Every finding on record at Arista Healthcare

Based on observation, interview, and record review, the facility failed to provide grooming/hygiene to residents who require assistance for activities of daily living (ADL) care.This applies to 4 of 7 residents (R3, R39, R52, R89) reviewed for ADL care in the sample of 23. The findings include:1. On April 13, 2026, at 11:52 AM, R39 was sitting in his wheelchair in the dining room. R39's fingernails on both hands were long with jagged edges, with brown- black substances under the fingernails. On April 14, 2026, at 12:42 PM, R39 was eating in the dining room. R39 was attempting to open a carton of milk, using his hands and a fork. R39 touched the inside of the milk container with his hands while attempting to open it and drank some of the milk. According to the Electronic Medical Record (EMR), R39 had multiple diagnoses, including unspecified dementia, cognitive communication deficit, muscle weakness (generalized), and other specified arthritis, multiple sites. R39's Minimum Data Set (MDS) dated [DATE], showed R39 had moderate cognitive impairment and required moderate assistance from the staff for personal hygiene, shower, and bath. R39's care plan initiated on October 24, 2025, showed R39 had Activities of Daily Living (ADL) self-care deficit, and the interventions included Certified Nursing Assistants (CNAs) to assist with hygiene tasks as needed. 2. On April 4, 2026, at 12:44 PM, R52 was in the dining room during lunchtime. R52's nail had brown, black substances underneath the fingernails of both hands. According to the EMR, R52 had multiple diagnoses, including active primary progressive multiple sclerosis, cognitive communication deficit, other symptoms and signs involving the musculoskeletal system, and other fatigue. R52's MDS dated [DATE], showed R52 had moderate cognitive impairment and was dependent on the staff for personal hygiene, and shower or bath. 3. On April 4, 2026, at 12:42 PM, R89 was sitting at the nursing station in his wheelchair. R89's fingernails had black substances underneath them. On April 4, 2026, at 1:05 PM, V3 (Assistant Director of Nursing/ADON) said R89 had some black substances underneath his fingernails, and CNAs are responsible for cleaning residents' nails during showers, baths, and as needed. According to the EMR, R89 had multiple diagnoses, including vascular dementia, unspecified severity, disorder of muscle, unspecified, and other seizures. R89's MDS showed R89 had memory problems and required supervision and/or touching assistance for personal hygiene and showering or bathing. On April 15, 2026, at 10:52 AM, V2 (Director of Nursing/DON) said the CNAs are responsible for cleaning and trimming the residents' nails. V2 said the CNAs clean the residents' nails during showers or baths, and as needed. V2 said the residents' nails should always be clean to prevent the risk of infections. V2 said the residents' nails should not have jagged edges and should be trimmed to prevent scratches on their skin and prevent the risk of infections and skin conditions. 4. The Electronic Medical Record (EMR) shows R3 has multiple medical diagnoses including generalized muscle weakness, lack of coordination, and legal blindness. Minimum Data Set (MDS) dated [DATE], shows R3 is alert and oriented and requires assistance for grooming. On April 13, 2026, at 11:30 AM, R3 was resting in bed awake, R3 displayed thick, overgrown facial hair to upper lip and chin about 0.5 to 1 inch long. When asked if she wanted facial hair shaving, R3 touched her face and felt the overgrown facial hair and said she wants it shaven, but she needs someone to help shave her facial hair. On April 15, 2026, at around 2:35 PM, V2 (Director of Nursing/DON) stated hygiene/grooming includes oral, nail, and hair care, facial hair shaving for both men and women as needed or requested, shower, bathing and dressing. This must be provided for dignity and comfort.

