sacrum. R3 lacked any elbow or heel protectors. R3's Minimum Data Set (MDS), dated [DATE], documents in part, that R3 was admitted on [DATE], requires extensive assistance of two for bed mobility, dressing, toileting, and personal hygiene. The MDS also documents R3 requires extensive assistance of one for transfer and locomotion in a wheel chair. R3's MDS also documents that R3 is incontinent of bowels and bladder, is cognitively impaired, and at high risk for pressure ulcers. R3's Care Plan, dated 4/11/16, documents that R3 is at high risk for falls and pressure ulcers and has pressure ulcers. R3's Care Plan documents that R3 is to have elbow and heel protectors and wound care as ordered. R3's Care Plan documents that staff are to assist as needed to reposition/shift weight to relieve pressure. R3's Care Plan lacks any documentation of R3's tendency to slide down in wheelchair, or the use of sponge boots on feet. The Facility's admission nursing assessment has no documentation that R3 had any open ulcers on admission on 4/8/16. The facility's Pressure Ulcer Report documents that R3 developed a coccyx and sacral pressure ulcers on 4/21/16, 13 days after admission to the facility. R3's hospital progress notes, dated 4/5/16, documents that R3 had no open areas. The Facility's SBAR (Situation Background Assessment Recommendation)Communication Form for R3, dated 4/21/16, document in part, Resident has two new unstageable pressure ulcers to sacrum measuring 5 cm by 3 cm and coccyx measures 3 cm by 3 cm. Moderate amount of drainage noted. The Facility's SBAR Communication Form for R3, dated 4/26/16, documents in part, (R3) has a open area on the left medial heel measuring 1 cm by 2.5 cm. R3's Physician order [REDACTED]. The POS also documents [REDACTED]. Z2's, Facility Wound Physician's, Wound Notes for R3, dated 4/26/16, document in part, Unstageable Tissue Injury of the left medial heel, duration one day, is healing, and measures 1.0 cm by 2.5 cm. Recommend sponge boot, float heels in bed and off load wound; Coccyx wound, stage 3 and one day in duration with moderate drainage, measures 2.5 cm by 3.0 cm by 0.3 cm; Sacrum pressure area is unstageable, is one day in duration and has moderate drainage. Sacral pressure area measures 3.0 cm by 2.5 cm. R3's Registered Dietitian Note, dated 4/26/16, documents that R3 has a good appetite. There are no labs available for Total Protein or [MEDICATION NAME]. On 4/26/16 at 9:00 AM, E12 stated All dressings should be checked during care to ensure they are clean dry and intact. All residents with open areas should be care planned and the care plan should be followed. On 4/26/16 at 10:30 AM, E18 stated, (R3) slides down in the wheelchair all the time. (R3) wont fall out. On 4/28/16 at 7:20 AM, E21, Licensed Practical Nurse (LPN), stated, There is no dressing on (R3's) left heel pressure area and (R3's) sacrum's pressure area dressing is coming off. There should be dressings on both of those areas. (R3's) left heel area looks like a pressure area. (R3) does not have any elbow or heel protectors on. On 4/28/16 at 8:20 AM, E12 stated, (R3) should have a foam dressing on the left heel pressure ulcer and the sacral and coccyx areas at all times. (R3) was admitted [DATE] and developed the pressure areas while here. (Z2, Facility Wound Doctor) measured (R3's) areas on 4/26/16 and cleaned the middle open area on (R3's) sacrum with a [MEDICATION NAME] stick. (Z2) did not debride the sacral or coccyx wound. (Z2) nor our wound staff measure each of (R3's) sacral open areas. We measure them as a cluster area. On 5/4/16 at 11:45 AM, E13 stated that she found R3's sacrum and coccyx ulcers originally on 4/21/16 and did not know why they would not have been identified by the direct care staff first. E13 stated that the areas had granulation present with beefy red appearance and some subcutaneous tissue visible when found. E13 also stated that she found the heel ulcer, as well, which was identified as a deep tissue ulcer measuring 1 cm x 2.5 cm and was purplish, but not mushy. E13 stated that the heel protectors were placed after she found the heel ulcer, not as a preventative measure upon admission from the hospital. E13 agreed that R3 slid down in the chair and also had loose stools upon admission to the facility which would play a part in the development of the sacrum and coccyx ulcer. E13 stated that daily skin checks were done on 3-11 shift for R3, but failed to identify the open areas the night before she discovered the ulcers. On 5/4/16 at 12:30 PM, Z8, Facility Physician, stated I possibly would have expected the staff to find the coccyx and sacral areas before they became such a significant size. Preventive measures may have benefited (R3). I would have expected staff to take preventive measures for the sliding down in the chair. The sliding may have contributed to the development of the open areas. The Facility's Skin Management Guidelines policy, revised June 2016, documents in part, If the resident is found to be at risk for pressure ulcers or has a history of pressure ulcers an initial care plan is developed and individualize interventions are intimated. Daily Skin Inspections: Skin evaluation should continue on a daily basis for all residents that are at risk for skin breakdown. It can be done by a Licensed Nurse or a CNA. Weekly Skin Evaluations: A weekly skin evaluation should be done on all residents. Minimize skin exposure to moisture: Moisture alone can make skin more susceptible to injury. Therefore it is necessary ensure that moisture form urine, stool, perspiration, and wound drainage is wiped away from the skin as much as possible. Friction and Shear: Friction and sheering are important contributing factors to the development of pressure ulcers. Proper positioning, transferring, and turning of residents will avoid injury due to friction and shear. Accurate Documentation: Accurate documentation is needed to ensure continuity of care. The care plan should directly address risk factors, pressure points, under nutrition and hydration deficits and moisture and its impact. All residents who are in bed and have been assessed to be at risk for skin breakdown. should be repositioning at least every 2 hours. This repositioning should also take place when residents are in a wheel chair. 2. R2's MDS, dated [DATE], documents R2 as being totally dependent on staff for all activities of daily living. The MDS also documents R2 has a urinary catheter and is incontinent of bowel. R2's Care Plan, dated 2/10/16, identifies R2 as having a facility acquired stage IV pressure ulcer to his coccyx and trauma areas to right/left buttocks due to dressing removal. Interventions include turn every one hour and according to the turn schedule, provide heel and elbow protectors, low air mattress, and provide incontinence care when needed. There are no interventions written toward ensuring that dressing changes and treatment orders are followed and dressings remain intact at all times. R2's April 2016 POS documents R2's current pressure ulcer treatment as: apply [MEDICATION NAME] spray to buttocks twice daily and cleanse sacrum with NS (normal saline). Spray with [MEDICATION NAME]. Cover with ABD (abdominal) pad and secure with [MEDICATION NAME]. On 4/26/16 at 9:05 AM, E12 and E13 rolled R2 to the left side. R2's Sacrum pressure ulcer dressing was saturated with a moderate amount of brownish drainage. On 4/28/16 at 8:41 AM, E12 rolled R2 to his right side. R2's sacrum dressing was saturated with red blood and the top left corner and top left side of the dressing was not intact. There was a bath towel folded in thirds positioned directly under his sacrum which had smears of blood on it. Under the towel, there was a cloth incontinent pad and a quarter folded top sheet used as a turning sheet. E12 stated R4 did not have the correct dressing/treatment on as he should have an ABD on it which is more absorbent. E12 removed the dressing and washed her hands with soap and water after removing the dressing. E12 then cleansed the wound, sprayed it with [MEDICATION NAME] and applied an ABD dressing which she covered with a large adhesive dressing. E12 stated the physician had just recently debrided the pressure sore which was a elongated open area directly over the coccyx. E12 stated that since the debridement, the area has been, as expected, bleeding a lot more. 3. R1's MDS, dated [DATE], documents R1 is cognitively intact and requires extensive assist of one staff for bed mobility and transfers. R1's Care Plan, dated 4/22/16, documents R1 is at risk for impaired skin integrity with the goal to have her skin remain intact through the next review (7/22/16). Interventions include report changes to physician, notify nurses of any new areas of skin breakdown during care, reposition resident per protocol, provide pressure relieving mattress and chair cushion, provide heel/elbow protectors, and incontinence care after episodes along with provide treatments and medications as ordered in part. R1's physician's orders [REDACTED]. On 4/26/16 at 8:52 AM, R1's Sacrum pressure ulcer dressing was rolled up and was not covering the sacral pressure area. E12 removed the sacral dressing and applied a new dressing to the area. On 4/26/16 at 9:00 AM, E12 stated All dressings should be checked during care to ensure they are clean, dry and intact. All residents with open areas should be care planned and the care plan should be followed. On 4/28/16 at 10:40 AM, R1 was sitting in her wheelchair at bedside. At 10:45 AM, R1 was laying in bed. R1 stated that the dressing came off the second day and when rolled over, her coccyx had a small slit in it with the surrounding areas being white as if from moisture. R1 had a disposable incontinent brief on which was clean and dry. The [MEDICATION NAME] dressing was not in her brief or in her bed. According to Admission Nursing Assessment, R1 had only a reddened area on her coccyx when admitted on [DATE]. The Braden Scale (to assess level of risk for developing pressure ulcers) was dated 4/11/16, but was blank except for the date and R1's name. R1's Interim Care Plan, dated 4/11/16, has poor skin integrity checked along with see risk analysis for interventions and See current PO (physician's orders [REDACTED]. The April 2016 TAR shows nothing until 4/13/16 when the [MEDICATION NAME] dressing was ordered. The TAR then has that order discontinued and an order to cleanse sacrum and apply Santyl, Calcium Alginate and cover with adhesive dressings which was initialed as done from 4/19 - 4/21/16. No treatment documented for 4/24/16, then the [MEDICATION NAME] dressing again started on 4/25/16. The daily skin checks are not initialed as occurring until 4/26/16, 15 days after admission.

Based on interviews, observations and record review, the facility failed to adequately assess and develop an effective falls prevention plan, and failed to provide adequate supervision and devices to prevent accidents for 4 residents of 5 (R4, R5, R9 and R12)) reviewed for falls and fall prevention in a sample of 19. This failure resulted in R4 falling from the side of the bed after being left unassisted sustaining an intracranial bleed on 4/22/16. Findings include: 1. R4's Admission Sheet documents R4 was admitted with [DIAGNOSES REDACTED]. The April 2016 physician's orders [REDACTED]. R4's Minimum Data Set (MDS), dated [DATE], 11/5/15 and 1/27/16 document R4 has moderate cognitive impairment and requires extensive assist of one staff for transfers and locomotion on and off her unit. R4's MDS also documents that when moving from a seated to standing position, and moving on/off toilet and surface to surface, R4 is not steady, only able to stabilize with staff assistance. R4's Care Plan, dated 11/15/15, identifies R4 as at risk for falls due to history of falls, with an annual review identifying R4 as having muscle weakness due to past Cerebral Vascular Accident and right hemiparesis with resident refuses therapy. The goal is for R4 to sustain no major injury from fall thru next review. Interventions include providing call light, area free from clutter, provide bed/chair alarm as ordered PRN (as needed)STATUS: active current, 2/4/15 - educate resident and family that pillows in wheelchair is not appropriate, 3/22/15 - offer wheelchair cushion, 7/14/15, encourage fluids, use fall screen to identify fall factors, report falls to physician and responsible party, provide/monitor use of adaptive devices, remind resident and reinforce safety awareness, educate/remind resident to request assistance prior to ambulation, provide appropriate footwear in part. R4's Incident Report, dated 7/14/15, documents R4 slipped out of her wheelchair and was found face down. The Report also documents R4 was transported to the emergency room due to complaining of neck and back pain. The Report documents R4 was a high fall risk at the time. R4 returned to the facility and a Z6's Physician's Note regarding R4, dated 8/1/15, documents pt (patient) was hosp (hospitalized ) p (after) fall from w c (wheelchair) in dining room. She 'did a face plant.' She still c/o (complains) of some pain to the right forehead and periorbital area. The Care Plan revisions, added 7/14/15 as a result of the fall, were to encourage fluids and encourage resident to not use pillow behind her back in the wheelchair. The etiology of the fall fails to identify a pillow as a causative factor of the fall. R4's Incident Report, dated 9/21/15, documents R4 was observed on the floor in the dining room on right side with wheelchair next to her. R4 sustained a contusion right temporal region measuring 3 cm (Centimeters) x 3 cm. Fall risk included in the investigation documents R4 to be a low risk for falls even though she'd had a fall two months prior and one at the time of the evaluation. Z6 documents on 10/2/15 pt fell a few days ago on face and significant bruising on face - is resolving. Z6 documented that the falls and Care Plan were reviewed with no interventions or revision added to the Care Plan for falls preventions as a result of this fall. R4's Incident Report, dated 3/4/16, documents R4 fell at 6:15 AM as she was sitting in her wheelchair in front of the Nurses Station outside her room. No injury was noted. The evaluation documents R4 is alert with confusion. The fall risk at that time was 13 or high. The witness statement is blank and there is no causative factor or etiology of the fall determined. The Care Plan documents an intervention added 3/4/16 for an Occupational Consult for w/c screening to be done for positioning and nothing else in terms of added supervision or assistive devices to prevent further falls. R4's Rehabilitation Screen, dated 3/6/16, documents res (resident) states 'she doesn't want any therapy.' I like my chair the way it is. Pillow under R (right) UE (upper extremely) for support. Sitting upright c (with) no leanings at this time. According to the Nurses Notes, R4 was transferred to the hospital 3/16/16 for Pneumonia and was readmitted to the facility on [DATE]. According to E2, Director of Nurses (DON) on 4/28/16 at 9:05 AM, R4 returned to the facility in a much weakened state than prior to her hospitalization requiring more assistance than she use to. E2 stated R4 was a one person assist prior to her hospitalization and when she returned, she herself had to get assistance from someone to move her one day. There is no documentation the facility reassessed R4's fall risk and needs and no revisions made to the Care Plan following her hospitalization to ensure added assistance and supervision was provided given her decline in functional ability. R4's Occupational Therapy Note (OT), dated 4/5/16, documents This [AGE] year old female admitted from acute care hospital setting presents to therapy with multiple conditions, including pneumonia, CVA, and COPD (Chronic Obstructive Pulmonary Disease). The Patient has shown a significant decline in wheelchair seating posture, positioning and right arm edema over recent hospitalization due to medically complex conditions resulting from current illness. The OT further documents patient will have assistance of facility staff for w/c positioning an placement of appropriate adaptive seating devices for proper seating posture and right UE (upper extremity) placement for edema control. The OT note also documents the patient demonstrates sitting balance of P+ dynamic (able to maintain balance with minimal assistance, moderate assist to reach ipsilateral side and unable to weight shift). Current level of function at that time (4/5/16) was near total dependence (90-95% assist). On 4/11/6 at 1815 (6:15 PM), an Incident Report documents R4 was observed/witnessed sliding out of wheelchair and then sat on the floor. E6, LPN documents R4 was sitting in her wheelchair by the Nurses Station and slid out of the chair. Under Medical Conditions, E6 checked yes for recent change in medical condition? and describes it as recently readmitted from hospital . had pneumonia. E6 documents R4 has no injuries noted. Again, the witness statement is blank, fall risk is 11, less than it was 3/4/16 at 13, but still high. The Care Plan documents one intervention added 4/11/16 to continue therapy, chair evaluated and adjusted after resident self manipulated, family and resident educated. On 4/18/16, a quarterly MDS was completed for R4 and also documented a functional decline in transfer ability from a extensive assistance of one to extensive assist of two staff. Balance was documented as the same. Again, no evidence of assessment with revision and/or additions to the falls Care Plan to ensure safety. R4's Incident Report, dated 4/22/16 at 2:30 AM, R4 is documented as falling from the side of the bed. The fall was witnessed by E7, CNA, who documented on a Statement sheet R4 was on edge of bed, I turned around, she slipped off the bed and went down to the floor, she fell on right side of body hitting head and leaving a bruise. I got the nurse and got her up and got vitals on her. There is no indication E7 had another staff in the room with her during care of R4. R4's Nurses Notes, dated 4/22/16 at 10:30 AM documents resident up in wheelchair with (no) c/o (complaint of) pain. Monitoring bruising on forehead. R4's Physician's Note by Z6, dated 4/22/16, documents pt fell face forward out of her wheelchair early this am. She often will slump sideways or forward in chair. She has had several falls of this type. I am wondering if any adjustments to her wheelchair would help - a higher back reclined vs (verses) a slight backward seat tilt. Z6 also documents R4 to answer yes/no appropriately, speech no diff (different) than usual. The note ends with Z6 documenting I think she is somewhat post-concussion. An SBAR (Situation Background Assessment Recommendation), dated 4/23/16 documented by E5, LPN, that E5 was notified that R4 was not acting like her normal self and when evaluated, R4 was incontinent which she never was, had slurred speech and was not verbalizing needs as normal. The physician was notified and R4 was transferred to the emergency room . On 4/24/16 at 9:20 AM, the Nurses Notes document that hospital was called and R4 was admitted with intracranial bleed. R4's Hospital Record, dated 4/23/16, Cranial tomography (CT) scan of the brain documents R4 has an Acute left frontoparietal subdural hemorrhage measuring up to 1 cm in width. Possible additional small right tentorial subdural hemorrhage. On 4/28/16 at 9:30 AM, E2 stated that the physician was misinformed about R4 falling from her wheelchair, that she actually fell from the side of the bed and had one CNA in the room with her. E2 stated R4 would often want to sit on the side of her bed at night. On 4/28/16 at 10:30 AM, R4's room was observed to have her wheelchair at bedside. The wheelchair had a pressure relieving cushion in its seat along with a piece of crumpled non skid material in it. On 5/4/16 at 8:40 AM, Z6, Medical Director/Physician, stated that R4 was in a much weaker condition upon her return from the hospital the first part of April. Z6 stated that she assumed the facility reassessed R4's fall risk given her weakened condition and would have expected them to do so to ensure her safety. Z6 stated that she saw R4 the afternoon after the fall on 4/22/16 and she appeared okay at that point. Z6 stated R4 had had several falls with head injuries prior to 4/22/16 and she had talked with the nurses that afternoon about putting wedges, tilt back chair, something in place to prevent her from falling again. Z6 stated did not recall the nurse, but stated the nurse told her that it could be discussed in a meeting that afternoon. On 5/4/16 at 9:00 AM, E7 stated she was the only CNA on 200 hall that night along with the nurse, E4, LPN, taking care of some 50 residents. E7 said on 4/22/16 she had changed R4's incontinent pad, sat her on the side of the bed, gave her a glass of water and went down the hall to help another resident. E7 said she heard someone fall and found R4 on the floor. E7 said she did not witness the fall nor was she in the room at the time. E7 stated R4's roommate was asleep and the curtain was pulled. E7 stated she had taken care of R4 before and knew she'd had a recent hospitalization but had not been told she was in a weaker condition. E7 stated when she found R4 on the floor, she noticed the bruise on the right side of her head. The facility's policy entitled Fall Management Guidelines, dated 10/2014, documents that the guidelines are a interdisciplinary process designed to assist in the development of systems to provide individualized person centered care, to assist the resident in obtaining and/or maintaining their highest level of function and minimize the risk of falls and fall related injuries. Under Care Plan, the facility will review risk factors, environmental factors and other clinical conditions, the resident's initial care plan is updated or a comprehensive care plan is developed to include individualized person centered interventions. The team designs the plan to address the problem associated with potential or actual falls, measurable goal is developed with a target date and approaches are selected based on residents preferences, risk factors, co-morbid conditions and willingness to participate in the new plan. The policy documents Regardless of the interventions that are put in place a key factor to success is the timely review of the interventions as the patient's condition and needs change. 2. R12's MDS, dated [DATE], documents R12 has cognitive impairment and requires extensive assist of one staff for transfer and locomotion. The MDS also documents R12's balance for moving from seated to standing position and surface to surface is not steady only able to stabilize with staff assistance. R12's Care Plan, dated 4/12/16, documents R12 is at risk for falls related to generalized weakness and Alzheimer's Disease with the goal not to have any major injury due to fall through next review (7/12/16.) Interventions do not include the type of transfer R12 currently is or how much assistance she needs. On 4/27/16 at 2:07 PM, E19, CNA, assisted R12 into a standing position from the sofa in the lobby to her wheelchair without using a gait belt. R12 was not steady on her feet as she turned and sat down in her wheelchair. E19 did not have a gait belt visible on her person at the time. On 4/29/16 at 2:50 PM, E1, Administrator, confirmed that all pivot transfers are to be done with a gait belt according to their policy. The facility's policy entitled Safe lifting and movement documents it's the policy of the facility to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. The Guidelines documents lifting of residents will be eliminated when feasible, staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 3. R5's MDS, dated [DATE], documents that R5 is cognitively impaired, requires extensive assist of two for bed mobility and transfer. The MDS also documents R5 does not ambulate and mobility is per wheelchair. R5's Care Plan, dated 4/5/16, documents that R5 is at risk for falls, requires assistance for all staff for all Activities of Daily Living (ADL's), R5 sleeps in the wheel chair, and refuses to lay down in bed or use recliner. R5's Care Plan lacks any individualized fall interventions addressing right leg amputation and R5's tendency to fall asleep in the chair. R5's Incident Report, dated 1/12/16, documents that R5 fell out of wheelchair due to slipped out of chair and was nodding off. R5 sustained injuries. On 1/13/16 R5's Care Plan was adjusted to include, offer 2 pillows when sitting in wheelchair for positioning. No other interventions were added to address sleeping in chair or slipping out of wheelchair. R5's Incident Report, dated 1/14/16, documents that R5 fell out of recliner and sustained injuries. R5's Care Plan was not adjusted to include any added fall prevention interventions for this fall. R5's Incident Report, dated 1/21/16, documents that R5 slid out of recliner and fell . On 1/21/16 R5's Care Plan was adjusted to include the removal of the recliner in which R5 liked to sleep. R5's Incident Report, dated 2/10/16, documents that R5 leaned forward in wheelchair, fell and hit R5's head. R5's Care Plan was not adjusted to include Therapy to evaluate for wheelchair positioning. R5's file lacked any therapy evaluation for repositioning after the 2/10/16 fall. R5's Incident Report, dated 4/11/16, documents that R5 fell at 10:15 PM by falling out of bed and was found lying on R5's right side. The Report documents that R5 sustained a raised area on the right forehead. R5's Care Plan was not adjusted after the 4/11/16 fall. 4. On 4/26/16 at 11:00 AM, R9 was transferred from the shower chair to the wheelchair with the assistance of E22, CNA, and a sit to stand mechanical lift. R9's Care Plan, dated 1/13/16, documents that R9 is transferred with the assistance of 2 and a sit to stand mechanical lift. On 4/26/14 at 11:05 AM, E22 stated I transferred (R9) with the sit and stand and a gait belt. On 4/27/16 at 3:30 PM, E2 stated that the residents' Care Plans are to be followed, as well as the facility's policies when it comes to falls and accidents. The Facility's policy titled Fall Management Guidelines (10/2014) documented in part, Fall reduction/injury prevention can be implemented upon admission. The approaches for fall prevention are clear, specific and individualized for the resident needs. Regardless of the interventions that are put into place a key factor to success is the timely review of the interventions as the patients condition and needs change. A comprehensive care plan is developed to include individualized person centered interventions.

Based on interview and record review, the Facility failed to provide on-going monitoring, assessment and timely treatment of [REDACTED]. This failure resulted in R11 and R25 being hospitalized for [REDACTED]. Findings include: 1. On 4/8/15, at 10:30 AM, E4, LPN/Infection Control Nurse, stated that due to a Strep-A outbreak in the Facility, the Center for Disease Control (CDC) personnel working for the Illinois Department of Public Health (IDPH) have been providing ongoing consultation with the Facility. E4 said that the Facility was following recommendations for culturing of all residents throats, wounds and pressure sores which was given to them by the IDPH CDC personnel on 3/19/15. These recommendations included an Algorithm "Investigation of One Culture-Confirmed Invasive GAS Infection which documents; "1. Identification of additional cases: Maintain "active surveillance" for additional invasive or noninvasive cases for 4 months from onset of most recent case." R11's nurses notes document "3/31/15, 10:45 PM, Wound team assessed wounds. Resident has a bruise to Left and Right dorsal hands. Skin Tear to Left dorsal hand." R11's "Nurses Progress Note", signed by E34, Licensed Practical Nurse, documents on 4/5/15, 11:00 AM, Residents left hand red, warm to touch, swollen + 2 [MEDICAL CONDITION]. Complaining of pain, green pus-like drainage noted. Z2, R11's physician, called. New Order received for [MEDICATION NAME] 250 milligrams (mg) orally, daily for 7 days, and Tylenol 1000 mg orally every 6 hours as needed. Make appointment for him to come to the office for the physician to evaluate him". There is no documentation in the Nurses Notes, or Wound Log that on 4/5/15, R11's hand was cultured as part of the ongoing survelliance for additional Strep A infections in the facility. R11's nurses note dated 4/6/15 document "2:30 PM, Wound nurse assessed wound to Left dorsal hand. Left hand [MEDICAL CONDITION] and red. Warm to touch. Resident complaining of discomfort to hand. Area measures 1.1 cm by 3.5 cm by undetermined depth. 100% loose yellow [MEDICATION NAME], moderate serous drainage noted. Z2 notified. New Orders received. Discontinue previous treatment to Left hand. Cleanse, Santyl Calcium Alginate. Wrap with [MEDICATION NAME] daily". E24, Nurse Practitioner, (NP), documented on a Progress Note for R11 on 4/6/15 "Problem: left hand [MEDICAL CONDITION]. Description: [MEDICAL CONDITION] and abscess of hand, except fingers and thumb. New Order: Culture left hand wound. Continue [MEDICATION NAME]. Wound nurse to see. Monitor redness, warmth and swelling". R11's Progress Note, signed by E24 documents "4/6/15 - Wound nurse, E5, saw patient reportedly around 3:00 PM and discussed with me at 7:20 PM. E5 reported there was no redness up the arm, only to fingers, dorsum of hand and wrist. At 7:45 PM, E3, Director of Nursing (DON), notified of patients condition and of order for IV antibiotics for backup pharmacy to deliver. New Order given to evening supervisor at 8:00 PM; [MEDICATION NAME] 100 mg IV NOW. [MEDICATION NAME] 50 mg IV starting tomorrow morning, every 12 hours for 5 days. R11's "physician's orders [REDACTED]. [MEDICATION NAME] IV STAT 100 mg now. 2. [MEDICATION NAME] 50 mg IV dose for AM". This order is signed by E24. R11's nurses note dated 4/6/15, 8:15 PM, documents "Intravenous (IV) Line, 22 gauge, placed in left forearm as ordered for IV antibiotic." There is no further documentation in R11's nurses notes that a culture was done of R11's hand. Progress Note written by E24 documented on 4/7/15, "reassessed patients condition. [MEDICAL CONDITION] has spread to mid-upper arm with 2-3+ [MEDICAL CONDITION], [DIAGNOSES REDACTED] and warmth. [MEDICATION NAME] not yet available from pharmacy. Sending to emergency room ". R11's Wound Culture - Left Hand Wound, documents a culture was obtained on 4/7/15 (obtained two days after wound was noted draining pus) and the results dated 4/9/15, documents "Streptococcus Pyogenes (Group A) Heavy Growth". On 4/9/15, at 4:30 PM, during a daily meeting with the facility, E2, Corporate Regional Director, was asked what guidelines the Facility is following for monitoring resident's current / new wounds at this time; especially with ongoing and new cases of Strep A in the facility. E2 replied "that is a good question I'll ask the CDC on our next phone conference." E1 administrator and E4 Infection control Nurse were also present but gave no answer regarding ongoing/new wound monitoring. No information was given as to why R11's hand wound was not cultured on 4/5/15 when it was observed to be draining green pus. R11's hospital "Consultation" form from the hospital, dated 4/9/15, documents "R11's hand began to swell on about 4/5/15..... but a Gram stain collected in the emergency room from fluid draining from the dorsal left has has yielded gram-passivity cocci in pairs. Impression: Severe [MEDICAL CONDITION], left hand. Plan: I would be concerned about the possibility of group A beta [DIAGNOSES REDACTED] [DIAGNOSES REDACTED] infection. The [MEDICAL CONDITION]-resistant Staphylococcus aureus or an entorococcal infection should also be considered. We will treat him with [MEDICATION NAME]." On 4/13/15 at 11:59 AM. E24, NP, stated that she saw R11 on 4/6 and 4/7/15 and ordered a culture and medication. E24 said that the Facility was unable to obtain the [MEDICATION NAME] from the pharmacy so, R11 never received the IV antibiotic - that is why R11 was sent out to the emergency room the next day. E24, stated she did not notify R11's physician concerning the infected skin tear on R11's arm. E24 stated she did not work for Z2 nor did she coordinate care with R11's physician, Z2. On 4/14/15, a list of prepared questions was given by telephone to Z11, who is Z2's Assistant. Z2 is R11's physician. Z11 stated in the telephone interview that Z2 had reviewed R11's clinical record with Z11, and Z11 was speaking for Z2. Z11 stated that no one at the Facility has told Z2 that there is a Streptococcus A outbreak in the Facility Z2 did not find out about the outbreak until R11 was sent to the hospital. Z11 stated "Z2 did not approve of E24-NP, treating R11 without notifying him, and Z2 would expect E24 to coordinate R11's care with Z2." E3, Director of Nursing, stated on 4/15/15 at 3:20 PM that R11 continues to remain in the hospital for the infection in his hand / arm. On 4/16/15, at 10:48 AM, E3, Director of Nursing, stated the contract pharmacy which the Facility utilizes is about 2 hours away. E3 said that if a STAT medication order is received, staff are supposed to call and fax the contract pharmacy and the contract pharmacy will contact a local pharmacy to obtain the medication. E3 stated that the nurse on duty when the STAT [MEDICATION NAME] order was received stated she called the pharmacy. However, there is no record / documentation in the record that she did call for the medication. The Facility's Outbreak of Communicable Disease policy, revised 2012, documents: Policy Interpretation and Implementation "8. The Infection Preventionist and Director of Nursing Services will be responsible for: c. Notifying the Medical Director and the Attending Physicians." 2. R25's Face Sheet documents [DIAGNOSES REDACTED]. R25's care plan dated 1/29/15, documents that R25 is at risk for falls, with interventions including educate/remind resident to request assistance prior to ambulation. Physicians Order Sheet (POS), for R25, on 3/16/15, documents "May obtain throat culture, wound culture to rule out Strep A when supplies available." R2's Nurses Notes, dated 4/2/15 at 2:30 AM, documents in part; "Loud noise heard, upon entering room resident found lying face down. Resident rolled herself onto back. Resident stabilized on floor. Lacerations noted to forehead 2 centimeters (cm) X 0.2 cm. Laceration to right cheek 2 cm X 0.2 cm and laceration to side of right head 2 cm X 0.4 cm. Pressure applied to lacerations and ice applied...." On 4/2/15 at 2:53 AM, orders received to transfer resident to local emergency room for evaluation and treatment. On 4/2/15 at 8:30 AM, E8's Licensed Practical Nurse (LPN), Nurses Notes documented, "Resident (R25) returned to facility - noted various bruising and 3 lacerations to residents head." On 4/2/15 at 12:30, E5 LPN, Wound Nurse, documented in R25's Nurses Notes "Wound team assessed residents wounds. Resident has a scratch to the right cheek that measures 1.5 cm X 0.1 cm X UTD (unable to determine), no drainage. Laceration to right forehead that measures 2.2 cm X 0.5 cm X UTD, moderate sanguineous drainage. 3 sutures intact. Bruise to right eye that measures 6.0 cm X 6.5 cm X UTD." On 4/7/15 at 9:30 AM, E17 LPN, documented in Nurses Notes for R25 "Temperature 100, heart rate 68, respirations 18, blood pressure 100/50. Resident unresponsive to verbal & physical stimuli. Won't eat or take medicine. Right forehead, right eye and right cheek very red and warm to touch. Shiny appearance. Having trouble breathing through her nose. Spoke with (Z12) and informed of residents condition. Orders received to send resident to Hospital for evaluation. Daughter aware." On 4/7/15 at 9:55 AM, E17 documented on R25's transfer sheet "Resident had a fall on 4/2/15 with facial injuries. Sutures to right forehead. Areas on face more swollen today, very red and warm to touch. Right eye still swollen closed. Appears to be having trouble breathing through her nose." On 4/7/15, Z13, Medical Doctor (MD), "Hospital History and Physical Report" documents that R2 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Had a laceration on the right forehead about a week ago after falling on her face, with no loss of consciousness per nursing home staff. Laceration was sutured and discharged with Keflex in the emergency department. Later started developing swelling at the suture site which progressively got worse." On 4/10/15, Z14, Infectious Disease Medical Doctor, Hospital Progress Note, for R25 documented "Assessment: Right eye orbital [MEDICAL CONDITION]/right face [MEDICAL CONDITION] abscess. Wound culture from the forehead is growing [MEDICAL CONDITION]-resistant Staphylococcus aureus, Group A Strep and yeast." On 4/14/15 at 11:10, E5 LPN, was asked why a culture of R25's facial wound was not obtained in the facility. E5 stated "there was no drainage on R25's facial wounds." E5 was asked about her charting dated 4/2/15, in R25's nurses notes regarding the laceration to R25's right forehead which measured 2.2 cm X 0.5 cm with moderate serosanguinous drainage. E5 stated "We were not doing cultures that day, on 4/2/15." When asked if R25's wound had ever been cultured at this facility as part of ongoing surveilllance, E5 stated "No." On 4/8/15, at 10:30 AM, E4, LPN/Infection Control Nurse, stated that due to a Strep-A outbreak in the Facility, Center for Disease Control (CDC) personnel working for the Illinois Department of Public Health (IDPH) have been providing ongoing consultation with the Facility. E4 said that the Facility was following recommendations for culturing throats, wounds and pressure sores which was given to them by the IDPH CDC personnel on 3/19/15. These recommendations included an Algorithm "Investigation of One Culture-Confirmed Invasive GAS Infection which documents; "1. Identification of additional cases: Maintain "active surveillance" for additional invasive or noninvasive cases for 4 months from onset of most recent case." Additionally, E4 stated that as part of the Facility's response to the outbreak,the Facility obtained a Facility-wide order from Z3, Infectious Disease Physician, on 3/16/15, to obtain throat and wound cultures to rule out Strep A when supplies became available. E4 said "we cultured everyone in the facility we thought should be cultured with the order of 3/16/15. I did not get a discontinue order for those resident wounds which we did not culture." On 4/8/15, at 2:30 PM, Z3 was interviewed by telephone. Z3 said that he issued the Facility-wide order to obtain throat and wound cultures to rule out Strep A when the supplies were available. Z3 stated "I would not necessarily culture all wounds if a resident has more than one wound. I would definitely culture the worst wound - the worst wound would have the highest chance for Strep A." Z3 stated "No staff has asked me to clarify, change or discontinue the order for any resident in the faciliy. On 4/14/15 at 11:10 AM, when asked who was responsible for deciding which resident wounds to culture, E2 Cooperate Regional Director, stated "E4 LPN and E5 LPN, collaborated to decide which wounds to culture." E4, LPN defined Active Surveillance on 4/14/15 at 11:15 AM as "any active signs of infection - foul odor, purulent drainage, pain, redness or drastic decline in a wound. E4 stated; she (E4) and E5 also review newly developed wounds weekly as part of facility surveillance. 3. R22's Physician order [REDACTED]." Z1, Wound Specialist Medical Doctor, documented in the Wound Care Specialist Evaluation report on 3/20/15 and 3/27/15, "Diabetic Wound of the Left Heel, Moderate Serous Exudate. " Wound Care History notes written by E5, Wound Nurse/LPN, documented on 3/20/15 and 3/27/15, "Left Heel, Moderate Serous Exudate." E5 documented R22's Skin Assessment: "3/22/15 Nec (Necrotic) No drainage, (left heel circled on the diagram)." On 4/15/15 at 10:30 AM, E9 Licensed Practical Nurse (LPN), completed a dressing change to R22's left heel. The dressing was saturated with serous sanguineous drainage. E4, Infectious Disease Nurse/LPN, performed a wound culture on the drainage from the left heel wound and E6, LPN, assisted with the procedure. During R22's dressing change on 4/15/15 at 10:30 AM, E9 stated, "There is a lot of sero-sanguineous drainage on the old dressing." On 4/14 /15 at 11:15 AM, E5 stated that "A culture of R22's left heel was not done (prior to this day) because it was 50% necrotic on 3/22/15." E5 confirmed that R22's left heel wound has not been cultured despite having sero-sanguineous drainage off and on between 3/20/15 through 4/15/15. E5, then stated she "I am not concerned that the wound has not been cultured for Strep A, as everyone in the facility is going to be treated anyway." E5 did not state when this treatment for [REDACTED].

Based on interview and record review, the Facility failed to ensure residents with Pressure Ulcers receive timely necessary monitoring and treatment to prevent infections for 2 of 9 residents (R2, R11,) reviewed for infected Pressures Ulcers in the sample of 33. This failure resulted in R2 being hospitalized with [MEDICAL CONDITION] with Group A Strep (GAS) bacteremia, multiple bacteria, in Sacral Decubitus Ulcer." Findings include: 1. R2's Face Sheet, dated 2/4/15, documents that R2's [DIAGNOSES REDACTED]. R2's Physician order [REDACTED]." On 3/20/15, Z1, Wound Care Specialist, documented on R2's Wound Care Specialist Evaluation form "left Ischium stage 4 pressure wound: Wound size: 7.5 centimeter (cm) X 8.0 cm X 5.5 cm, surface area: 60.00 cm, undermining: 6 cm at 11 o'clock, Exudate: Heavy Serous. Right Ischium pressure wound, unstageable. Wound size: 2.8 X 2.0. Surface area: 5.60 cm. Exudate: Moderate Serous. A Laboratory Analysis documents that on 3/22/15 at 1:00 PM, a throat culture and culture to R2's left shin was obtained. There is no record that a culture of R2's Stage 4 Pressure Ulcer on the left ischium was obtained at this time. On 3/29/15 at 2:30 PM, E25, Licensed Practical Nurse (LPN), documented in R2's nurses notes "staff into room checking on resident, felt warm to touch, T&P (turn and reposition) at this time. Temperature (Tw) 101.4. Writer gave resident Tylenol at this time. B/P (blood pressure) 130/70 P (pulse) 74, Respirations (R) 20." On 3/29/15 at 2:35 PM, orders received from Z5, R2's Physician, to obtain urinalysis and culture and sensitivity for possible urinary tract infection, Stat CBC (statim, complete blood count), chest x-ray due to increased temperature and congestion. Isolation until influenza swab can be done. R2's Laboratory Analysis, dated 3/29/15 at 5:00 PM, documents the results of R2's CBC: "White Blood Cells 47.3 (normal 3.4-9.4)." R2's nurses notes document that R2 was sent and admitted to local hospital in Intensive Care Unit with [DIAGNOSES REDACTED]. On 4/3/15 at 4:00 PM, Z9, Hospital Physician, documents "Hospital Progress Notes - [MEDICAL CONDITION] with Group A Strep (GAS) bacteremia, multiple bacteria in Sacral Decubitus Ulcer." R2's hospital records include documentation on 4/3/15 at 10:48 PM, by Z6, Infectious Disease Medical Doctor: "History of Present Illness/Reason for Consultation: Group A [MEDICAL CONDITION]. Under Assessment/Plan: Group A [MEDICAL CONDITION]; characterized by shock liver, acute [MEDICAL CONDITION], marked leukocytosis, elevated creatinine phosphokinase (CPK), [MEDICAL CONDITION] requiring pressors. Multiple decubiti / soft tissue wounds. Breakdown of left fasciocutaneous rotation flap to Stage 4 pressure sore over the left ischium. Right middle lobe infiltrate (though without dramatic additional oxygen requirements or [MEDICAL CONDITION] symptoms). Cerebral palsey. Multinodular goiter-status [REDACTED]. Under Discussion: includes Group A Strep is an unusual [MEDICAL CONDITION] or urinary pathogen but is quite typical for the soft tissue." On 4/6/15, the algorithm which the CDC gave the facility to follow was reviewed and documents "IDPH Investigation of One Culture-Confirmed Invasive GAS Infection. 1. Identification of additional cases: Maintain "active surveillance" for additional invasive or noninvasive cases for 4 months from onset of most recent case." On 4/6/15 at 11:00 AM, E4 Licensed Practical Nurse (LPN), stated "I have cultured all of the residents throats in the facility and have cultured all of the wounds in the facility." E4 stated "I am following the algorithm from the Center for Disease Control (CDC)." E4 stated "R2 had multiple wounds and as we had cultured his leg wound, We (E4 and E5 LPN) felt the coccyx ulcer didn't need to be done." E4 stated they did not verify with or ask Z3 for an order not to culture R2's Stage 4 Pressure Ulcer. On 4/8/15 at 2:30 PM, Z3 Infectious Disease Medical Doctor, was asked if any staff had asked for a clarification of what wounds to culture if a resident had more than one wound. Z3 stated "I would not necessarily culture all wounds if a resident had more than one wound, I would definitely culture the worst wound - the worst wound would have the highest chance for Strep A." Z3 stated, No staff has asked me to clarify, change or discontinue the order for any resident. No facility staff asked for clarification on which wounds to culture. On 4/14/15 at 11:10 AM, E2 was asked who at the Facility decided which wounds to culture. E2 Cooperate Regional Director, stated "E4 and E5 LPN collaborated to decide which wounds to culture." 2. R11's nurses notes document "4/1/15, 4:30 PM, Certified Nurses Aide (CNA) alerted writer that resident has an open area 2 centimeters (cm) by 1.5 cm to the [MEDICATION NAME] spine. No drainage noted. Wound team alerted and family made aware". This nurses note was signed by E8, Licensed Practical Nurse (LPN). There is no documentation regarding the open are on R11's [MEDICATION NAME] spine in R11's current physicians order's or on the April 2015 Treatment Administration Record (TAR). There is no further documentation regarding the open area on R11's [MEDICATION NAME] spine in R11's nurses notes. E5, Wound Nurse, stated in an interview on 4/13/15 at 12:56 PM, that no one ever told her about the open area on R11's [MEDICATION NAME] spine. E5 said that there is no record of R11's physician being notified of the area and a treatment order was not obtained. E8, Licensed Practical Nurse, stated on 4/13/15 at 1:08 PM, that she "said something in passing" about the new area on R11's [MEDICATION NAME] spine to E5. E8 said that E5 has a lot of responsibility so E5 "probably forgot" that E8 told her about R11's new open area. R11's Facility Admission Record, dated 2/5/15, documents diagnoses, in part, of End Stage [MEDICAL CONDITIONS] and Hypertension. R11's most recent plan of care (undated) does not address the open area on R11's [MEDICATION NAME] spine. R11's most recent Minimum Data Set (MDS), dated [DATE], documents that he is cognitively intact, is dependent on the extensive assistance of one staff member for transfers and bed mobility, and does not ambulate. R11's "Braden Scale - For Predicting Pressure Sore Risk", dated 3/10/15, documents that R11 is at "High Risk" for skin breakdown. On 4/14/15, a list of prepared questions was given by telephone to Z11, who is Z2's Assistant. Z2 is R11's physician. Z11 stated in a telephone interview on 4/15/15 at 2:00 PM that Z2 reviewed R11's clinical record with Z11 and Z11 was speaking for Z2. Z11 said that the Facility did not notify Z2 regarding a pressure sore on R11's [MEDICATION NAME] spine.

Based on record review and interview the facility failed to ensure residents are monitored for changes in post surgical incisions for 1 of 5 residents (R3) reviewed for wound care in a sample of 15. This failure resulted in R3's wounds dehissing, developing a post surgical wound infection and needing hospitalization . Findings include: Review of R3's "Face Sheet" documents R3 was admitted to the facility at 4:00 p.m. on 11/26/14 with a diagnoses, in part, "Open wound of hip/thigh and Diabetes Mellitus." Review of R3's "Dictated Operative Report" from the hospital dated 11/13/14 documents R3's operative procedure as a Right Common Femoral Artery to Right Anterior Tibial Artery Bypass with Non-Reversed Saphenous Vein Graft and Right Common Femoral Endarterectomy. Review of R3's "Hospital Discharge Summary" dated 11/26/14 documents " Instructions after discharge" Wound care - Keep incision clean and dry until staples removed. Showering okay with mild soap and water. Pat dry. In addition, call your primary doctor for the following problems: 1) signs of infection (warmth, fever, drainage, opening). 2) bleeding (excessive) at site, call 911. Review of hospital "Additional Transfer Orders" dated 11/26/14 documents R3's "Dressings" - left and right leg - staples open to air - keep clean and dry; Rooke boots; and right groin - wet to dry dressing, change daily. Follow-up with Z4 (surgeon) for staple removal. Review of R3's "Admission Nursing Assessment" completed by E14 Licensed Practical Nurse (LPN)dated 11/26/14 documents R3 to have; 11 staples in right groin, 84 staples in the right inner leg, 11 staples in the right outer calf, 11 staples in the right upper thigh and 7 staples to left inner thigh. In addition, R3 has an open area top of right foot and side by big toe of right foot. The Nurses Notes dated 11/26/15, documented R3's Left inner leg has 84 staples, not his right inner leg as noted above. Review of "Nurses Notes" at 1:10 a.m. on 11/28/14 documents R3's vitals. "Denies pain. Refuses to keep bilateral lower extremities elevated, seated on bed with legs dangling and touching floor. Refuses to wear Rooke Boots...staples open to air/intact to bilateral lower extremities...". There are no further nurses notes documented on 11/28/14. On 11/29/14 at 1345 (1:45 p.m.), R3's nurses notes document "...Has surgical incision from right lower leg extending up to right groin staples. Surgical incision to right groin with dehiscence. Wet to dry dressing changed as ordered. Wound bed with yellow slough with moderate amount of yellowish drainage. No odor. Complains of pain to area and bilateral lower extremities (BLE). Has 2 surgical incisions to bilateral upper and lower leg with staples intact. Some redness noted to right lower incision. +3 tight [MEDICAL CONDITION] to (BLE). Encouraged to elevate, but is non-compliant...Page out to Z5 (on-call surgeon for Z4) to update about R3's right inner groin incision...R3 aware." On 11/30/14 at 11:45 AM, the Nurses Notes document "...Redness to incision to Left lower leg. Wet to dry dressing continues to right groin. Large amount of yellow drainage with yellow slough to wound bed. [MEDICAL CONDITION] continues to BLE. Encouraged to elevate and is non compliant...Fluids offered and accepted." On 12/1/14 at 0400 (4:00 a.m.), the Nurses Notes document "...encouraging fluids". "...Dressing removed for R3. Wet to dry dressing done again at this time. Has yellow greenish drainage right groin area...Staples right upper and lower intact and open to air. Left lower leg with staples dry and intact open to air...Encouraging fluids." On 12/3/14 - 7 to 3 shift, R3 up in wheelchair. Dressings changed to groin, right hand and left forearm..." Nurses notes at 10:00 a.m. on 12/4/14 are nearly illegible, E2 Director of Nursing (DON) attempted to decipher and unable to reach E16 (Wound Nurse). At 10:00 a.m. on 12/4/14, nurses notes document "...Right groin surgical site noted dehiscence. 90% slough with 10% granulation tissue. Noted staples to area of upper right groin intact. R3 moving about, making it difficult to assess...R3 allowed E16 to finish measuring wounds...old dressing saturated with serosanguinious fluid...notified nurse of findings." From 11/29/15 to 12/4/15 there is no documentation evidenced in the Nurses Notes that Z4 or Z5 returned the call regarding R3's leg, or that staff made any additional attempts to notify Z4 or Z5 of the worsening of his wounds, or attempt to seek additional treatment or interventions to care for R3's worsening wounds. On 12/5/14 at 0900 (9:00 a.m.) E17 Unit Manager/Registered Nurse documents that Z6 (R3's sister) here to visit R3 and is concerned about R3's surgical wound. R3's right groin surgical incision had dehisced. No staples seen. Wound team paged. R3 assessed. R3 refused vitals. At 9:06 a.m. ambulance called to transport R3 to the hospital emergency room . At 9:08 a.m. Z7 (physician) notified by phone. At 9:30 a.m. R3 left facility by ambulance. Review of hospital emergency room records dated 12/5/14 documents "R3 two weeks post operative thigh/hip wound dehiscence with possible infection at site." R3's physical examination in the emergency room documents "Extremity: large are of dehiscence in right groin, deep, this is packed with gauze, there are stapled wounds throughout medial portion of both legs, several areas on left show dehiscence, right calf wound reddened and appears infected, staples intact." "Impression and Plan" wound dehiscence/infection, [MEDICAL CONDITIONS] and insulin dependent diabetes mellitus, Plan to Admit and refer to Z4 (surgeon) for further treatment and care. Review of R3's "wound culture" documents on 12/5/14, "grew diphtheroids and [MEDICATION NAME] cloacae". Interview with E2 (DON) at 10:00 a.m. on 2/4/15 states E12 Licensed Practical Nurse (LPN) worked the day shift of 12/4/14. Interview with E12 at 12:35 p.m. on 2/4/15 states R3 removed his dressings and picked at the wounds sometimes, but E12 did not see R3 remove any staples. E12 said she is a float nurse and only was R3's nurse a couple of times. E12 does not know when R3's wound dehiscence got worse, she said if she knew it was worse she would have called the doctor. Surveyor asked E12 to review the nurses notes, which she did. E12 was unable to find a nurses note she wrote for R3. E12 said she didn't think everything was in R3's chart. Interview with E14 (LPN) at 11:45 a.m. on 2/11/15 states she cannot remember which side R3's long incision was on. E14 said she is a float nurse and she really does not remember R3 very well. On 2/10/15, in a further interview E2 (DON) states she has gone through all the boxes of medical records that have not been filed for R3. E2 says she cannot find any further documentation for R3. In addition, E2 was unable to say if R3's physician was notified of R3's declining wound condition between 11/29/14 and 12/4/14.

Based on observation, record review and interview, the facility failed to timely identify/monitor and treat pressure ulcers and failed to follow preventative measures 4 of 9 residents (R1, R4, R11, R14) reviewed for pressure ulcer prevention in a sample of 25. This failure resulted in R11's developing multiple facility acquired pressure ulcers including two unstageable pressure ulcers to his ankle and toe. Findings include: 1. R11's Admission Sheet documents was admitted on [DATE]. R11's Minimum Data Set ((MDS) dated [DATE] documents that R11 is an extensive assistance with one person for bed mobility, transfers, toileting, personal hygiene and bathing. The Weekly Pressure Ulcer Record dated 9/19/14 documents that R11 had a Stage 2 pressure ulcer measuring 2.0 centimeters (cm) by 2.0 cm to his right buttock. R11's Braden Scale for Predicting Pressure Sore Risk documents that on 9/19/14 R11 had a score of 16 with mild risk being score of 15-18 even though R11 had a pressure ulcer on admission. R11's Weekly Pressure Ulcer Record dated 9/25/14 written by E18, Wound Nurse, documents R11's pressure ulcer as healing scar tissue, resolved. R11's weekly Pressure Ulcer Record dated 10/10/14 documents R11 had a newly in- house developed Stage 2 pressure ulcer, measuring 6. cm x 5.4 cm to Right trochanter. There is no explanation as to why the facility did not identify this area sooner since he was dependent on staff for all activities of daily living according to the care plan. R11's Braden Scale, dated 10/10/14, documents R11 has a score of 11 (high risk 10-12). R11 was at high risk for skin breakdown. R11's Care Plan dated 10/13/14 documents that R11 is at risk for impaired skin integrity related to fragile skin. R11's care plan documents that staff are to float R11's heels, report changes in skin status to physician and complete the Braden Scale. The Care plan documents that staff are to notify the nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing and daily skin care. R11's Care Plan dated 10/13/14 documents that R11 has a stage 2 facility acquired pressure ulcer to Right and Left trochanter and R ishium. The Care Plan documents that R11 is to use wheelchair cushion to reduce pressure. Reposition/redistribute weight every 2 hours while awake in bed and hourly while in wheelchair. The Facility's Weekly Pressure Ulcer Record, dated 10/17/14, documented R11 developed a new, unstageable pressure ulcer on his left toe measuring 1.0 cm by 1.0 cm with 100% brown eshcar, and an unstageable pressure ulcer to his Left dorsal foot measuring 0.5 cm x 0.5 cm with 100% brown eschar. Again, the facility had no explanation as to why these areas were not identified more timely given his dependency on staff for all cares. On 10/27/14 at 11:00 AM, R11 was lying on his back in low bed with mat beside bed. E40, Licensed Practical Nurse (LPN) was doing skin check and R11 did become combative so E40 did not proceed. Dressing to L greater trochanter was in place during skin check. E40 did undo dressing and L greater trochanter had area that was unstageable due to dark eschar covering area. On 10/27/14 at 11:00 AM , E40 LPN stated that R11 can be combative and does pick at his dressings so they keep pants on him while in bed. R11's Care Plan fails to document these behaviors. The facility failed to develop interventions for R11's behaviors. On 10/31/14 at 9:55 AM, E18 stated that stage 2 pressure ulcer to the left trochanter was found during a random whole house skin check on 10/10/14. E18 stated that she would have expected staff to have found this during care prior to this time. E18 stated that E18 was incontinent of urine during the random whole house skin check on 10/10/14. The facility's Policy Pressure Ulcers/Skin Breakdown- Clinical Protocol documents under Interventions and Preventative Measures to immediately report any signs of a developing pressure ulcer to the supervisor. The Policy documents that if chair fast to change position at least every hour. 2. R4's MDS dated [DATE], documents that R4 requires an extensive assist with two plus persons physical assist for bed mobility. R4's MDS documents that R4 requires total dependence with two persons physical assist and is frequently incontinent. R4's Physician order [REDACTED]. On 10/26/14 at 1:55 PM, R4 was observed to have opened areas on L (Left) buttocks. No dressing was in place when incontinent brief was removed. R4 was incontinent of urine. 0n 10/29/14 at 2:00PM, E39, Treatment Nurse stated that R4's open areas on L buttocks was from moisture associated skin [MEDICAL CONDITION]. E39 stated that R4 is to have a duoderm to left buttocks and changed every three days. 3. R1's Braden Scale Risk for Pressure Ulcer Assessment of 10/10/14 documents R1 is at high risk for developing pressures. R1's MDS of 9/8/14 documents R1 is totally dependent on 1 or more staff for transfer and bed mobility. R1's Care Plan of 9/18/14 does not address R1's high risk for development of pressure sores. R1 was observed on 10/27/14 from 8:50 AM to 10:33 AM to be up in his wheel chair without being repositioned. At 10:33 AM, E15, Certified Nurse's Assistant (CNA) was in R1's room and stated she and E31, CNA, had just transferred R1 to bed. R1's incontinent brief was saturated with feces and urine and the back of his thighs were deep creased and red. E15 stated R1 had been up in his wheel chair since 7:45 AM. 4. R14's MDS of 8/14/14 documents R14 is totally dependent on 2 or more staff for transfer and bed mobility. R14's Care Plan of 8/19/14 documents R14 is at risk for impaired skin integrity related to incontinence of bowel and bladder. Care Plan approach, in part; reposition resident as per facility protocol, provide incontinence care after incontinence episodes and apply barrier cream PRN (as needed). R14 was observed on 10/27/14 every 5 to 10 minutes, to be up in a geriatric reclining chair from 8:50 AM to 11:40 AM with no positioning or checking for incontinence. At 2:55 PM, R14 was observed in bed and E15 was in the room and stated she had just put R14 to bed. R14 had a large bowel movement and she had an opaque hydrocholloid dressing on her coccyx that was soiled with feces. E39 stated the dressing was for a preventative and R14 did not have a pressure sore at this time

Based on observation, record review and interview, the facility failed to provide adequate supervision and develop effective interventions to prevent further falls for 3 of 3 residents (R8, R10, R11) reviewed for falls in a sample of 17. This failure resulted in repeated falls for R8 resulting in fractures of the thumb, radius, shoulder and hip. Findings include: 1. The Minimum Data Set, ((MDS) dated [DATE], documented R8 had severe cognitive impairment requiring assist of at least one staff for transfers, ambulation, toileting and eating; and required extensive assist with bed mobility, hygiene and bathing. The MDS documented R8 could not maintain balance for herself without staff assist and had Range of Motion, (ROM) deficits of one side of the upper extremity. The Care Plan for R8, dated 10/26/13, documented R8 was alert and oriented x 1-2 with confusion and was at risk for falls "secondary to impaired cognition and generalized instability on feet without assist." On 08/07/13 0045, Nurse's Notes documented R8 was found on the floor in her room sustaining a large 2 1/2 inch raised area on the right side of forehead. No other injuries noted. On 08/08/13 at 1800, a Nurse's Note documented R8 was "overheard complaining to her friend that her right thumb hurt and it wasn't being addressed. Writer assessed right hand was noted to be bruised and swollen." The physician was notified and X-ray ordered and confirmed a fracture of the right thumb. R8 later had a cast applied to the right hand. The Care Plan documented new interventions to do patient teaching for wearing socks with shoes. On 09/29/13 at 0710, a Nurse's Note documented R8 fell from bed landing on right side. Nurse's Notes also documented R8 "unable to move right arm ROM (Range of Motion). Edema noted to right shoulder. Complains of pain rating 10." R8 was transferred to the hospital and a fracture to the right shoulder was confirmed via X-ray. R8 was sent back to the facility. On 10/14/13, Nurse's Notes documented R8 was sent to the hospital for right shoulder surgery. The interventions put into place on 09/29/13 were personal alarms placed and therapy to evaluate and treat. On 10/15/13 at 0800, Nurse's Note documented R8 "found on floor at side of bed. States she was going to bathroom. Call light on bed within reach. Slipper socks on and sling on right arm. Resident complains of pain to right shoulder." There were no new interventions put into place after this fall. On 10/29/13 at 2025, Nurse's Note documented "A Certified Nurses Assistant, (CNA) heard resident bed alarm sound then resident yell for help. Resident was noted on the floor at her bedside with her left arm twisted up under her." During ROM assessment, R8 "complained of pain to left and right arms/shoulders and left leg with outward rotation." After notifying the physician, R8 was transferred via ambulance to (hospital #1) for evaluation. Nurse's Notes documented that R8 was supposed to go to (hospital#2). On 11/05/13 at 11:00 AM, E4, Assistant Director Of Nursing, (ADON) stated that it is unclear as to why ambulance personnel took R8 to (hospital #2). The Ambulance Run Sheet, dated 10/29/13, documented send to (hospital#2). The Care Plan documented interventions as "move closer to nurses station, alarms already applied, therapies to evaluate and treat." On 10/30/13 at 3:30AM, R8 was transferred back to the facility with the [DIAGNOSES REDACTED]. On 10/30/13 at 12PM, a Nurse's Note documented when R8 was transferred from wheelchair to toilet by CNA, R8 complained of "pain in leg all the way up and down. Some edema noted to area. MD notified order received for left hip X-ray." Nurse's Note documented that portable X-ray done at 12:30PM. At 2:25PM, a Nurse's Note documented R8 had a left femoral neck fracture, the physician was notified of the X-ray results and R8 was transferred to hospital #2 for admission. A Nurse's Note documented at 3:45PM that after speaking with hospita l#2 staff, R8's left femoral neck fracture required surgical intervention. On 10/30/13 at 9PM and 10PM, Nurse's Notes documented that the Orthopedic Resident from the hospital called the facility and "asked if there was anything I can do to prevent this patient from falling again." Further notes documented, "he (Ortho Resident) was made aware that resident (R8) had bed alarm and chair alarm implemented for safety. And he was made aware of the X-ray performed at St. John's Hospital was negative and the portable X-ray done the next day at the facility confirmed left hip fracture." On 10/31/13, Nurse's Note documented R8 was being discharged from the facility. On 11/01/13 at 11:00 AM, E4 confirmed that R8 was discharged and not returning this facility. On 11/01/13 at 2:20 PM, E8, CNA stated that R8 was alert to herself, but was forgetful. She stated that R8 would be reminded "all the time" to use the call light and to wear shoes, but R8 would not remember. E8 stated that R8 would repeat things like walking from one room to another over and over and would frequently try to get up without assist. During an interview on 11/07/13 at 2:00 PM with E1, Administrator, E3, Director of Nursing and E4, Assistant Director Of Nursing, it was determined that the facility did not have a system in place to prevent further falls from those residents who have frequent falls that assesses, analyzes, implements and monitors the effectiveness of new or existing interventions put into place. 2. The MDS, dated [DATE], documented R11 had cognitive impairment and required extensive assist of at least one staff for bed mobility, transfers, ambulation, dressing, hygiene, bathing and toilet use. The MDS documented had a balance deficit and required assist with stabilization of staff. The Care Plan, dated 08/29/13, documented R11 was alert and oriented to self and requires assist with transfers, bed mobility and toileting. The Care Plan identified R11 as a fall risk. On 08/30/13, Nurse's Note documented R11 was found on the floor in her room. Documented "resident confused, not sure what happened." Intervention put in place was alarm placement. On 09/02/13, Nurse's Note documented R11 was found on the floor on her back. R11 stated "she was trying to go to the bathroom." Interventions put in place was to continue with alarms, neuro checks, one to one to educate on safety and low bed. On 10/03/13, Nurse's Note documented R11 found on floor, "Resident continues to climb out of bed and scoot on bottom on the floor." Interventions put in place were frequent checks and visual checks when passing by room. On 10/21/13, Nurse's Note documented R11 found sitting on floor in front of wheelchair in her room. No new interventions put in place. On 10/23/13, Nurse's Note documented R11's "bed alarm heard sounding. CNA witnessed resident stumble and fall to her bottom." Interventions were to move to another floor near nurses station, patient safety teaching and encourage activities participation. On 11/07/13 at 1:20 PM, E11, Licensed Practical Nurse,( LPN) stated that R11 was pleasantly confused and would have moments of verbal and physical abuse toward staff. E11 also stated that R11 "lacked safety awareness" and cannot remember to use the call light or stay in the wheelchair. E11 stated that R11 has personal alarms, but doesn't seem to notice that it's there to remind her to sit or not to get up. Also stated that R11 was taken to activities, but would be disruptive and staff would take her back to her room. On 11/07/13 at 1:35 PM, R11 was observed in her room on a low bed yelling out as people walked by her room. E10, CNA entered room and asked if R11 needed to use the restroom. R11 replied yes. E10 was observed to take R11's hands in her own hands and pull her up to a standing position from the low bed. R11 was observed to be very unsteady on her feet. R11 took 4 very small steps to the wheelchair and sat down. No gait belt was used. E10 then stated she needed to get a gait belt and left the room. R11 was very confused and kept asking to go to the bathroom. E10 returned and applied a gait belt to R11 and assisted to a standing position. R11 took very small steps approximately 5 feet to the toilet. E10 then with one hand removed R11's pants and incontinent brief, which was dry. R11 sat down on the raised toilet seat. When finished, E10 asked R11 to stand up and she would wipe her clean. R11 stood while E10 used a hand towel to clean the perineal area then the buttocks area. R11 asked "Are you done yet?" E10 replied "In just a minute." E10 then realized that she did not have a fresh incontinent brief and had to yell out to staff in the hallway to get her a new one. R11 remained standing and her legs began to shake violently and she said, "I'm going to fall to the floor if you don't get going." E10 told her to sit back down on the toilet. E10 then asked E4, ADON to assist her in applying the incontinent brief and pull her pants up. During this time, R11 repeatedly stated she was going to fall and wanted to know what was going on. E10 assisted R11 by ambulating back to the wheelchair. E10 stated that she wasn't sure if R11 was ambulated to and from meals today. 3. The MDS, dated [DATE], documents in part, R10 is dependent on transferring, ambulation, dressing, hygiene, and bathing extensively with assist of one staff. MDS documents balance during transition and walking as "not steady, only able to stabilize with staff assistance." MDS further documents that R10 has no falls since admission. R10's Care Plan dated 9/1/13, documents in part, that R10 is alert and oriented to only one of three: self, time, or place. Care Plan further documents R10 is at risk for falls. According to Nurse Notes and Incident Investigation Worksheets: On 7/21/13, at 6:00 p.m., R10 was found on floor. R10 stated he was trying to tie his shoe and fell out of wheelchair onto the floor. R10 had laceration to left eye. On 7/29/13, at 10:00 p.m., R10 was found on floor in room near bed. R10 stated he was going to the bathroom and lost balance. On 8/14/13, at 7:30 p.m., R10 was found on floor lying on his back. R10 requested staff to take him to the bathroom. On 8/15/13, at 3:20 a.m., R10 was observed by staff ambulating in room with walker and tripped over night stand and fell to ground. Call light was not in reach or functioning at the time of occurrence. Incident Investigation Worksheet dated 8/15/13 documents in part, R10 has unsteady gait with walker unassisted. On 8/15/13, at 5:50 p.m., R10 was found on floor in room in front of the door after staff heard a loud bang coming from R10's room. R10 stated he was going to the bathroom when he lost balance and fell to the floor. Call light was not in reach or functioning at the time of occurrence. On 8/16/13, at 7:35 p.m., R10 was found on floor of his bedroom in front of wheelchair. R10 unable to explain what happened. Incident Investigation Worksheet dated 8/19/13 documents in part, R10 is alert and oriented to self only and does not remember that he is unable to ambulate/transfer independently. On 8/17/13, at 3:00 a.m., R10 was found on floor in his room. R10 stated he was going to get something to eat. Call light was not in reach or functioning at the time of occurrence. Incident Investigation Worksheet dated 8/19/13 documents in part, R10 does not have orientation to place and does not remember he cannot ambulate. Worksheet further states that R10 does not remember to use call light to alert staff of needs. 8/17/13, at 2:00 p.m., R10 was found on floor in his room. Incident Investigation Worksheet dated, 8/17/13 documents in part, R10 does not remember to use call light to alert staff of needs. Worksheet further documents that R10 can not ambulate indecently causing him to fall due to unsteady gait. On 8/18/13, at 9:00 a.m., R10 was found on floor in his room. R10 ambulating to the bathroom and fell . Call light not in reach or functioning at the time of occurrence. Incident Investigation Worksheet dated 8/18/13 documents in part, R10 is confused and tried to transfer by himself. On 8/19/13, at 4:30 p.m., R10 was found on floor in his room between bed and recliner. Incident Investigation Worksheet dated 8/20/13 documents in part, R10 must be reminded frequently to seek assistance for transfers. On 8/25/13, at 9:15 a.m., R10 was found on floor in his bathroom. R10 ambulated in bathroom and fell to floor. On 11/6/13, at 11:58 a.m., during an telephone interview, E9 stated that she cared for R10 daily and R10 had cognitive decline since admission and had left sided weakness. R10 was aware to use call light only at times but R10 mostly called out for assistance. E9 also stated that R10 had frequent need to use the restroom and R10 transferred with gait belt and walker. On 11/6/13 at 2:20 p.m., E4 stated that R10 had a soft waist restraint ordered to prevent falls but was discontinued and was ineffective. E4 stated that R10 had alarms and the alarms were also ineffective but were the first line of intervention.

Based on interview and record review, the facility neglected to notify the physician of a decline in pressure ulcers and overall condition for 2 of 3 residents (R4, R8) reviewed for pressure ulcers and hydration in a sample of 10. This failure resulted in delay in treatment that resulted [MEDICAL CONDITION] from an infected pressure sore for R4 who expired. Findings include: According to Weekly Pressure Ulcer Reports, R4 had a right buttock pressure ulcer which was assessed as having 100% necrotic tissue on the wound bed, was unstageable on [DATE]. On [DATE], R4 went to the wound clinic and saw Z2, Wound Physician. The Physician's Wound Report documents that "an extensive excisional debridement was performed using a scalpel. This removed skin, subcutaneous tissue and a copious amount of muscle." Documentation continued to state "the wound was improved. The patient tolerated the procedure well. The size of the wound after debridement was significantly larger than that predebridement." R4 returned to the facility with orders for Santyl Dressings daily and for pressure / offloading. The next appointment was made for [DATE]. On [DATE], R4 went to the wound clinic. Clinic Notes dated [DATE], documented, "last week in clinic, we performed a significant debridement which included skin, subcutaneous tissue and muscle. We removed a fair amount of necrotic tissue. We were able to get back to essentially viable tissue around the entirety of the wound. The patient was to be getting pressure offloading and Santyl dressings changes daily. The patient today was accompanied by her family. There was no report given to us that her wound had at all deteriorated." A physical examination done on [DATE] during the visit, documented "R4's pressure ulcer was now 7 x 8.5 x 1 with copious necrotic tissue throughout the patient's right side of her buttock. She has a new area of skin necrosis, which extends over into the left buttock as well as inferiorly along the right." Z2, Wound Physician, again debrided the area to both buttock to remove an "an extensive amount of tissue. This was in excess of 20 square cm." The report documents R4 was sent from the wound clinic directly to the hospital emergency room for likely admission. According to hospital records, R4 was admitted to the hospital and later to home on Hospice. On [DATE] at 2:00 PM, Z2 stated in interview that he very well recalled R4 and remembered her coming into the clinic. Z2 stated when he saw her the first time, he did an extensive debridement to "good healthy tissue" and sent her back to the facility for daily dressing changes. Z2 stated when she returned a week later, she had a fair amount of necrotic tissue, "the whole wound actually," then stated "No Way they could have done dressing changes daily and not noticed the decline." Z2 stated he would have expected the facility to notify him on the first sign of decline and he would have seen her again adding that there was "No Way is this decline was an overnight thing." When asked if he felt this was neglect, Z2 stated "Yes, I would." Z2 stated R4 was transferred to the hospital then expired at home with family. The death certificate signed by Z2 identified the date of death as [DATE] with cause of death listed [MEDICAL CONDITION], decubitus ulcer and pneumonia/Dementia. In interview [DATE] at 8:30 AM, E8, Licensed Practical Nurse (LPN) stated she did the weekly wound sheet dated [DATE] and stated she thought the wound had deteriorated but when asked if she notified the wound Doctor, stated "No, I figured it was being followed by the wound clinic Doctor" who would be seeing her weekly. E8 stated R4's pressure ulcer had odor on [DATE]. The Weekly Wound Report dated [DATE] does not document the physician or family were notified. Nurses Notes from [DATE] through [DATE] are missing from R4's record. On [DATE] at 10:00 AM, E1, Administrator, stated the Nurses Notes are unable to be located. The Treatment Administration Record (TAR) documented from [DATE] through [DATE] R4's treatments were done by E15, LPN. On [DATE] at 10:10 AM, E15, stated "before R4 went to the wound clinic, the wound bed was covered with black eschar. After the wound clinic visit, E15 stated the wound bed was beefy red and was a deep hole, but by the 2nd or 3rd day, it had an odor, little patches of yellow slough in it." E15, also stated it appeared to be spreading toward the left side. Asked if she notified the wound physician or nurse of the decline, stated no, she "would only notify them if she felt the decline or change was significant." E15 identified herself as a staff nurse and does treatments on third floor. On [DATE] at 12:30 PM, Z3, R4's Niece, in interview stated she was aware that R4 had a pressure ulcer on her coccyx and three weeks before [DATE] clinic visit, the nurse told her the pressure wound was "out of control." She stated staff did not give her details but would tell her it was not healing, getting worse toward the end but she had no idea that it was as bad as it was. Z3 stated she did not attend the first wound clinic visit with R4 but was actually called by the clinic and asked to be with R4 on her second visit [DATE]. Z3 stated she observed the area and was shocked at the size and condition of the wound stating the odor was so bad she thought R4 had soiled herself.. Z3 stated Z2 sent R4 to the hospital then she took her home on Hospice where she expired. Z3 stated the Z2, Wound Physician, signed the death certificate since she died from [MEDICAL CONDITION] from the pressure ulcer. On [DATE] at 10:00 AM, E1, Administrator / Registered Nurse (RN) stated he would have expected E8 or E15 to call both the Z2, and the primary physician with a decline in wound condition. The facility's policy entitled "Change in a Resident's Condition or Status" documents the facility "shall promptly notify the resident, his or her attending physician and representative of change in the residents medical/mental condition and/or status." The policy documents "significant change" of condition is a decline or improvement in condition in the resident's status that will not normally resolve itself without intervention. The policy also indicate the Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on interviews and record review, the facility neglected to follow their policy/procedure for monitoring, treating and evaluating pressure ulcers and failed to assess and monitor fluid intake adequate hydration for 2 of 3 residents, (R4, R8) reviewed for pressure ulcers and dehydration in a sample of 10. This neglect resulted in a signfication decline in R4's coccyx pressure ulcer which increased greatly in size showing signs of infections. R4 was hospitalized with a [DIAGNOSES REDACTED].. The facility neglected to assess R8 for risks of dehydration, neglected to monitor his intake following an order for [REDACTED]. Findings include: 1. According to weekly wound report completed by E8, Licensed Practical Nurse (LPN) dated [DATE], R4's right buttock was identified an "unstageable" having 100% necrotic tissue present with light purulent drainage measuring 3.5cm x 2.5cm x 1cm deep. E8 documented that the primary physician was notified but not the family. On [DATE] at 8:30am, E8 Licensed Practical Nurse stated she thought R4 needed to be seen by the wound clinic because her wound kept getting worse. E8 stated she did not document that anywhere but made the appointment for R4 on [DATE] to see a wound specialist. On [DATE], R4 was seen by Z2, Wound Physician at the wound clinic. Wound notes from the clinic dated [DATE] document under History "the best that we can ascertain from the records that were sent with her, she has had a pressure ulcer since April." The report identifies the initial evaluation of R4's pressure ulcer measured "4.3c, x 5cm x 2.5cm with a significant amount of necrotic material throughout the entire base of the wound and along the upper surface of the wound." The report documents that "an extensive excisional debridement was performed using a scalpel. This removed skin, subcutaneous tissue and a copious amount of muscle." It continued to state "the wound was improved. The patient tolerated the procedure well. The size of the wound after debridement was significantly larger than that predebridement." Plans were to have Santyl Dressings and pressure offloading done and to see R4 again in a week. On [DATE], R4 went to the wound clinic. Documentation dated [DATE] from the clinic states "last week in clinic, we performed a significant debridement which included skin, subcutaneous tissue and muscle. We removed a fair amount of necrotic tissue. We were able to get back to essentially viable tissue around the entirety of the wound. The patient was to be getting pressure offloading and Santyl dressings changes daily. The patient today was accompanied by her family. There was no report given to us that her wound had at all deteriorated." Physical examination recorded at the time documented R4's pressure ulcer 7 x 8.5 x 1 with copious necrotic tissue throughout the patient's right side of her buttock. She has a new area of skin necrosis, which extends over into the left buttock as well as inferiorly along the right." The Wound Physician, Z2 again debrided the area to both buttock to remove an "an extensive amount of tissue. This was in excess of 20 square cm." The report documents R4 was sent from the wound clinic directly to the hospital emergency room for likely admission. On [DATE] at 2pm, Z2 stated in interview that he very well recalled R4 and remembered her coming into the clinic. Z2 stated when he saw her the first time, he did an extensive debridement to "good healthy tissue" and sent her back to the facility for daily dressing changes. Z2 stated when she returned a week later, she had a fair amount of necrotic tissue, "the whole wound actually," then stated "NO WAY they could have done dressing changes daily and not noticed the decline." Z2 stated he would have expected the facility to notify him on the first sign of decline and he would have seen her again adding that there was "NO WAY this decline was an overnight thing.' When asked if he felt this was neglect, Z2 stated "Yes, I would." Z2 stated R4 was transferred to the hospital then expired at home with family. The death certificate signed by Z2 identified the date of death as [DATE] with cause of death listed [MEDICAL CONDITION], decubitus ulcer and pneumonia/Dementia. According to the Treatment Administration Record, (TAR)'s for [DATE], R4's treatments were initialed as done by E15, LPN from [DATE] thru [DATE]. On [DATE] at 10:10am in interview, E15 stated when R4 first came into the facility, she had very superficial pressure ulcers to her coccyx. E15 stated the wounds just kept "getting worse." E15 stated before R4 went to the wound clinic, the wound bed was covered with black eschar. After the wound clinic visit, E15 stated the wound bed was beefy red and was a deep hole but "by the 2nd or 3rd day, it had an odor, little patches of yellow slough in it." E15 also stated it appeared to be spreading toward the left side. Asked if she notified the wound physician or nurse of the decline, stated "no" she "would only notify them if she felt the decline or change was significant." E15 identified herself as a staff nurse and does treatments on third floor now. The facility skin report dated [DATE] completed by E8, Licensed Practical Nurse, (LPN) identifies R4's ulcer as measuring 4.3 x 5 x 2.5 with 100% necrotic tissue, odor present three days after the debridement was done. In interview with E8 on [DATE] at 8:30am stated she had seen R4's wound the day after it had been debrided and that it appeared as a hole the size of a golf ball to tennis ball. At that time, E8 stated it was mostly beefy red with bloody drainage and 25% black tissue present in it. E8 stated it had "really bloody drainage." E8 was asked about the measurements documented on [DATE] and stated she did not measure the wound herself, but took the measurements off of the Wound Clinics report from [DATE]. (These were measurements done prior to the debridement.) E8 stated she thought the wound had deteriorated on [DATE] but when asked if she notified the wound Doctor, stated "No, I figured it was being followed by the wound clinic Doctor" and would be seeing her weekly. E8 stated R4's pressure ulcer had odor on [DATE]. When asked if E8 had ever seen R4 without a dressing to her coccyx, stated "Yes, one time." E8 identified herself as the floor manager of R4's floor at the time and was responsible to do the weekly assessments on all residents with pressure ulcers although she stated she has had no training in Pressure ulcers. The weekly wound report dated [DATE] does not document the physician or family as notified and nurses notes from [DATE] thru discharge are missing and are unable to be located according to E1, Administrator in interview on [DATE] at 10am. The TAR for [DATE] thru [DATE] have no initials present on [DATE] and [DATE] and E8's initials on [DATE] and there are no nurses notes documenting her decline in condition from [DATE] thru [DATE] when she went to the wound clinic and did not return. On [DATE] at 12:30pm, Z3, R4's niece, in interview stated she was aware that R4 had a pressure ulcer on her coccyx and three weeks before [DATE] clinic visit, the nurse told her the pressure wound was "out of control." She stated staff did not give her details but would tell her it was not healing, getting worse toward the end but she had no idea that it was as bed as it was. Z3 stated she did not attend the first wound clinic visit with R4 but was called by the clinic and asked to be with R4 on her second visit [DATE]. Z3 stated while waiting in the reception area at the clinic, she thought R4 had soiled herself because the odor was so bad. Z3 stated she was in the room when Z2 removed the dressing and that she could tell he was shocked at what he saw stating "I can't tell you how it got this bad." Z3 stated she observed the area and was shocked as well. Z3 stated Z2 sent R4 to the hospital then she took her home on Hospice where she expired on [DATE]. Z2 stated the Wound Physician signed the death certificate since she died from [MEDICAL CONDITION] from the pressure ulcer. Hospital Discharge records for R4 dated [DATE] document [DIAGNOSES REDACTED]." Admitting [DIAGNOSES REDACTED]. E1 Administrator/ Registered Nurse (RN) on [DATE] at 10am confirmed that the nurses notes for R4 from [DATE] thru [DATE] are missing. E1 stated he would have expected E8 or E15 to call both the wound physician and the primary physician with a decline in wound condition. The facility's policy entitled "Pressure Ulcers/Skin breakdown - Clinical Protocol" (no date) documents that the nurse shall assess and document/report the following: b. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue and f. Current treatments, including support surfaces among others. The protocol documents under 4. The physician will help the staff define the type (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, status of wound bed, etc.) of ulceration. Under General guidelines for treatment, strategies will include assessing the resident and pressure ulcer, managing tissue loads, pressure ulcer care, managing bacterial colonization and infection, operative repair of pressure ulcers and education and quality improvement. The facility's policy entitled "Change in a Resident's Condition or Status" documents the facility "shall promptly notify the resident, his or her attending physiucan and representative of change in the residents medical/mental condition and/or status. The policy documents "significant change" of condition is a decline or improvement in condition in the resident's status that will not normally resolve itself without intervention. The policy also indicate the Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 2. According to the Admission Nursing assessment dated [DATE], R8 was described as continent, gait assist of one staff with transfers, could help himself turn in bed and was alert with periods of confusion. The assessment continues to document that he answered questions appropriately and was oriented to facility, family and staff. The physician's orders [REDACTED]. The diet ordered on admission was regular with thin liquids. Admitting nurses notes dated [DATE] at 5pm, documented that R8 arrived in w/c (wheelchair) from the hospital with a [DIAGNOSES REDACTED]. Minimum Data Set ((MDS) dated [DATE] assessed R8 to require extensive assist of one staff for all other activities of daily living including eating. E20, Registered Dietician, (RD), assessment dated [DATE] documents that R8's estimated daily fluids needs would be 2455cc/24 hours and that at the time of the assessment, R8 consumes approximately ,[DATE]cc/day. On [DATE], a speech evaluation was completed and R8's diet was changed to mechancial soft with nectar thick liquids. The Interim Care Plan dated [DATE] neglects to identify R8 risk for dehydratioin due to the use of diuretics, thickened liquids and insufficient fluids consumed as identified by the RD. Nurses Notes and Skilled Nursing Flow Sheets from [DATE] thru [DATE], document R8 to be alert and responsive and able to verbalize needs. On [DATE] at 10:55am, the nurse documented R8's appetite as being poor but "drinks lots of fluids." On [DATE] at 1:45pm, the nurse documented that R8 takes his medications whole, appetite continued to be poor but fluid intake good. R8 was documented as going out to a physician's appointment. On [DATE] at 1:30pm, E11, Licensed Practical Nurse (LPN) documented "called (Z5 - R8's primary physician) office "re: (regarding) tremors. Spoke to nurse (Z6), et MD (medical doctor) wasn't to see res. (resident) before referring to neurology as per niece request." There is no further information on the tremors R8 was documented as having. At 7pm, the nurse documented R8 "appetite poor. Did drink some of his ensure. Body twitches at times." The nurse further documented that fluids were offered and taken. According to nurses notes written on [DATE] at 9:35pm, "res ate evening meal in bed and was fed by staff." The nurses notes do not document that Z5, R8's primary physician, was notified of this decline in ADL's and no indication any further assessment was done regarding a causative factor of this decline. On [DATE], the nurses notes written at 3am document incontinent care was given. At 1145am, the nurse documents R8 "appears tired - but does answer yes/no questions fed per staff. Update to MD." At 1pm, the nurse documents that R8's medications were crushed, and he was again fed per staff." The note also indicates R8 "conts (continues) to rest c eyes closed." An additional nurses note written (no time) on [DATE] documents R8 going to see Z5, MD, "slumping over in his chair, not as alert as usual." At 1600 (4pm), the nurses notes written by E11, LPN documents that she received a call from Z6, Z5's nurse regarding R8 being transferred to the emergency room as resident was slumped over in chair and may be having a [MEDICAL CONDITION]. The History and Physical from the hospital dated [DATE] documented "(R8) is a [AGE] year old patient seen in our office yesterday. After talking to the nurses in the nursing home, they said that he was fine this morning or yesterday, although, he was having some twitching in his left upper extremely. The paramedics were called, and the patient was taken by ambulance to the ER (emergency room ). In ER, he was found to be severely dehydrated with acute on [MEDICAL CONDITION]." Hospital Lab results dated [DATE] document R8's BUN as 191 (normal ,[DATE]), Sodium 146 (normal ,[DATE]), urine was unremarkable. Interview with Z6, Z5's nurse, on [DATE] at 12pm indicates when R8 was brought into the building by the van driver (E21), he was slumped over, couldn't sit upright, was ashen in color and could barely respond when spoken to. Z6 stated the driver indicated that he was like this when he picked him up at the facility and that he talked with the nurses about taking him to a doctors appointment in this condition but was told to take him anyway. Z6 stated she recalled having a conversation with the facility nurses a few days prior to ,[DATE] and said they had told her they thought he was having another stroke with tremors and weakness. Z6 stated she was not told of his over decline and lethargy. Z6 stated R8's oxygen saturation in the office that day was 80% and it took three firefighters to transfer him to a gurney in order to transport him to the hospital via the ambulance. Z6 stated Z5, MD commented at the time that it was neglectful of the facility to bring R8 to the office in the condition he was in. Z6 stated Z5 was not informed of any condition change except the tremors and would have wanted to know about his overall general weakness, lethargy and inability to help himself as he had when he entered the nursing home a few weeks prior. Z6 stated another physician (foot doctor) in the practice had seen R8 on [DATE] and what they saw on [DATE], was a completely different person. On [DATE] at 3:30pm, Z7, R8's Power of Attorney, (POA), was interviewed and stated she noted a huge decline in the last 1 and ,[DATE] weeks he was at the facility and that she was at the facility when the nurse called the physician a few days before his appointment on [DATE]. Z7 stated she was told by the nurse R8 was possibly having another stroke. Z7 said she told them she didn't want him to go to the hospital only to be returned back to the facility if that was the case. Z7 stated she is not in the medical field and relied on the nurse to assess R8 appropriately. Z7 stated she was never told R8 was put on thickened liquids and that she never saw a water pitcher or glass of water at bedside or in his room during his entire stay at the facility except a couple on his meal trays. Z7 stated she had seen him on ,[DATE] or ,[DATE] and he seemed to be doing okay then did not come in until ,[DATE] or ,[DATE] and he was "jerking." Z7 stated she came again on [DATE], and called the nurse, E11 LPN to his room because he was again jerking and was sitting with his head down. Z7 stated she thought he was having [MEDICAL CONDITION] and didn't see him again until [DATE] when the van driver wheeled him into the physician's office in his wheelchair. Z7 stated he was slumped over in this chair and the driver had to hold him back to prevent him from falling. Z7 stated the driver told her he didn't want to bring him like that but that the nurse insisted he did. Z7 stated she was shocked that R8 was in as bad of shape as he was. On [DATE] at 2:03pm, E18, Speech Therapist recalled R8 well and responded "Yes, definitely" when asked in interview if she noted a significant decline in R8 in the last week or so he was at the facility. E18 stated R8 was able to feed himself when he first came in and could at times, complete a full sentence. E18 also stated he had a very good appetite when he first came and the last few days, she attempted to feed him lunch he wouldn't eat or drink anything. E18 stated she had changed his liquids to thickened liquids on [DATE] after an evaluation showed that he was having some difficulted with thin liquids. She stated she assumed the nurses were monitoring his intake and response but wasn't sure. E18 stated R8 would try to "mostly drink his drinks, but would get it about ,[DATE] way to his mouth and have a spasm then would give up." E18 state R8 "didn't drink anything all those last few days at lunch" when she attempted to feed him. E18 stated she discussed this with E16, LPN on several occasions. On [DATE] at 1:45pm, E16, LPN, stated in interview that she was the nurse that sent R8 to the doctor on [DATE]. E16 stated the first week R8 fed himself and slumped in the wheelchair some. E16 stated she had noticed a decline the prior week before he was sent to the doctors office and that she recalled calling Z5's office on [DATE] while R8's Power of Attorney (Z7) was at the facility. E16 stated she thought R8's decline was due to him having another stroke and that's what she told R8's POA.. E16 did not respond when asked if she did any further assessment and/or monitoring in a effort to determine the causative factor of R8's decline. E16 stated although R8's overall condition continued to deteriorate, she did not notifiy the physician again due to him having an appointment on [DATE]. E16 was asked about R8's fluid intake and the thickened liquids and responded, they didn't keep track of intake. When showed intake records from mealtime, responed "Oh, I didn't know we did that." R16 had no idea how much fluids or how R8 tolerated the thickened liquids in the week before he went to the hospital. According to the Intake records for meals only, R8 was recorded intake was as follows: 1320cc - [DATE], 900cc - ,[DATE], 1689cc - ,[DATE], 600cc - ,[DATE], 660cc - ,[DATE], 480cc - ,[DATE] with refusing at the lunch confirmed in interview with E18. and no intake recorded for ,[DATE] all three shifts even though he didn't go to his appt until 2pm on [DATE]. On [DATE], interview with E17 CNA at 1:20pm indicates that she cared for R8 the last few days he was here and stated she noticed a major decline adding that he could talk when he first came in and the last day or so, he "jibber jabbered" that you couldn't understand. She stated she was off the weekend prior and when she came back on Monday ([DATE]), "he seemed to have had a stroke" keeping his eyes closed, sleeping more, not eating or drinking. E17 was asked about thickened liquids and facility's process stated that they get fluids with snacks.

Based on interviews, observations and record review, the facility failed to identify, assess, evaluate, monitor and treat pressure sores for 3 of 3 residents (R1, R2, and R4) reviewed for pressure ulcers in a sample of 10. This failure resulted in deterioration of R4's coccyx pressure sore which increased significantly. R4 was hospitalized with a [DIAGNOSES REDACTED]. Findings include: 1. According to the admission sheet, R4 was admitted to the facility on [DATE] from another long term care facility. [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] and [DATE] identify her to have long/short term memory deficits with severe cognitive deficits and requires extensive assist of two staff for mobility. The MDS also assessed her to be frequently incontinent of bowel and bladder. Discharge records from the prior facility identified R4 to have a pressure ulcer on her coccyx "Stage II to lt (left/Rt (right) buttock - [MEDICATION NAME] cream to rt/lt buttock every shift t/h (til healed.)" The care plan dated [DATE] identifies pressure ulcers on R4's coccyx with interventions to assess for pressure sores size depth & color every week, assist resident out of bed several times a day, check and change after each incontinent episode and encourage resident to follow turning and positioning schedule. Weekly wound report dated [DATE] identies R4's right buttock to have a pressure ulcer measuring 2cm (centimeters) x 2cm x .10cm 100% pale pink granulating tissue. Weekly reports document that R4's pressure right buttock was healed on [DATE] with left buttock healed on [DATE]. Weekly skin reports identified R4 as developing an in-house acquired right buttock pressure ulcer on [DATE] which measured 1.5cm x .8cm x .10cm for which Hydrogel was ordered BID (twice daily.) On [DATE], a newly developed ulcer was identified on R4's left buttock and the order was changed to [MEDICATION NAME] dressing every three days and PRN (as needed) til healed. The weekly reports indicate R4's ulcers continued to decline and on [DATE], the physician changed the order for the upper coccyx to hydrogel and the lower coccyx wound to Santyl BID. Wound reports dated [DATE] identify the right buttock as 2cm x 2.3cm x .3cm 100% necrotic tissue. Subsequent weekly wound reports dated [DATE] and [DATE] document the same wound measurements with 100% necrotic wound bed with no change in treatment although on [DATE], the physician ordered labs which identified normal levels of [MEDICATION NAME] 3.6 (normal 3XXX,[DATE].5) and Pre-[MEDICATION NAME] 20.3 (normal ,[DATE]). physician's orders [REDACTED]. There was no treatment change from [DATE] until ,[DATE]//13 when R4 went to the wound clinic. According to Weekly Wound Report completed by E8, Licensed Practical Nurse (LPN) dated [DATE], R4's right buttock was identified an "unstageable" having 100% necrotic tissue present with light purulent drainage measuring 3.5cm x 2.5cm x 1cm deep. E8 documented that the physician was notified. On [DATE] at 8:30am, E8 Licensed Practical Nurse (LPN) stated she thought R4 needed to be seen by the wound clinic because her wound kept getting worse. E8 stated she did not document that information anywhere but made the appointment for R4 to see seen by a wound specialist on [DATE]. On [DATE], R4 went to the wound clinic and saw Z2, Wound Physician. Wound notes from the clinic dated [DATE] document under History "the best that we can ascertain from the records that were sent with her, she has had a pressure ulcer since April." The report identifies the initial evaluation of R4's pressure ulcer measured "4.3c, x 5cm x 2.5cm with a significant amount of necrotic material throughout the entire base of the wound and along the upper surface of the wound." The report documents that "an extensive excisional debridement was performed using a scalpel. This removed skin, subcutaneous tissue and a copious amount of muscle." It continued to state "the wound was improved. The patient tolerated the procedure well. The size of the wound after debridement was significantly larger than that predebridement." Plans were to have Santyl Dressings and pressure offloading done and to see R4 again in a week. On [DATE], R4 again went to the wound clinic. Documentation dated [DATE] from the clinic states "last week in clinic, we performed a significant debridement which included skin, subcutaneous tissue and muscle. We removed a fair amount of necrotic tissue. We were able to get back to essentially viable tissue around the entirety of the wound. The patient was to be getting pressure offloading and Santyl dressings changes daily. The patient today was accompanied by her family. There was no report given to us that her wound had at all deteriorated." Physical examination recorded at the time documented R4's pressure ulcer 7 x 8.5 x 1 with copious necrotic tissue throughout the patient's right side of her buttock. She has a new area of skin necrosis, which extends over into the left buttock as well as inferiorly along the right." The Wound Physician, Z2 again debrided the area to both buttock to remove an "an extensive amount of tissue. This was in excess of 20 square cm." The report documents R4 was sent from the wound clinic directly to the hospital emergency room for likely admission. On [DATE] at 2pm, Z2 stated in interview that he very well recalled R4 and remembered her coming into the clinic. Z2 stated when he saw her the first time, he did an extensive debridement to "good healthy tissue" and sent her back to the facility for daily dressing changes. Z2 stated when she returned a week later, she had a fair amount of necrotic tissue, "the whole wound actually," then stated "NO WAY they could have done dressing changes daily and not noticed the decline." Z2 stated he would have expected the facility to notify him on the first sign of decline and he would have seen her again adding that there was "NO WAY this decline was an overnight thing.' When asked if he felt this was neglect, Z2 stated "Yes, I would." Z2 stated R4 was transferred to the hospital then expired at home with family. The death certificate signed by Z2 identified the date of death as [DATE] with cause of death listed [MEDICAL CONDITION], decubitus ulcer and pneumonia/Dementia. According to the Treatment Administration Record (TAR) [DATE], R4's treatments were initialed as done by E15, LPN from [DATE] through [DATE]. On [DATE] at 10:10am in interview, E15 stated when R4 first came into the facility, she had very superficial pressure ulcers to her coccyx. E15 stated the wounds just kept "getting worse." E15 stated before R4 went to the wound clinic, the wound bed was covered with black eschar. After the wound clinic visit, E15 stated the wound bed was beefy red and was a deep hole but "by the 2nd or 3rd day, it had an odor, little patches of yellow slough in it." E15 also stated it appeared to be spreading toward the left side. Asked if she notified the wound physician or nurse of the decline, stated "no" she "would only notify them if she felt the decline or change was significant." E15 identified herself as a staff nurse and does treatments on third floor now. The facility skin report dated [DATE] completed by E8 identifies R4's ulcer as measuring 4.3 x 5 x 2.5 with 100% necrotic tissue, odor present three days after the debridement was done. In interview with E8 on [DATE] at 8:30am stated she had seen R4's wound the day after it had been debrided and that it appeared as a hole the size of a golf ball to tennis ball. E8 stated it was mostly beefy red with bloody drainage and 25% black tissue present in it. E8 stated it had "really bloody drainage." E8 was asked about the measurements documented on [DATE] and stated she did not measure the wound herself, but took the measurements off of the Wound Clinics report from [DATE] which according to the report, were done prior to the debridement. E8 stated she thought the wound had deteriorated on [DATE] but when asked if she notified the wound Doctor, stated "No, I figured it was being followed by the wound clinic Doctor" and would be seeing her weekly. E8 stated R4's pressure ulcer had odor on [DATE]. When asked if E8 had ever seen R4 without a dressing to her coccyx, stated "Yes, one time." E8 identified herself as the floor manager of R4's floor at the time and was responsible to do the weekly assessments on all residents with pressure ulcers although she stated she has had no training in Pressure ulcers. The Weekly Wound Report dated [DATE] does not document the physician or family as notified and nurses notes from [DATE] through discharge are missing and are unable to be located according to E1, Administrator in interview on [DATE] at 10am. Treatment Administration Records (TAR's) for [DATE] thru [DATE] have no initials present on [DATE] and [DATE] and E8's initials on [DATE] and there are no nurses notes documenting her decline in condition from [DATE] thru [DATE] when she went to the wound clinic and did not return. The Weekly Wound Report dated [DATE] also identifies R4 developing a Stage II pressure ulcer on her right elbow measuring 3.4cm x 2.1cm x 0 depth bright red beefy in color with light serosanguineous exudate. On [DATE] at 12:30pm, Z3, R4's family member, stated she was aware that R4 had a pressure ulcer on her coccyx and three weeks before [DATE] clinic visit, the nurse told her the pressure wound was "out of control." She stated staff did not give her details but would tell her it was not healing, getting worse toward the end but she had no idea that it was as bad as it was. Z3 stated she did not attend the first wound clinic visit with R4 but was called by the clinic and asked to be with R4 on her second visit [DATE]. Z3 stated while waiting in the reception area at the clinic, she thought R4 had soiled herself because the odor was so bad. Z3 stated she was in the room when Z2 removed the dressing and that she could tell he was shocked at what he saw stating "I can't tell you how it got this bad." Z3 stated she observed the area and was shocked as well. Z3 stated Z2 sent R4 to the hospital then she took her home on Hospice where she expired. Z2 stated the Wound Physician signed the death certificate since she died from [MEDICAL CONDITION] from the pressure ulcer. Hospital Discharge records for R4 dated [DATE] document [DIAGNOSES REDACTED]." Admitting [DIAGNOSES REDACTED]. E1 Administrator/ Registered Nurse (RN) on [DATE] at 10am confirmed that the nurses notes for R4 from [DATE] thru [DATE] are missing. E1 stated he would have expected E8 or E15 to call both the wound physician and the primary physician with a decline in wound condition. The facility's policy "Change in a Resident's Condition or Status" documents the facility "shall promptly notify the resident, his or her attending physician and representative of change in the residents medical/mental condition and/or status. The policy documents "significant change" of condition is a decline or improvement in condition in the resident's status that will not normally resolve itself without intervention. The policy also indicate the Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. The facility's policy entitled "Pressure Ulcers/Skin breakdown - Clinical Protocol" (no date) documents that the nurse shall assess and document/report the following: b. Full assessment of pressure sore including location, Stage, length, width and depth, presence of exudates or necrotic tissue and f. Current treatments, including support surfaces among others. The protocol documents under 4. The physician will help the staff define the type (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, status of wound bed, etc.) of ulceration. Under General guidelines for treatment, strategies will include assessing the resident and pressure ulcer, managing tissue loads, pressure ulcer care, managing bacterial colonization and infection, operative repair of pressure ulcers and education and quality improvement. 2. The Admission Sheet documents that R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] identifies no deficits in memory and/or cognitive abilities. The MDS identifies R1 to require extensive assist of 2 staff for mobility and is incontinent of bowel movement with a urinary catheter. The Admission Nursing assessment dated [DATE] identifies multiple areas on R1's buttocks and upper thighs. Orders on Admission include a [MEDICATION NAME] dressing (Drsg) change every three days dated [DATE] for the right buttock, Right posterior thigh and left buttock. Nursing admission notes dated [DATE] documents on admission that R1 had three pressure ulcers, is incontinent of soft formed stool and repositioned q (every) hour per res (resident request." The careplan identifies that R1 was admitted with pressure ulcers and that she is "not always compliant with positioning" although there is no plan in the interventions addressing this concern. Interventions include: treatment to pressure ulcer as ordered, observe for any signs of infections, and report any red areas among others. Laboratory reports dated ,[DATE] show R1 to have a normal total Protein level but a low [MEDICATION NAME] level. The first assessment documented on R1's ulcers following admission on [DATE] is for the week [DATE]-[DATE] and identifies a Stage III left buttock 3cm x 1.5cm x .1. On the weekly report for [DATE]-[DATE], the area again is identified as left buttock Stage III measuring .6cm x 1.3cm x .1cm and right buttock Stage III measuring 5.5cm x 6.5cm depth NA, a substantial increase in size from the prior week. Treatments were changed to Santyl with a dry dressing BID (twice daily) on [DATE]. On [DATE], R1 complained of chest pain and according to the transfer sheet, was sent to the emergency room . Hospital records reviewed for the visit dated [DATE] documented "Warm dry sacral [DIAGNOSES REDACTED] going down thighs BL ( bilaterally.) Interview with Z4, emergency room nurse on [DATE] at 12:30pm, indicates R1 presented to the emergency room soiled with bowel movement. Z4 stated when she saw R1, her dressing was a 4x4 gauze crumpled up and laying on the bed with feces across both buttocks. Hospital reports document that R1 did not want to return to the facility as they did not give her adequate care there. Z4 confirmed this in interview. According to the Weekly Wound Report dated [DATE]-[DATE], R1's left buttock measured .6cm x 3cm x 0cm depth but was Stage III. The right buttock is documented as measuring 6cm x 6.5cm, now with Unknown depth with 25% beefy red tissue, 75% loosely adherent slough with a moderate amount of serous exudate, Stage III. The treatment was again changed and under current plan and treatment, E11. LPN documents "res (resident) remains incontinent and non compliant with turning and repositioning." E11 has identified this ulcer as a Stage III although she has documented that the depth is unknown with 75% loosely adherent slough. Orders dated [DATE] are for Packing the wound with Calcium Alginate, cover with abdominal pad every day and PRN (as needed.) On [DATE] at 8:51pm, R1 was observed in her bed laying on her left side with E4, LPN assisting. R1 had no dressing/treatment on her right buttock pressure ulcer and there was none in her bed. R1's right buttock ulcer presented as an irregular shaped ulcer with varying depths, yellow-grey slough present. In addition, she had additional open areas on her upper left thigh red wound beds. and superficial areas on her left buttock. She had three cloth incontinent pads under her. R1 stated her ulcer had been without a dressing all night and had come off on the ,[DATE] shift the night before. On [DATE] at 6:20am, R1 was again found with no dressing/treatment on her right buttock pressure ulcer. R1 stated at the time, the dressing had been off since changed of ,[DATE] shift to ,[DATE] shift the night before. R1 identified E9, Certified Nurses Aide (CNA) as finding the dressing on the floor after 11pm when she first came into her room after coming on duty. R1 stated the the nurse, E7, LPN, was also notified that the dressing had fallen off. At 6:30am, E11 LPN staff nurse entered R1's room to do her treatment. R1 was laying on her right side with her urinary catheter tubing stretched from her urethra down directly across her ulcer bed under her right hip. E11 did not reposition R1 for better access to the pressure ulcer but left her laying on her catheter tubing. E11 put gloves on, then placing the wound cleanser, gauze pads and abdominal pad directly on R1's bottom sheet without setting a clean field, attempted to cleanse the right buttock ulcer as she pulled the catheter tubing side to side wiping around it. She then let the tubing fall back across the wound bed after cleansing it. E11 measured the wound width, length and depth with a paper strip, again moving the tubing side to side. E11 then pulled the catheter to the side as she placed the Calium Alginate inside the wound and covered it with an abdominal pad and tape. She then pushed the dressing in place under her as the R1 continued to lay on her right side with the outer edge of the wound at the level of the bed. E9 then assisted E11 to turn R1 to her left side. R1 stated she had been laying on her catheter tubing since around 3am. It left a deep red/white stripe across her hip and buttock that remained for at least 25 minutes. E11 acknowledged the indentations from laying on the tubing. E11 then had to redo the dressing since it came off as they turned R1 to the left side. The wound bed appeared irregular with two distinct patches of yellow-grey patches of slough/necrotic tissue with very minimal beefy red present. R1 had one cloth pad under her that had a smear of brown substance on it. The pad was not changed. In interview on [DATE] at 6:30am, E9, CNA confirmed that she found R1's dressing on the floor at shift change the night before and when asked if she informed the nurse, stated "yes, I told E7." At 6:52am, E7, LPN stated she was not told by E9 that R1's dressing was not on or she would have replaced it. Nurses notes for [DATE] were reviewed and found to only have a few instances where R1 was documented as refusing repositioning and/or treatments on ,[DATE], ,[DATE] and [DATE]. TAR's were also reviewed for [DATE] and found to have circled initials where treatments were not done only on ,[DATE] and [DATE]. R1's care plan has no plans in place to ensure that turning/repositioning is done accordingly when refused and treatments are completed as ordered. On [DATE], E1 Administrator, stated in refutation that when he spoke with E9, CNA, she couldn't really remember if she'd told the nurse or not. E1 did agree that it was her responsibility to inform the nurse and the nurses responsibility to ensure that the dressing is intact. On [DATE] at 3:04pm, E4 identified herself as the facility's wound nurse. E4 stated that each of the 4 floors have a nurse manager who is responsible for weekly assessments of pressure ulcers and the staff nurses do the daily treatments. E4 stated if a decline is identified in between the weekly rounds, floor nurses wound be expected to document them after assessing them in the nurses notes. E4 stated most nurses are new, and that she is constantly working with them to do correct assessments. E4 stated most of the nurses need training E4 stated she has had no training other than clinical work with the previous administrator and Director of Nursing but that she is suppose to be going to a class of pressure ulcers in the future. On [DATE] at 10am, E2, Director of Nursing provided inservice sheets for E11 on treatments and stated she will be implementing new policies for nurses to check every shift on dressing. 3. R6's MDS of [DATE] documents R6 as having no cognitive impairment and requiring extensive assistance of 2 or more staff for bed mobility and totally dependent on 2 or more staff for transfer, toilet use, and hygiene and being frequently incontinent of urine. R6's Care Plan of [DATE] documents documents R's skin is intact at this time. He has decreased mobility. He is incontinent of bowel and bladder....also has a history of Stage 2 on left buttock. Note of [DATE] documents right and left post thigh, treatment as ordered. Note of [DATE] documents treatment change to right and left post thigh and [MEDICATION NAME]/[MEDICATION NAME] as ordered for 10 days. There is no documentation as to what the areas on the post thighs were or what the treatment was. Care plan approach documents, in part: to encourage resident to follow T & R (turning and positioning) schedule; check and change after each incontinent episode, Pressure reduction mattress on bed; transfer with mechanical sling lift; treatment as ordered. Care Plan note written on [DATE] documents that R6 is non compliant with T and R. R6's Nurses Notes of [DATE] documents R6 is compliant with care. R6's SKILLED NURSING FLOW SHEET of [DATE] documents R6 is alert and oriented, is cooperative, is incontinent, repositioned every 2 hours, pericare PRN (as needed) Nurses Note of [DATE] documents CNA (Certified Nurse Aide) reported skin concerns. Upon investigation noted Stage II to right post thigh approximately where mechanical sling lays and excoriation to left post thigh. MD notified and treatment orders received. Another Nurses Note of [DATE] documents excoriation noted to right post thigh and 3 x 3 Stage II to left post thigh... and 1 to 1 teaching given to R6 and staff on proper use of mechanical lift sling. Note on [DATE] documents, "Wound rounds unavailable @ this time will input assessment next week." Note of [DATE] documents, "Assessment completed of blat posterior thighs. Areas have abscess characteristics. Will update Doctor of resident condition. Will input assessment into wound rounds." Nurses Notes from [DATE] through [DATE] documents R6 has abscess on posterior right and left thighs. R6's POS of [DATE] documents an order for [REDACTED]. R6's POS shows an order of [DATE] for hot packs to left and right posterior thighs Bid and PRN. Dry dressing to left and right posterior thighs daily. [MEDICATION NAME] DS BID x 10 days. [MEDICATION NAME] 300 mg TID X 10 days. Multi vitamin with mineral daily. R6's WOUND ASSESSMENT DETAILS REPORT of [DATE] documents a Stage I pressure sore facility acquired and identified on [DATE] on the left back of thigh. The report identifies the pressure sore as being a healing Stage I, size 5.5 cm x 6 cm x unknown depth. Current Plan and comments, "R6 encouraged to allow frequent pericare and turning and repositioning. R6 started on abt (antibiotic) times 2 for 10 days." R6's WOUND ASSESSMENT DETAILS REPORT of [DATE] documents a Stage I pressure sore which is facility acquired and identified on [DATE]. The pressure sore is identified as being a blister measuring 4.5 x 5.0 cm with depth unknown. On [DATE] at 9;07am, E4 assisted in a skin check on R6. He had no dressing on his wound, three pads on his bed and had three open areas (StageII) on his inner left thigh. There was no dressings in his bed which E4 confirmed at the time. At 12:30pm, R6 was observed in his wheelchair in the dining room for lunch and at 1:30pm, he was asked about his pressure ulcer dressings. He said "No, not really" when asked if the nursing were consistent as keeping a dressing on his sores. At 3:30pm, E4 LPN stated in interview that the wound on R6 was originally identified as an abscess but then the physician (Z1) determined it was a pressure ulcer. E4 stated it started out as a blister At 4pm, he was still in his wheelchair in the lobby area of the facility.

Based on interviews, observations and record review, the facility failed to have a system in place to identify residents at risk for dehydration, failed to monitor for signs/symptoms of dehydration including poor fluid intake and failed to develop a plan to provide each resident with sufficient fluid intake to maintain proper hydration and health for 3 of 3 residents (R8, R9 and R10) reviewed for hydration in a sample of 10. This failure resulted in R8 developing severe dehydration exhibiting symptoms of lethargy, weakness, incontinency, poor intake, and increased assistance in activities in daily living (ADL's.) which caused hospitalization for acute [MEDICAL CONDITION]. Findings include: 1. R8's Admission Nursing assessment dated [DATE], R8 was described as continent,transfer assist of one, able to turn himself in bed and alert with periods of confusion. The assessment documents that R8 answered questions appropriately and was oriented to facility, family and staff. The physician's orders [REDACTED]. The diet ordered on admission was regular with thin liquids. Admitting nurses notes dated 8/22/13 at 1700 (5pm), documented that R8 arrives in w/c (wheelchair) from the hospital with a [DIAGNOSES REDACTED]. Minimum Data Set ((MDS) dated [DATE] assessed R8 to require extensive assist of one staff for all other activities of daily living including eating. E20's, Registered Dietician, (RD) assessment dated [DATE] documents that R8's estimated daily fluids needs would be 2455cc/24 hours and that at the time of the assessment, R8 consumed approximately 1000-1499cc/day. A Telephone order dated 9/4/13 changed R8's diet order to mechanical soft with nectar thick liquids. The Interim Care Plan dated 8/22/13 neglects to reflect R8's dehydrational risk due to the use of a diuretic and thickened liquids ordered 9/4/13. Nurses notes and Skilled Nursing Flow Sheets from 8/22/13 thru 9/7/13, document R8 to be alert and responsive and able to verbalize needs. Nurses Skilled notes reviewed from 9/4/13 when R8's liquids were changed to nectar thickened to 97/13, fail to document any monitoring for acceptance and/or intake. In addition, no changes to the interim care plan was noted to ensure that R8's was afforded sufficient fluids since he required assistance. On 9/8/13 at 1055 (10:55am), the nurse documents R8's appetite as being poor but "drinks lots of fluids." On 9/9/13 at 1345 (1:45pm), the nurse documented that R8 takes his medications whole, appetite continued to be poor but fluid intake good. On 9/10/13 at 1330 (1:30pm), E11, Licensed Practical Nurse (LPN) documents "called (Z5 - R8's primary physician) office "re: (regarding) tremors. Spoke to nurse (Z6), et MD (medical doctor) wants to see res. (resident) before referring to neurology as per niece request." There is no further documentation as to R8's tremors and no further nursing assessment documented toward possible causative factors. At 1900 (7pm) on 9/10/13, the nurse documents R8 "appetite poor. Did drink some of his ensure. Body twitches at times." The nurse further documents that fluids were offered and taken. According to nurses notes written on 9/11/13 at 2135 (9:35pm), "res ate evening meal in bed and was fed by staff." The nurses notes do not document that the physician, Z5, was notified of this decline in in eating since he was assisting himself on addition and no documentation that any further assessment was done regarding a causative factor of R8's continued decline. On 9/13/13, the nurses notes written at 3am document incontinent care given. At 1145am, the nurse documents R8 "appears tired - but does answer yes/no questions fed per staff. Update to MD." At 1300 (1pm), the nurse documents that R8's medications were crushed, and he was again fed per staff." The note also indicates R8 "conts (continues) to rest c eyes closed." An additional nurses note written (no time) on 9/13/13 documents R8 going to see Z5, MD, "slumping over in his chair, not as alert as usual." At 1600 (4pm), the nurses notes written by E11, LPN documents that she received a call from Z6, Z5's nurse regarding R8 being transferred to the emergency room as resident was slumped over in chair and may be having a [MEDICAL CONDITION]. The History and Physical from the hospital dated 9/13/13 documented "(R8) is a [AGE] year old patient seen in our office yesterday. After talking to the nurses in the nursing home, they said that he was find this morning or yesterday, although, he was having some twitching in his left upper extremely. The paramedics were called, and the patient was taken by ambulance to the ER (emergency room ). In ER, he was found to be severely dehydrated with acute on [MEDICAL CONDITION]." Hospital Lab results dated 9/13/13 document R8's BUN as 191 (normal 6-22), Sodium 146 (normal 133-142), urine was unremarkable. Interview with Z6, Z5's nurse, on 9/17/13 at 12pm indicates that when R8 was brought into the building by the van driver (E21), he was slumped over, couldn't sit upright, was ashen in color and could barely respond when spoken to. Z6 stated the driver indicated R8 was like that when he picked him at the facility and that he discussed his condition with the nurses before being to told to take R8 to his appointment anyway. Z6 stated she recalled talking with the facility nurses a few days prior to 9/13 and said the nurses told her at that time, they thought he was having another stroke with tremors and weakness. Z6 stated she was not told of his over decline. Z6 stated R8's oxygen saturation in the office that day was 80% and it took three firefighters to transfer him to a gurney in order to transport him to the hospital. Z6 stated R8 was so dehydrated, they had difficulty drawing blood. Z6 stated Z5, MD commented at the time that it was neglectful of the facility to bring R8 to the office in the condition he was in and that he had not been informed of his decline except the tremors. Z6 said Z5 would definitely want to know about R8's overall general weakness, lethargy and inability to help himself. Z6 stated another physician, a foot doctor, in the practice had seen R8 on 9/9/13 and what they saw on 9/13/13, was a completely different person. On 9/17/13 at 3:30pm, Z7, R8's POA was interviewed and stated she noted a huge decline in the last 1 and 1/2 weeks he was at the facility and that she recalled the nurse calling the physician a few days before his appointment on 9/13/13 while she was there. Z7 stated she was told by the nurse that she though R8 was having another stroke and that she didn't want him to go to the hospital only to be returned back to the facility if that was the case. Z7 stated she is not in the medical field and relied on the nurse to assess R8 appropriately. Z7 stated she was never told R8 was put on thickened liquids and that she never saw a water pitcher or glass of water at bedside or in his room during his entire stay at the facility except a couple on his meal trays Z7 stated she had seen him on 9/5 or 9/6 and he seemed to be doing okay then did not come in until 9/9 and he was "jerking." Z7 stated she came again on 9/11/13, and called the nurse, E11 LPN to his room because he was again jerking and was sitting with his head down. Z7 stated she thought he was having [MEDICAL CONDITION] and didn't see him again until 9/13/13 when the van driver wheeled him into the physician's office in his wheelchair. Z7 stated he was slumped over in this chair, ashen and barely responded when spoken to. Z7 said the driver (E21) had to hold him back in his chair to prevent him from falling out. Z7 stated the driver told her he didn't want to bring him like that but that the nurse at the facility insisted he did. Z7 stated she was shocked that R8 was in as bad of shape as he was. On 9/17/13 at 2:03pm, E18, Speech Therapist recalled R8 well and responded "Yes, definitely" when asked in interview if she noted a significant decline in R8 in the last week or so he was at the facility. E18 stated R8 was able to feed himself when he first came in and could at times, complete a full sentence. E18 also stated he had a very good appetite when he first came and the last few days, she attempted to feed him lunch he wouldn't eat or drink anything. E18 stated she had changed his liquids to thickened liquids on 9/4/13 after an evaluation showed that he was having some difficulty with thin liquids. She stated she assumed the nurses were monitoring his intake but wasn't sure. E18 stated R8 would try to "mostly drink his drinks, but would get it about 1/2 way to his mouth and have a spasm then would give up." E18 state R8 "didn't drink anything all those last few days at lunch" when she attempted to feed him. E18 was unaware of the hydration policy for thickened liquids. E18 stated she discussed this with E16, LPN on several occasions. According to E18's assessment dated [DATE], under "Patient/Family/Caregiver training and response, E18 wrote "family very attentive, Caregivers are not helping set up meals with "0" compliance" noted for assisting with meals for the prior week. On the evaluation dated 9/10/13, E18 writes "still no divided tray or set up (< 10%)", and "Overall cognitive skills have declined over this week due to (decreased) responsiveness and illness." Also, documented was "staff concerned over decline." E18 did not document her discussions with E16, LPN in regards to R8 having no intake at lunch on the days prior to R8's discharge. On 9/17/13 at 1:45pm, E16, LPN, stated in interview that she was the nurse that sent R8 to the doctor on 9/13/13. E16 stated the first week R8 fed himself and slumped in the wheelchair some. E16 stated she had noticed a decline the prior week before he was sent to the doctors office and that she called Z5's office on 9/10/13 while R8's Power of Attorney (Z7) was at the facility. E16 stated she thought R8's decline was due to him having another stroke and that's what she told R8's POA.. E16 did not respond when asked if she did any further assessment and/or monitoring in a effort to determine the causative factor of R8's decline. E16 stated although R8's overall condition continued to deteriorate, she did not notified the physician again due to him having an appointment on 9/13/13. E16 was asked about R8's fluid intake and how he accepted the thickened liquids, stated R8 was not on "I & O" (intake and output) and responded, "Oh, I didn't know we did that" when shown meal intake records with fluids recorded on them. R16 had no idea how much fluids or how R8 tolerated the thickened liquids in the week before he went to the hospital. According to the Intake records for meals only, R8's intake daily was low. Recorded intake was as follows: 1320cc - 9/6/13, 900cc - 9/7, 1689cc - 9/8, 600cc - 9/9, 660cc - 9/10, 480cc - 9/12 with refusing at the lunch confirmed in interview with E18. and no intake recorded for 9/13 all three shifts even though he didn't go to his appt until 2pm on 9/13/13. On 9/17/13, interview with E17 CNA at 1:20pm indicates that she cared for R8 the last few days he was here and stated she noticed a major decline adding that he could talk when he first came in and the last day or so, he "jibber jabbered" that you couldn't understand. She stated she was off the weekend prior and when she came back on Monday (9/9/13), "he seemed to have had a stroke" keeping his eyes closed, sleeping more, not eating or drinking. E17 was asked about thickened liquids and facility's process stated that they get fluids with snacks. On 9/17/13, a policy on Thickened Liquids and Hydration was requested from E2, Director of Nursing and E6, a short time later. Two separate policies were provided. One entitled "thickened liquid protocol/guidelines" documents that a physician's orders [REDACTED]. That policy indicates the dietary department will supply additional thickened liquids three times daily at 10am, 2pm, and 8pm but offers no interventions in regards to ensuring that those residents placed on thickened liquids are monitored for intake and amount since their risk for dehydration is higher. The Clinical Protocol on Hydration covers assessment and identification for causative factors of fluid imbalance but does not include any interventions in assessing, monitoring and/or care planning hydration for those on thickened liquids. On 9/17/13 at 11:20am, a list of residents on thickened liquids was requested and provided by E20, RD. The facility currently has 28 residents receiving thickened liquids. According to E6, RN on 9/17/13 at 10am, the facility has no policy in writing for thickened liquids except dietary sending out 180cc of snacks at 10am, 2pm and 8pm. 2. According to the Initial Nutritional assessment dated [DATE], R10 has [DIAGNOSES REDACTED]. The Assessment identifies that R10's minimum Daily fluid requirement is 1590cc/24 hours and that she requires supervision while eating, chewing, swallowing and is totally dependent while eating. The assessment documents that her daily fluid consumption is 1000-1499cc/day. The POS for September documents her diet as regular with honey thick liquids and she receives [MEDICATION NAME] 40mg daily in additional to other medications. The care plan dated 8/10/13 fails to identify her to be at risk for dehydration based on the use of diuretics and being on thickened liquids and failed to develop a plan to ensure that R10 receives sufficient fluid. The care plan does identify her being on thickened liquids under diet for weight maintenance, however there is no interventions written to ensure that R10 consumes sufficient fluids. On 9/17/13 at 11:20am, R10 was laying flat in bed with a hospital gown on . The curtain was pulled between the beds. She had a small plastic glass of thickened water on her bedside table that was marked "10am snack" that still had the lid on it and had not been opened. R10 had dry lips and mouth. When asked if she wanted a drink, R10 stated "yes." E23 and E22 CNA's were passing by in the hallway and were asked about R10's ability to drink herself, stated she was a "Feeder." Both staff then went in to sit her up and give her a drink. Meal Intake records for the month of September show R10 to take on an average of 1000cc for the three meals combined. There is no record of what fluids she takes in between meals. At lunch on 9/17/13, R10 was given two small glasses (180cc each) of fluids. When she left the table following the meal around 1pm, she had taken less than 25% of each glass of liquid.. 3. According to the Admission Record, R9 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Skilled Nursing Flow Sheet dated 9/17/13 indicates staff are to encourage fluids. At 9am, R9 was observed in bed in a hospital gown. His untouched breakfast tray was on the overbed table pushed off to the side of his bed out of reach. He had juice, coffee and a carton of 20% milk on his meal tray. He had no water pitcher and/or water glass in his room and there was a partially drank carton of milk sitting within a few inches of his 1/2 full urinal on the bed side stand. E4 LPN was asked whether he had had breakfast and she stated he had refused. His tray was removed from the room with no fluids left at bedside. The urinal and partial carton of milk remained on the bedside stand. At 10:15am, and 11:07am, R9 still had no water at bedside. E1, Adm was informed of him not having a fluid at bedside and at 11:45am, R9 was observed to have a water pitcher of ice water on his overbed table taking a drink when he was observed. At 12:55pm, R9 was fed his lunch meal. He had coffee and juice on his tray. At 1:20pm, R9's tray was removed by E5 LPN with no encouragement and/or cueing to drink more. He had eaten 100% of his meal but only consumed 1/3 of the 180cc of juice and no coffee. On 9/17/13 at 2:03pm, E18 Speech Therapist stated often residents do not have water pitchers or water at bedside.

Based on record review and interview, the facility failed to respond to changes in condition and to a critically low blood sugar level, for 1 of 3 residents (R4) reviewed for a change in condition, on the sample of 6. This failure resulted in R4 not getting immediate care for a blood glucose level of 34, having a [MEDICAL CONDITION] and expiring. Findings include: R4's Face Sheet of [DATE] shows a [DIAGNOSES REDACTED]. The Physician order [REDACTED]. The POS shows orders for Oxygen ,[DATE] liters continuous due to [DIAGNOSES REDACTED]. Review of the Facility Skilled Nursing Flow Sheet dated [DATE] documents R4's blood pressure (BP) at ,[DATE]; Oxygen (O2) at 94% on 3 liters of O2; Skin warm and dry; Cooperative, alert and oriented; and appetite fair. Note at 1330 (1:30PM) documents, in part, R4 is alert and oriented. Able to make needs known. unable to finish Physical Therapy (PT) due to not feeling well. Vital signs taken at that time and BP ,[DATE], Blood oxygen at 88% at 2 liter per nasal cannula (n/c). O2 turned up to 3 liters per n/c and Blood oxygen now at 94%. No signs or symptoms of pain or discomfort or distress noted. Nurses Notes were reviewed with the following entries noted: [DATE] at 4:15PM written by E5, Licensed Practical Nurse/Nurse Manager (LPN) for R4's documents Z6, R4's daughter, was visiting and thought R4 had confusion and needed to be sent to the ER (emergency room ). The Note documents that E5 tried to explain to daughter that R4's BP was a little high today ,[DATE], O2 Sats was 88% at 2 liters and O2 was increased to 3 liters with a pulse ox of 94%. No shortness of breath. Lungs diminished. Laid down after therapy. On [DATE] at 1:20PM, E5 stated R4 didn't seem any different and didn't have any reason to go to the hospital. [DATE] at 4:15PM by E2, Director of Nursing, DON,documents, R4's Daughter , Z7, called and stated she wanted her mother sent to ER. E2 asked reason for need for R4 to go to the ER. Z7 stated that her other sister told her that "mom was out of it, unresponsive." The note documents E2 called Z5, another sister, with R4's medical status. [DATE] at 7:40PM written by E8, LPN, documents R4 alert and oriented to self...clear speech... No complaints and does not appear in any distress. "Writer asked R4 how she felt. R4 replied with "I'm tired" R4 also stated she had " a long day with therapy." R4 complained of BLE pain of 6 on ,[DATE] scale @ 1800 (6PM) . R4 medicated with PRN (as needed) [MEDICATION NAME]. + results obtained pain down to 2 at 1900 (7PM). R4 in room for supper per her request. Appetite poor. R4 encourage to eat by writer d/t diabetes et to have energy for ADL's therapy...No signs or symptoms of hypo/[MEDICAL CONDITION]. [DATE] at 5:50AM, documents blood glucose check at 34. R4 unresponsive, respiration even and unlabored pale and cold to touch. Z1 paged awaiting return call. [DATE] 6 AM, paged a second time. Still awaiting return call. [DATE] 6:05 AM, note documents Telanurse called and told this was an emergency and that the Nurse needed orders. [DATE] 6:10 AM the Nurse documents she went into R4's room to check on her and R4 was in full [MEDICAL CONDITION]. CPR was initiated and R4 had a large amount of dark brown discharge coming from her mouth and nose. Emergency Medical Service (EMS) called. [DATE]:20 AM, EMS arrived and took over with CPR. [DATE] 6:35 AM documents Z13, Physician, returned call and ordered [MEDICATION NAME]. [DATE] 6:40PM documentation states the Nurse went to administer the [MEDICATION NAME] and EMS did not allow her to give the [MEDICATION NAME]. [DATE] 6:50AM documents EMS transported R4 to the hospital. [DATE] 7:45 documents R4 expired. Record review of R4' Physical Therapy Notes of [DATE] show that R4 refused Therapy due to being ill. The Note documents, "R4 feeling unable to perform in therapy today. R4 stated feeling weak & participation unwilling. Ng (nursing) notified vitals taken:" During interview with E 9, Physical Therapy Assistant, on [DATE] at 1:50 PM, E 4 stated that [DATE] was the first time R4 had refused therapy. Record review of R4's Food Intake Records for [DATE] show she ate between 50 to 100% at meals from [DATE] through [DATE]. The Record shows R4 ate only 25% for breakfast and 20% at lunch and the evening meal was not documented as to intake on [DATE]. There is nothing in R4's Nurses Notes that show R4 was assessed for decreased appetite, refusing therapy, increased blood pressure, requiring O2 to be increased from 2 liters to 3 liters and assessment of R4's low Fasting Blood Sugar of 50 mm/dl on [DATE]. On [DATE] at 3:30PM, Z10, Paramedic, stated by the time the Nurse came into the room to give the [MEDICATION NAME]. R4 was in asystole. Z10 stated they were going to give glucose which would work faster than the [MEDICATION NAME]. E 1, Administrator, stated on [DATE] at 1:10 AM, the facility does not have a Policy and Procedure for response to low blood sugar. E5 stated on [DATE], that the Nurse should have called the Medical Director when she did not get a response from Z1. E5 stated E 1 was going to talk to the Medical Director to get standing orders for [MEDICATION NAME]. R4's Care Plan of [DATE] show there is no plan in place to address low blood sugars.

Based on record review and interview, the facility failed to follow their policy for notifying the Physician of laboratory results for 1 of 1 residents, R4, reviewed for notification of laboratory results in the sample of 6. This failure resulted in R4 not getting necessary tests/treatment to determine internal bleeding and she expired. Findings include: The facility Policy on "Physician Notification" that is undated, documents, "The Physician will be notified of any changes in the resident's condition that deviate from the established base line and/or results of laboratory test..." Z3's Progress Note of [DATE] documents orders for BMP, CBC to be drawn weekly with results to Z3. BMP, CBC Phosphorus, [MEDICATION NAME], Vitamin D, Iron panel to be drawn in 3 weeks. Laboratory tests of [DATE] show abnormal laboratory values of Blood Urea Nitrogen (BUN) of 58 (normal ,[DATE] mg/dl); Creatinine 2.2 (normal 0.5 - 1.5 mg/dl); BUN/[MEDICATION NAME] Ratio within normal level at 26 (normal ,[DATE]) and Hemoglobin 8.4 (normal 12.0 - 16 g/dl); Hematocrit 24.7 (normal 36 -48 %). A note was written "Z1 Any N.O. (new orders)? Any Orders? Our fax xxx-[MEDICAL CONDITION]. ,[DATE] faxed to Z3." There is nothing in R4's Nurses Notes addressing the above labs. Laboratory test for [DATE] document ; BUN elevated at 87; Creatinine of 2.2; BUN/[MEDICATION NAME] Ratio was now elevated at 40; Hemoglobin 8.3; Hematocrit 24.6. There is no documentation in R4's medical record that would indicate Z3 or any Physician was notified of the above lab results of [DATE] and these laboratory results were not in R4's medical record until [DATE] when Surveyor inquired about the results. On [DATE] at 12:10PM, E2, Director of Nursing, (DON) stated she thought labs were drawn on [DATE] but stated she didn't know where they were and confirmed they were not in R4's medical record. At 1:02PM, E2 stated she found the [DATE] labs in the "to do file." When asked what the to do file is, E2 stated it means maybe needs to be reviewed. Doctor may need to be notified. At 1:20PM, E2 stated the facility has no information to prove Z3 was notified of the [DATE] labs. On [DATE] at 11:20AM, Z14, Z3's Nurse, stated Z14 had not been notified of R4's laboratory tests for [DATE] or [DATE]. Z14 was informed it was documented on the labs of [DATE] that they were faxed to Z3. Z14 stated the labs were not faxed to Z3 and the computer shows labs of [DATE] were faxed to Z1 and fax transcript shows they were not faxed to Z1 until [DATE]. Z14 stated Z3 ordered the labs and didn't understand why the facility would fax the labs to Z1 and not Z3 when Z3 ordered the labs. Z14 stated Z3 was not informed of the [DATE] at all. At 1:00PM, Z14 stated Z3 was shown the labs and stated he would have ordered an iron panel and stool card due to concern of bleed out. He would not have left it alone. "With the BUN/Creatinine Ratio and low Hemoglobin there would be a concern of internal bleed." Nurses Note of [DATE] at 5:50AM, documents R4's blood glucose level at 34. R4 unresponsive, respiration even and unlabored pale and cold to touch. At 6:10AM the Nurse documents she went into R4's room to check on her and R4 was in full [MEDICAL CONDITION]. CPR was initiated and R4 had a large amount of dark brown discharge coming from her mouth and nose. Emergency Medical Service (EMS) called. EMS report of [DATE] documents arrival to patient at 6:35AM with blood/fluid loss of ,[DATE] ml. Airway partially obstructed with blood; cyanosis; pupils fixed and dilated; unresponsive. Note documented, " Due to down time, excessive amount of blood that came from patient, EMS attempted to get time of death in the field...Intubation unsuccessful due to the copious amount of blood in the airway...Copious amounts of dark blood was coming from the patient's mouth, Cyanosis and mottling was also noted...EMS notified Medical Control and requested to cease all treatment. EMS advised to continue efforts and transport." Hospital ER records showed asystole and time of death [DATE] at 7:06AM

Based on observation, record review and interview, the facility failed to ensure 4 residents, R1, R3, R4 and R21 of 9 sampled residents review for pressure sores, receive necessary care and treatment to prevent pressure sores from developing and promote healing of existing pressure sores. This resulted in a decline of R21 and R1's pressure sore and reopening of R3's pressure sore. Findings include: 1. R21's Physician order [REDACTED]. POS shows [MEDICAL CONDITION] Resistant Staff Aures of the pressure sores on the right ankle. R21's most recent Care Plan identifies R21 as being at risk for skin breakdown related to decreased mobility, [MEDICAL CONDITION], occasionally incontinent of urine, obesity and Diabetes Mellitus. Care Plan approach, in part, states, "Treatments as ordered." R21 was observed on 12-10-10 at 9:40AM to have dressing changes on her right outer leg and left heel by E9, Licnense Practical Nurse (LPN). The gauze dressing on R21's right leg was dated 12-8-10, 3-11, with initials of the nurse, E15. E9 confirmed the dressing was dated 12-8-10. R21's left heel did not have a dressing. E9 was observed to remove gauze pads from the treatment cart and place directly onto the top of the treatment cart then used the same gauze pads as treatment to R21's pressure sores. R21 used scissors to remove the dressing from R21's right lower leg and then placed the scissors on the seat of the chair in the room. E9 did not cleanse R21's pressure sores on the right leg before dressing with Santyl and gauze pads. E9 then used the same scissors to cut gauze wrap and then wrapped R21's ankle. E9 confirmed R21's left heel was scabbed and proceeded to try to pick off the scab as R21 complained of pain. R21 put skin prep and gauze on the left heel but failed to cleanse the heel prior to doing treatment. E9 washed the scissors with water and dried with a paper towel and then placed the scissors in her pocket. On 12-15-10 at 8:50AM, E3, Charge Nurse, stated that she interviewed E9, E15 and E16, Certified Nurse Aide (CNA). All stated R21 had a shower on 12-9-10 and E9 had removed the dressing on her right leg prior to the shower and redressed the ankle after the shower. E15 stated she did the treatment on the 3-11-10 shift but must have written the wrong date. The facility WEEKLY WOUND LOG FOR PRESSURE ULCER log of 12-5-10 to 12-11-10 shows R21 has an acquired in house stage 2 pressure sore on the left heel measuring .2 c.2 <.1 cm. The log identifies two Stage 2 Pressure Sores measuring 1 x .7 x <.1cm and the other measuring 1x1 x <.1 cm on the right leg. This is an increase from the previous log of 11-28-10 to 12-4-10 where pressure sores on the right leg measured .5 x .3 x <.1 cm and .7 x .5 [MEDICAL CONDITION] cm. 2. Facility WEEKLY WOUND LOG FOR PRESSURE ULCER log for the week of 11-28-10 to 12-4-10 shows R1 has a stage 2 pressure sore on her coccyx measuring .5 x 1 x .2 cm with [MEDICATION NAME]/dressing. A stage 1 on left buttock measuring .6 x .2 c <.1 cm and a stage 2 on right buttock measuring .6 x .2 x <.1 cm. Log for the week of 12-5-10 to 12-11-10 show the pressure sore on the coccyx increased in size to 1.5 x .8 x .2 cm. The stage 1 on left buttock measured 1.5 x 1.2 cm and stage 2 on right buttock measured .4 x .4 x < .1 cm. R1 was observed on 12-10-10 at at 8:55AM to be lying in bed. Skin check showed oozing feces at anal area and a dressing on her coccyx and white cream on her buttocks. E3 removed the dressing from her coccyx. E11, CNA, gave incontinent care washing anal area and buttocks. E11 washed R11's left buttock then proceeded to put a thick layer of white cream into the open pressure sore on R1's coccyx and over buttocks with the same soiled glove. 3. R3's Care Plan dated 10/8/10 identifies her to be incontinent of urine and bowel, and requires assist of all activities of daily living including mobility. According to the physician's orders [REDACTED]. The care plan interventions include checking/changing after each incontinent episode, skins checks daily, assist and teach resident to reposition herself and pressure reduction mattress/cushion among others. On 12/10/10 at 8:20am, R3 had been incontinent of urine and had three incontinent briefs under her. She had a pressure relieving mattress. R3 was observed to lay on her back the remainder of the morning. At 11:40am, R3 was transferred to her wheelchair at bedside where she remained until the observation stopped at 1:50pm without repositioning. On 12/14/10, R3 was identified with a reopened pressure sore on her coccyx which was identified as a stage II. An order was obtained for [MEDICATION NAME]. [MEDICATION NAME] and Protein dated 4/2010 show levels within normal limits. There is no information in the care plan that would indicate R3 is resistive to turning and repositioning except under decreased activities of daily living. 4. According to the care plan, R4 is at risk for pressure ulcers with no history of sores. The care plan also identifies R4 as being incontinent of bowel and bladder. R4's care plan interventions include toileting/repositioning, checking/changing when needed among others. On 12/10/10 at 10:30am, R4 taken to the toilet by E5 and 6, CNA's. R4's buttock and coccyx area was deep red and creased. E6 stated R4 was up in her wheelchair already when she came to work around 6:50am. R4's toileted then was transferred back into the wheelchair.

Based on observation, record review and interview, the facility failed to ensure that bed cranks were placed under the bed after use to prevent accident/injury for 1 sampled resident, R1, and 9 residents off the sample, R15, R16, R17, R18, R19, R20, R22, R23 and R24. This failure resulted in harm to R1, who's wheel chair got caught in her bed crank causing R1 to fall from the wheel chair. R1 was sent to the emergency room with a laceration on the left side of her face 4 cm with 2 cm depth and a laceration on her forehead 1 cm both requiring sutures. Findings include: 1. During tour of the facility on 12-10-10 at 8:55AM, R1 was in bed and her face was black and blue with scabs. E3, Charge Nurse/Licensed Practical Nurse, stated R1 had fallen from her wheel chair when her wheel chair got caught in the crank used to elevate her head. On 12-14-10, at 4:30PM, E1, Administrator, E2, Director of Nursing and E3, Charge Nurse stated R1 would not be capable to use the crank on her bed. E2 stated staff had been inserviced as to put the bed cranks back into place after use. R1's most current Minimum Data Set (MDS) identifies R1 as having no cognitive impairment; requires extensive assistance of 1 for transfer, bed mobility, ambulation, toilet use and bathing. R1's Care Plan of 11-22-10 identifies R1 as requiring extensive assist with bathing, dressing, and grooming needs. Care Plan identifies R1 as being at risk for falls due to decreased mobility and generalized weakness of bilateral lower extremities. Care Plan note of 12-6-10 states, "fall from w/c (wheel chair) d/t (due to) when got w/c caught on bed laceration to forehead." Care Plan approach, includes in part, "Encourage staff to put bed cranks folded under bed." Nurses Note of 12-3-10 at 8:30AM states, R1 was found laying on stomach with left side of head on floor and left arm in pronation position next to stomach. R1's wheel chair was at the end of the bed and the wheel chair was caught on the bed crank. R1 said she was trying to get to the other side of the bed. There was a large amount of blood on the floor. Upon assessment noted laceration to left forehead approximately 4 cm in length and about 2 cm deep. and a laceration to the right forehead approximately 2 cm. There was a large amount of blood and bruising to the left eye. Unable to check left eye pupil reacting due to bleeding/bruising. Alert and oriented x 3... Note at 8:35AM says Dr. okayed to send to ER (emergency room ). Facility Accident/Incident Investigation Report states under conclusions: "Res (R1) found laying on stomach with L side of face on floor Lg (large) Amt (amount) blood on floor. Laceration x 2 to L & R forehead. Neuro checks initiated AOx3 (alert and oriented x 3) ROM (range of motion) WNL (within normal limits)...Res was propeling on w/c w/c got caught on crank handle to bed. Res said she hit head on foot board & then floor. No blood noted on foot board sent to ER for evaluation...Staff inserviced to ensure residents bed crank is returned to under bed after care" Hospital ER report of 12-3-10 states shows left eye soft tissue hematoma. Note states to R1 received 10 stitches to the left eye and 6 to the right eye. 2. On 12-15-10 at 2:30PM, R15, R16, R17, R18, R19, R20, R22, R23 and R24 beds were observed to have the bed crank pulled out where residents or staff could get injured if they bumped into the crank.

Based on observation, interview and record review, the facility failed to identify and assess new pressure sores and those showing a decline; and failed to implement new treatment; failed to follow manufacturers recommendations for pressure relieving devices; and failed to ensure the application and adhesion of pressure sore dressings for 8 of 15 sampled residents R3, R8, R17, R11, R13, R20, R19, R25 and 2 residents off the sample, (R29,R30) who were at risk for developing pressure sores. These failures resulted in R8 developing two tunneling stage 4 pressure sores and two stage 2 pressure sores and unstageable pressure sores that the facility failed to identify and assess. R3 developed three new pressure sores the facility was not aware of and the pressure sore on his outer right foot increased in size. R17 had a pressure sore on her buttocks that would improve and decline with no change in treatment for [REDACTED]. Findings include: 1. R8's Minimum Data Set (MDS) of 8-3-10 identifies R8 as having no cognitive impairment; independent in transfer, bed mobility, dressing, eating; and continent of bowel and bladder. MDS identifies R8 as having 2 stage 2 pressures. R8's BRADEN SCALE -For Predicting Pressure Sore Risk of 10-14-10 identifies R8 as scoring a "20" which is low risk for development of pressure sores. R8's Care Plan of 8-4-10 states, "R8 was admitted with areas to right foot tips of toes and bottom of foot. He has amputation of left leg. Areas to right leg/foot treated with ABT (antibiotic). He is paraplegic from accident in 1990. He is continent of bowel and bladder. He is independent with ADL's (Activities of Daily Living). He has DM (Diabetes Mellitus),[MEDICAL CONDITION](Hypertension) and he is a smoker." Care Plan note of 9-24-10 states open area Left buttock stage 2. Note of 9-28-10 states, "2nd toe R (right) foot." Care Plan approaches include: "Body/skin audit at least weekly; Encourage intake of fluids and food on all shifts; Float heels when in bed; Observe for any signs and symptoms of infection; Pressure reduction mattress in chair; Pressure relieving mattress on bed. Protective skin barrier as needed; Report any red or open areas; Skin checks daily; Skin checks during routine daily care; Treatments as ordered." Care plan notes were added under approaches, "9-23 Tx (treatment) as ordered 9-24 9-29 Tx as ordered. Nutritional Support wound healing." On 10-25-10 the facility provided a Weekly Wound Care Log dated 10/10/10 - 10/16/10 and identified the Log as being their most current assessment of facility pressure sores. The log identified R8 as having a stage 2 pressure sore on his left buttock, that was acquired in house. The Weekly Wound Care Log identified the pressure sore as measuring 1.5 x 1.1 <.1 cm with no drainage and pink in color. The treatment was identified as [MEDICATION NAME]. On 10-27-10 at 10:45AM, E40 (Licensed Practical Nurse/Treatment Nurse) changed R8's pressure sore dressing. R8 was lying crossways over his bed on his back and stated the pressure sore on his bottom was painful, "like sitting on thumb tacks." E40 stated, "That's why you're in bed instead of your chair." E40 stated R8 is always in his wheel chair. R8 was observed to have a peeling [MEDICATION NAME] on his sacrum and had multiple pressure sores on his left buttock with no dressing and an area on his right buttock with no dressing. The pressure sore on R8's sacrum was deep and had tunneling. There was another deep pressure sore beneath the pressure sore on the sacrum. E40 measured the pressure sores and measured tunneling on the pressure sore on his sacrum as 3 cm and the deep pressure sore below to have 1.5 cm tunneling. E40 failed to set up a clean field to do the treatment. E40 wet the gauze pads that were on the bed pad with saline solution and then cleaned the pressure sores with the gauze. E40 cut [MEDICATION NAME] AG with the scissors that were lying on the soiled pad and put the [MEDICATION NAME] into the tunneling wounds and then used skin prep around the wounds. R8 covered the sacrum wounds with [MEDICATION NAME] and the other pressure sores with [MEDICATION NAME] without ensuring the edges of the [MEDICATION NAME] adhered to R8's skin. E40 then put 2 pieces of tape over the [MEDICATION NAME]. There was no treatment done on the mid right buttock. The mattress on R8's bed was a regular mattress. (On 10-29-10, E51, Registered Nurse confirmed the mattress was the regular mattress the facility uses and stated all their mattress are pressure relieving.) On 10-27-10 at 11:30AM, E4, Nurse Manager for 3rd and 4th floor, stated she did not have any current assessment/measurements for R8's Pressures sores other than the Weekly Wound Care Log of 10/10/10 - 10/16/10. E4 stated she did the dressing change on 10-25-10 and got new orders for the pressure sore on R8's sacrum. E4 stated R8 did not have any other pressure sores at that time. At 1:28PM, E4 again stated there was only 1 pressure sore which was on R8's sacrum when she saw it on Monday, 10-25-10. E4 stated the pressure sore had undermining, but she did not measure the pressure sore. E4 says E40 does the treatment and gets the measurements of pressure sores. E40 was present and stated she gets 3rd and 4th floor measurements on Wednesday, Thursdays and Fridays. Both stated E40 gets the measurements and then they meet and discuss findings and they both then stage the pressure sores. E40 stated she is uncomfortable with staging the pressure sores. She's still in training. E4 confirmed that she and E40 do not assess the wounds and measure together. When E4 was asked how she can assess a pressure sore without being there for the measurements and from observation 2 days prior, E4 stated she already knows what the pressure sores look like. "I have it in my head from the last time I saw it." E40 then tells E4 what the measurements are and then they stage the pressure sores together. E40 stated she had done the treatment on the previous Friday (10-22-10) and would have staged it as a stage 3 at that time.."it was superficial with yellow slough." E40 stated they paged her on Monday 10-25-10 about the decline. She did not assess the pressure sore because it already had a new dressing. Both E4 and E40 stated that R8 was found on the floor in the shower room the previous week and think R8's pressure sores could be deep tissue injury. R8 was interviewed on on 10-28-10 at 9:15AM and stated he did not fall in the shower. He was transferring himself from his motorized wheel chair to a regular wheel chair to take into the shower and slid to the floor between the wheel chair. R8 stated "Eased down between the wheel chairs." R8 stated he did not fall on his buttocks and did not hurt himself. The facility Policy and Procedure updated 10-1-10, for MEASUREMENT & ASSESSMENT OF PRESSURE ULCERS, WOUNDS AND OTHER SKIN PROBLEMS states, "Policy: At first observation of any skin condition, the charge nurse or treatment nurse is responsible to measure and describe skin condition in the clinical record. All measurements will be recorded in centimeters. All ulcers (Pressure, arterial, diabetic, venous) will be measure weekly and results recorded on a Wound Assessment Form." The procedure states to identify type of ulcer present such as pressure, arterial etc...Identify the stage or extent of tissue destruction involved. For pressure ulcers. Stage 4 Ulcer: "Full thickness skin loss involving epidermis, dermis, subcutaneous tissue, fascia, and underlying structures such as muscle, tendon, joint capsule, or bone. May have undermining or tunneling present." The facility Policy and Procedure updated 10-1-10 for SKIN CONDITION AND PRESSURE ULCER ASSESSMENT POLICY states, "It is the policy of this facility that pressure and other ulcers, (such as diabetic, arterial, venous) will be assessed and measured at least every seven (7) days by licensed nurse and recorded on the Wound Assessment Record." The policy states, "Care givers are responsible for promptly notifying the charge nurse who will perform a detailed assessment of skin observations, including: a. redness/swelling b. bruises c. skin tears d. blisters e. excoriations f. wound drainage g. crusts i. any type lesion j. skin discolorations k. bleeding l. changes in skin temperature." "An individual Wound Assessment Form will be initiated when pressure and/or other ulcers (such as Diabetic, arterial, venous) are identified by licensed nurse. This form is a permanent clinical record. Until the wound heals, the assessment may be maintained with the resident's Treatment Administration Record or a designated location determined by the facility." "With each dressing change the nurse will monitor for changes, such as suspected wound infection, which requires physician and responsible party notification. Documentation of findings will be made on Wound Assessment Form. Physician and responsible party notification will be documented in the clinical record. These changes include, but not limited to: a. new onset of purulent drainage b. new onset of odor c. [MEDICAL CONDITION] d. increased pain related to wound e. significant increase in wound measurements f. onset of new ulcers g. periwound redness/changes." On 10-27-10, at 4PM, after R8's pressure sores were discussed with the facility, E4 provided a Wound Assessment Progress Report for R8 and stated she, E4, E2 (Director of Nursing) and E51 (Registered Nurse) had reassessed R8's pressure sores together and had gotten new treatment orders. The Wound Assessment Progress Report showed the following pressure ulcers. Pressure Ulcer #1 - initial identification on 10-22-10 unstageable pressure sore with slough measuring 1x 1cm with unstageable depth and slight drainage. Measurements of 10-27-10 identifies the pressure sore as being unstageable measuring 6.5 cm x 2.2 cm with unstageable depth and tunneling through to another pressure sore on the left lower buttock wound with wound bed pink, yellow and brown with 95% slough. Note states "Wound open in middle 1.5 cm x 2.2 cm circular open." Surrounding tissue "Wound bed covered with slough surrounding tissue light brown." Moderate yellow drainage. Comments: Current treatment pack with [MEDICATION NAME] and cover with [MEDICATION NAME]. Change to pack with normal saline wet to dry, cover with dry dressing. Ordered low air loss bed. Prostat with multivitamin with minerals. Pressure Ulcer #2 - identified on 10-27-10 left lower buttock unstageable pressure ulcer measuring 1.6 x 1.5 cm depth unstageable tunnels thru to the left and buttock wound . moderate yellow slough. Pressure Ulcer #3 - identified on 10-27-10 left mid buttock unstageable pressure ulcer measuring 2 x 1.3 cm unstageable depth with 100% slough with drainage. Pressure Ulcer #4 - identified 10-27-10 right mid buttock stage 2 measuring .5 cm x .5 cm x <.1 cm. pink with no drainage. Pressure Ulcer #5 - identified 10-27-10 right inner buttock stage 2 pressure sore measuring .3 x. 3 x < .1 cm, pink with no drainage WOUND CARE NOTES that were attached to the above assessments show documentation of 10-27-10 stating late entry for 10-25-10. E43 LPN (Licensed Practical Nurse) informed E4 that R8's area to the sacrum was worse. Assessed area which is now circular, open and is undermining at 6 o'clock. Wound bed covered with slough...area now needs to be packed and new order for treatment was received. "E43 also states a superficial area to the L (left) buttock she noted which area healed on 10-22 so she got tx (treatment) of [MEDICATION NAME] change q (every) 3 days for this." E2, DON, confirmed at the Daily Status Meeting at 4:30pm on 10-27-10, that the Wound Assessment Progress Report provided earlier by E4 is the form the facility is to be using to document pressure ulcers according to their policy and procedure. E2 confirmed the facility has failed to follow their own policies and procedures concerning pressure sores and stated, "That's going to change." On 10-29-10, at 3PM,Z2, R8's Physician, stated he would expect the facility to do a thorough assessment on R8's pressure sores once they noted a decline. R8 stated, "How could they not!" Z2 agreed it was good nursing practice. At 4:10PM, Z3 (Z2's Nurse) stated that the Physician on call for Z2 on 10-27-10 had been notified on that date of R8's tunneling pressure sores. The Physician was told R8 had 2 stage 4 pressure sores and stage 2 pressure sores. Z3 stated the Physician had this information in her notes and gave new treatment for [REDACTED]. R8's Physician orders [REDACTED]. 2. R3's Minimum Data Set (MDS) of 9-21-10 identifies R3 as having mild cognitive impairment with decision making in new situations only; being resistive to care; requiring extensive assistance of 2 with bed mobility; and requiring extensive assistance of 1 for transfer, dressing and hygiene. R3's Braden Scale For Predicting Pressure Sore Risk of 9-21-10 shows R3 scored a 15 which is low risk for developing pressure sores. R3's current Care Plan of 3-29-10 and updated 9-22-10 shows R3 is confused and requires extensive assistance with bed mobility, transfers dressing, eating, toileting and bathing and is dependent for hygiene. The Care Plan states R3 has a stage 3 pressure sore on his coccyx and has a urinary catheter. The Care Plan note of 4-1-10 states R3 has a stage 3 pressure sore on his right lateral foot. Note of 9-21-10 states stage 3 coccyx and stage 2 to ankle. Care Plan approaches include, in part, "Assess for pressure sore's size depth & color weekly; Body/skin audit at least weekly; Pressure reduction mattress on bed; Treatments as ordered; Float heels; Daily skin checks; Encourage to follow turning and positioning schedule; Urinary Catheter. Care Plan note of 9-21-10 states, "All wounds are unavoidable due to comorbidities." On 10-25-10, the facility provided a Weekly Wound Care Log dated 10/10/10 -10/16/10. E4 stated it was the most current assessment of R3's pressure sores. The log showed R4 has a unstageable pressure sore on his right outer foot acquired in the facility measuring 1.7 x 2 cm open with no drainage and purple in color. The log states no improvement. The report shows R3 was admitted to the facility on [DATE] with a pressure sore on his coccyx. The log showed the pressure sore measured 4 x 3.4 x .5 cm with a small amount of drainage with yellow slough and no improvement. The log showed a stage 2 pressure sore on his right buttock measuring .5 x .6 [MEDICAL CONDITION] cm with a small amount of drainage that was acquired in house identified on 9-12-10. The log shows another pressure sore on his left buttock measuring .3 x .3 x <.1 cm. developed in house and identified 9-24-10. R3 was observed on 10-25-10 from 8:40AM to 12:45PM to be in his room in his bed lying on his back with no positioning devices. R3 had a fitted sheet over his air loss mattress and a folded sheet between the air loss mattress and the fitted sheet under R3's buttocks area. R3 was also lying on 2 bed pads. During skin check on 12-27-10 at 9:53AM, with E40, R3's [MEDICATION NAME] was folded back in half and sticking to his bed pad. R3 had a deep wound on his coccyx with yellow slough and 4 more stage 2 pressure sores on his left buttock. E40 stated the 3 areas on his buttock were new and she was unaware that he had them. E40 measured the pressure sores stating the coccyx was 3.8 x 3.4 x .7 cm in depth. The 3 pressure sores on his left buttock measured 4 x .5 cm; .5 [MEDICAL CONDITION] cm; .2 x .2 cm; and .5 x .5 cm. R3 also had a pressure sore on his right buttock that was covered with a thin [MEDICATION NAME]. That pressure sore measured .7 x .5 cm. R3 had a red area on his heel measuring .6 x .3 cm that E40 identified as being new. R3 had a protective boot on his right outer foot. There was blood on the boot and 2 spots of dried blood on the fitted sheet. R3 had a gauze bandage that had blood on the outside of the bandage. E40 removed the bandage and measured the pressure sore stating it measured 2 cm x 2.4 cm and had bright red beefy tissue. Z4, representative for the low air flow mattress, stated on 10-29-10 at 2:15PM that they provide a vinyl over lay for the air flow mattress. Z4 stated the facility should not be using a fitted sheet on the mattress because it decreases the low alternating air flow. Z4 stated she would not recommend the facility put a folded sheet, tight fitting sheet, and two bed pads on the mattress. "It decreases the functioning of the mattress and decreases prevention and purpose of the mattress." 3. R17's MDS of 8-17-10 identifies no cognitive impairment; resists care; and requiring extensive for transfer, bed mobility, hygiene and toilet use. R17's Care Plan of 8-18-10 identifies R17 as being at risk for skin breakdown due to history of incontinence and non compliance with turning and repositioning. Prefers to be on back. R17 has resolving stage 3 to right buttock. Note of 9-28-10 states Unstageable to left heel. Undated note states revolving open, healed reopened areas on Right buttock and left heel. Care Plan approaches, in part, are for a pressure reduction mattress in chair; pressure relieving mattress on bed; and supplements as ordered. R17 was observed on 10-29-10 to be in bed with a low air loss mattress. There were 2 sheets folded in fourths and 1 bed pad on the mattress under R17's buttocks. R17 had 2 bed pads folded in quarters on her wheel chair seat. R17 stated that she sits on the folded bed pads when in her wheel chair. There was no pressure relieving pad in her wheel chair. On 1029-10, Z4 stated it is not recommended to put folded sheets and bed pad on air flow mattress because it decreases the functioning of the mattress and decreases pressure sore prevention which is the purpose of using the mattress. On 10-25-10 the facility provided a Weekly Wound Care Log dated 10-10-10 - 10-16-10 showing R17 has an acquired in house pressure sore on her right lower buttock a stage 2 measuring .4 x .5 <.1 cm; an unstageable pressure sore on her left heel, acquired in house/reopened, measuring 2 x 1.8 with unstageable depth; and an acquired in house/re opened on her right buttock, stage 2 pressure sore 1x .8 x<.1 cm Interview with E4 on 10-27-10 reflected that the above Weekly Wound Care Log was the most current assessment of R17's pressure sores. E40 stated on 10-27-10 she had measured R17's pressure sores that day. E40 provided measurements to the pressure sore on R17 right lower buttock as .5 x .5 , the upper right buttock as .3 x .2 cm and the left heel as 1.5 cm x 1.5 cm. E40 stated the above pressure sores show an improvement and then decline. The previous week measurements showed the lower right buttock pressure sore was .2 x .2 cm and the heel measured .8 x 1 cm. E40 stated she did not have staging of pressure sores because she and E4 had not yet gotten together to stage the pressure sores. Record review of R17's Treatment Records and Physician order [REDACTED]. Records show R17 had a treatment of [REDACTED]. On 10-29-10, Z5, R17's Physician's Nurse, stated that the Physician would expect the facility to follow the manufacture's recommendations for the low air loss mattress. Z5 stated that she couldn't imagine the Physician refusing to change a treatment for [REDACTED]. 4. R29's Minimum Data Set (MDS), dated [DATE], documented that R29 was a cognitively impaired resident who required extensive assistance of one to two plus persons physical assist with mobility and transfer, functional limitation in range of motion for arm, hand, leg and foot and no pressure ulcers. R29's Care Plan, onset dated 6-15-10, documented that R29 was at risk for skin breakdown with preventive treatment to right buttock, right hip and bilateral heels. It was also documented that staff were to provide skin checks during daily care and to float heels R29's heels when she was in bed. R29 was continuously observed, on 10-26-10 from 8:10a.m. to 10:25a.m., at 10-15 minute intervals at 8:10a.m., 8:20a.m., 8:35a.m., 8:50a.m., 9:05a.m. to 10:25a.m., sitting up in her wheel chair. During observation of R29's care, on 10-26-10 at 10:25a.m., E23, Certified Nursing Assistant (CNA) and E18, Certified Nursing Assistant (CNA), transferred R29 from chair to bed. R29's pants were observed wet during the transfer. After E23 and E18 cleansed R29 the following three undressed Stage II open areas were observed: Two Stage II areas, both approximately 0.5cm x 0.5cm round, on R29's right buttock and One Stage II area, approximately 0.2cm x .3cm, on R29's left upper thigh. The facility's Weekly Wound Care Log, dated 10-10-10 to 10-16-10, documented that R29 did not have any wounds/pressure ulcers. R29's Treatment Records, dated 10-16-10 to 10-26-10, documented that R29 did not have any treatments for the two Stage II areas on R29's right buttock or the one Stage II area on her left upper thigh. R29's Treatment Record did document treatment to her left lower extremity, right hip and bilateral heels. E4, provided physician's telephone order, dated 10-26-10, after the 10:20a.m. observation, that documented that the physican was notified of two right buttock areas and a treatment was ordered. E19, Third Floor Manager, provided, on 10-28-10 at 1:20p.m., measurements of the three new areas with which documented, "10-25-10 right upper buttock Stage II 0.3cm x 0.2 x less than 0.1", "10-25-10 right lower buttock Stage II 0.1cm x 0.1 x less than 0.1" and "posterior (L) (left) thigh 0.1 x 0.3 scabbed area." E4, stated during refutation, that the skin assessment were dated wrong and re-dated the assessments for 10-26-10. During skin check with E4, 10-27-10, E4 stated that she was not aware of R29's Stage II pressure area on the back of R29's left thigh, and did not provide justification for the development of R29's Stage II pressure ulcers. 5. R11's MDS, dated [DATE], documented alert and oriented, extensive to total staff assistance of one to two persons physical assistance with transfer and mobility, incontinent of bowel and bladder and three pressure sores. R11's outside wound care documentation, documented that R11 had a 0.2 x 0.3 x 0.1 pressure ulcer on his right heel, a 3.5 x 0.l x 0.2 pressure ulcer on his coccyx and a 1.5 x 1.1 x 0.2 pressure ulcer on his left medial foot. The facility's Weekly Wound Care Log, dated 10-10-10 to 10-16-10, documented all three areas had developed in-house. R11's Treatment Record, dated 10-16-10 to 11-15-10, documented "(L) (left) foot, (R) (right) heel [MEDICATION NAME] foam dressing, Kerlix, tape q (every) 3 days", "Coccyx gauze [MEDICATION NAME] tape change every 2 days et (and) prn (as needed)" and "Rooke boot on at all times may remove for tx (treatment) & (and) showers." R11 was observed on 10-25-10 at 11:35a.m. through his noon meal and on 10-26-10 from 8:00a.m. to 9:00a.m. at 10 minute intervals to include 8:10a.m., 8:20a.m., 8:30a.m. to 9:00a.m., not wearing "rooke boots" During observation of R11's toileting, on 10-25-10 at 11:35a.m., R11 did not have a dressing in place on his coccyx. E19, Third Floor Manager, was informed and provided R11 with a coccyx dressing. R11's Care Plan, onset date 11-12-09, documented that R11 was at risk for skin breakdown and that he was to have a pressure relieving mattress on bed/chair. R11's mattress was observed on 10-25-10 at 11:35a.m. with double bed pads and a draw sheet and not just the bed itself. 6. R30's MDS, dated [DATE], documented cognitively impaired, extensive to total staff assistance of one to two person physical assistance with mobility and transfer and no pressure sores. R30's Care Plan, onset date 7-20-10, documented that R30 was at risk for skin breakdown with an entry dated 9-15-10 that R30 had right bottom heel unstagable area. The facility's Weekly Wound Care Log, dated 10-10-10 to 10-16-10, documented that R30 had developed an in-house 4 cm x 2.8 Stage I pressure area on her right heel. The facility did not provide a justification for the development of R30's right heel area. On 10-28-10 from 8:00a.m. to 9:15a.m. at 10 minute intervals 8:10a.m., 8:20a.m. 8:30a.m. to 9:15a.m., R30 was observed sitting in a reclining chair, at times hitting her right heel into her reclining chair without staff intervention or staff providing a protection device for her right heel. 7. R20's MDS, dated [DATE], documented cognitive impaired, extension staff assistance of one to two person physical assistance with mobility and transfer, limitation functional range of motion for leg and foot and no pressure areas. The facility's Weekly Wound Care Log, dated 10-10-10 to 10-16-10, documented that R20 had developed an in-house Stage II 1.0cm x1.2 x .1 pressure nurse to his right buttock. The facility did not provide a justification for the development of R20's right buttock pressure sore. 8. The MDS dated [DATE] identifies R13 to have no memory or cognitive impairment. The MDS indicates R13 requires extensive assist of one staff for bed mobility, is totally incontinent of bowel and bladder and had 4 stage II pressure ulcers. R13's physician's orders [REDACTED]. hip, upper coccyx, lower coccyx and right/left buttocks as having stage II's and on 8/17/10 the right heel was identified and on 8/20/10, the left heel was identified. The care plan reflects other areas on the bunion as 2 stage II's. Interventions include assessing pressure sores weekly, monitor labs, position resident off affected areas, pressure reducing mattress in chair and bed, low air loss mattress and rooke boots for protection with skin checks done daily. The facility failed to develop an adequate prevention plan that included her preference to lay on her back and failed to ensure that treatments were done appropriately. According to the WEEKLY WOUND CARE LOG for pressure ulcers dated 10/10/10 to 10/16/10, R13's bunion areas are identified as "unstagable" and measured 2 x .6 and 2 x 1.5cm, deep purple. However, when they were found on 9/5/10, they measured only 1.5 x 1cm and .5 x .5cm. According to the care plan, the rooke boots were added after the foot pressure ulcers developed and not before. E3, Nurse Manager stated on multiple occasions when asked why R13 developed the pressure ulcers following admission stated that R13 was not compliant with turning and repositioning and confirmed the boots were added after the foot sores developed. However, R13 being non-compliant is not identified within her current care plan nor has the facility developed a plan addressing this need. This was confirmed in interview with E3 during the daily status meeting on 10/29/10. On 10/25/10 at 11:50am, E9 and E41, Certified Nurses Aide (CNA) turned R13 over to provide incontinent care. R13 did not have any protection on her feet at the time. E9, CNA, removed the gauze dressing at R13's coccyx area. There was a wadded/bunched up [MEDICATION NAME] dressing over her coccyx area which E9 pulled off. The coccyx decub had white skin/ring surrounding the sore which was beefy red with some slough present. E41 washed R13 buttocks and coccyx area then drew the rag over the rectum and into the labial area. She repeated this several times. E5, Registered nurse (RN) then squirted a small [MEDICATION NAME] of saline into the coccyx wound, patted it dry, commented on the slough and then applied the treatment without properly cleansing the wound bed sore. The WEEKLY WOUND CARE LOG indicates that R13's coccyx pressure sore has remained with slough and drainage with minimal decrease in width over the past three weeks with no change in treatment being sought. According to the log dated 9/26/10 - 10/2/10, the coccyx was identified as a stage III measuring 2.5cm x .8cm with scant yellow drainage, wound bed pink/yellow. The log dated 10/10/10 - 10/16/10 again identifies the coccyx sore as a stage III measuring 2 x .7cm with scant yellow drainage and pink slough wound bed. Interview with E3, Nurse Manager on 10/29/10 during the daily meeting indicates that she has written narratives of all R13's wounds and that R13 is non-compliant with turning and repositioning but no plan to address that need to ensure R13 is turned and repositioned. On 10/29/10 at 11am E3 stated she wouldn't say that R13 was "non-complaint" but likes to be pampered and prefers to lay on her back. E3 stated if staff put her on her back, she will shimmy over to her back. This was confirmed also with E9 CNA on 10/29/10 who said they will put her on her side and she will wiggle over to her back. R13 also developed pressure sores on her feet. According to the log, R13 developed blisters on both heels on 8/17 and 8/20/10. On 9/5/10, R13 was identified to have multiple pressure ulcers on her right foot initially identified as stage II then unstagables all identified as "purple blisters". The WOUND CARE NOTES dated 9/8/10 written by E3, Nurse Manager indicated that R13 had "blue boots" and heels floated at the time. E3 again identified R13 as "non-compliant" with turning and repositioning but provides no justification for the development of the numerous foot ulcers. R13 was observed throughout the survey to be on her back. Interview with her family representatives indicate on 10/26/10 at 8:15am that her mother is often on her back and at times has the head of the bed elevated. 9. R19's most current Care Plan updated 10-8-10, shows he is at risk for developing pressure sores. R19 was observed on 10-28-10 to be up in his wheel chair from 8:50AM to 1:15PM to be up in his wheel chair without being repositioned. R19 was laid down in bed at 1:15PM for a skin check. R19's incontinent brief was soiled with urine and he had deep creases on his buttocks and back of thighs and open areas where staff say he scratches. 10. R25's MDS of 8-4-10 shows a history of pressure ulcers. R25 was observed to be up in a wheel chair in his room from 8:50AM to 10:40AM. At 10:40AM, R25 was taken to therapy. R25 remained in his wheel chair in therapy until 11:17AM when observation was discontinued. At 1PM, R25 was still up in his wheel chair after lunch. R25 had a bed pad folded into quarters on the seat of his wheel chair with no pressure relieving device. R25 was put to bed and had pinpoint open areas on his buttocks.

Based on interviews, observations and record review, the facility failed to ensure that 4 (R21, R16, R20, R14) of 25 sampled residents were transfered properly and that safety devices were implemented accordingly. Findings include: 1. R14's Minimum Data Set (MDS), dated [DATE], documented cognitively impaired with short and long term memory problems, a history of falls and a trunk restraint. R14 was continuously observed, on 10-15-10 from 10:30a.m. to 11:10a.m. at 10 minute intervals at 10:30a.m., 10:40a.m., 10:50a.m. to 11:10a.m., with the soft waist restraint not properly fastened to her wheel chair. E19, Third Floor Manager, stated, on 10-15-10 at 11:10a.m., that R14's soft waist restraint was not properly attached to her wheel chair. 2. R20's MDS, dated [DATE], documented cognitively impaired, total to extensive assistance of one person physical assistance with transfer and mobility. R20's Care Plan cover sheet document that R20 was an Above the Knee Amputee. During observation of R20's transfer from wheel chair to bed, R34, Certified Nursing Assistant (CNA) and R35, CNA, placed an assistive transfer device around R20's waist and raised him up from his wheel chair. R20 did not completely bearing weight during the transfer. R34 and R35 supported R20 weight with the transfer device while sliding him backwards toward his bed. 3. On 10/25/10 at 11:15 am, R21 was requesting to go to the bathroom. Upon entering the room, R21 was seated on the toilet secured in the Sit to Stand. E26, Certified Nurse Aide (CNA) left the room, leaving R21 on the toilet without supervision while she said she went to get gloves. E26 returned and secured the leg straps on the lift prior to transferring R21. R21 was upset asking E26 "What are you doing ? Why are you doing that? It hurts." E26 raised the Sit to Stand lift with R21 suspended in the air while she went to retrieve the wheelchair which had been removed from the bathroom. E26 pulled the wheelchair close to the sit to stand lift. Without locking the lift or the wheelchair, E26 lowered R21 into the seat of the wheelchair. The wheelchair was moving causing E26 to grab onto the wheelchair to keep it from rolling back and holding onto the lift to keep it from moving back. According to the most recent Minimum Data Set (MDS) assessment, R21 is non-ambulatory and requires extensive assistance with one staff person for transfers. R21 is 60 inches tall and weighs 196 pounds. R21 has Range of Motion limitations of both legs and feet with partial loss of voluntary movement. In addition, R21 cannot maintain standing balance without physical help. According to the weekly wound care notes, R21 has an unstageable pressure sore of the left foot and has two open areas on the right posterior leg (over the achilles tendon). The areas on the right posterior leg are infected with Methicillin Resistant Staph Aureus (MRSA). The leg strap of the lift were placed directly over this covered wound. 4. On 10/26/10 at 11:50 am, R16 was transferred from the bed to the motorized wheelchair by E14 and E34, CNAs. R16 had a transfer board in the room. Staff placed each end of the slide board on the bed and on the wheelchair seat. R16 was assisted onto the transfer board. Then each CNA put their hand directly under R16's armpit and lifted the resident from the end of the transfer board directly to the wheelchair seat. With staff holding R16 up by the armpits, the resident was not able to place his hands on the slide board to assist with the transfer. Both staff had gait belts around their waist, however, neither of them used one during this type of transfer. According to the Care Plan dated 9/15/10 R16 is at risk for falls due to self transfers. According to the most recent assessment dated [DATE], R16 is an above the knee double amputee, has Diabetes Mellitus. Interview with E37, Social Service Designee (SSD) on 10/26/10 at 4:00 pm, R16 is being prepared for discharge and has been referred to outside services for assistance. E37 also said R16 was referred to Physical Therapy/Occupational Therapy to become more independent. According to R16 he is using the slide board to become more independent in transfers so he can be discharged into the community.