Based on observation, interview, and record review, the facility failed to assess and monitor the nutritional intake of a resident who received a rapid acting insulin. This applies to 1 of 1 resident (R18) reviewed for insulin administration in the sample of 23. The findings include:R18's EMR (Electronic Medical Records) showed R18 was admitted to the facility on [DATE], with multiple diagnoses including type II diabetes, phantom limb syndrome with pain, absence of left and right legs above the knees, peripheral vascular disease, obesity, hypothyroidism, and anxiety disorder. R18's MDS (Minimum Data Set) dated March 3, 2026, showed R18 was cognitively intact and needed setup/clean-up assistance with eating and oral hygiene. On April 14, 2026, at 9:52 AM, there was a noise heard coming from R18's room. Once inside R18's room, R18 was in bed with her over the bed tray table in front of her. R18's breakfast tray was sitting on the over the bedside tray table. R18's body was shaking and coming into contact with the over the bed tray table causing the orange juice on her breakfast tray to spill on the bed and floor. R18 was saying ouch repeatedly and not able to answer questions appropriately as she had done earlier that morning. R18 was diaphoretic and flushed. At 9:53 AM, V22 (Licensed Practical Nurse, LPN) was notified about R18's condition. V22, V20 (Certified Nursing Assistant, CNA), and V3 (Assistant Director of Nursing, ADON), all went to R18's room. V22 checked R18's blood sugar, at 9:55 AM and it was 43 mg/dL. R18 continued to shake, say ouch, was diaphoretic and flushed. At 9:58 AM, R18 was given 1 mg (milligram) of Glucagon (emergency medication used to treat critically low blood sugar) subcutaneously. At 10:00 AM, V3 removed the plate cover from R18's breakfast tray and the scrambled eggs with cheese and toast were untouched. The yogurt container was opened but appeared untouched. The milk carton was open. There was a bowl of oatmeal on the tray, which was also untouched. At 10:04 AM, V3 gave R18 a nutritional supplement. R18 was able to drink the nutritional supplement and stated she was feeling better. At 10:06 AM, R18's blood sugar was 51 mg/dL, BP (Blood Pressure) was 88/44 mmHg (millimeters of mercury) and pulse was 66 bpm (beats per minute). V3 also fed R18 yogurt. R18's breakfast tray was still at the bedside, V3 the scrambled eggs, toast, oatmeal, and milk were all untouched. At 10:13 AM, R18's blood sugar was 71, BP was 106/42 mmHg and pulse was 72 bpm. R18's Order Summary Report showed a physician's order dated April 1, 2024, to check R18's blood sugar daily before meals and at bedtime, notify the physician or NP (Nurse Practitioner) if blood sugar was less than 7 or greater than 400. The Order Summary Report also showed a physician's order dated March 20, 2026, to administer 13 units of Insulin Lispro (rapid-acting insulin) daily with meals/15 minutes prior to meals. In addition, there was a physician's order dated March 20, 2026, to administer Insulin Lispro as per the sliding scale before meals (for blood sugars 151 to 200, give 4 units; for blood sugars 201 to 250, give 6 units; for blood sugar 251 to 300, give 8 units; for blood sugar 301 to 350, give 10 units). R18's Medication Administration Record (MAR) for April 14, 2026, showed R18's blood sugar at 7:00 AM was 163 mg/dL. Per the sliding scale, R18 was to receive 4 units of Insulin Lispro. At 8:36 AM, R18 was administered the 13 units of Insulin Lispro and the 4 units of Insulin Lispro per sliding scale. On April 14, 2026, at 12:56 PM, R18 stated she was eating less than what she normally eats, and stated she eats half or less than half of what she is served. R18's meal intake sheet from March 16, 2026, to April 14, 2026, showed R18's meal intakes were documented for only one to two meals per day, and R18's intake was 0 to 25 % (percent) for all meals, except one when the intake was 26 to 50 %. On April 14, 2026, at 12:25 PM, V22 stated she administered a total of 17 units of Lispro (4 units of sliding scale plus 13 units) at around 9:00 AM. V22 stated she has taken care of R18 before and R18 eats very slowly and eats independently. At 1:52 PM, V22 stated in the morning, R18 was half awake and half asleep, so she woke up R18, administered 17 units of Lispro, told R18 the breakfast tray was present, and left the room. V22 also stated R18 did not touch the breakfast tray. V22 also stated she makes sure the meal tray is on the table before administering insulin. On April 14, 2026, at 12:59 PM, V21 (R18's CNA) stated R18 was sleeping when she placed the breakfast tray in the room at 8:00 AM. V21 also stated R18 eats slowly and sometimes it takes R18 till 11:00 AM to eat her breakfast. On April 14, 2026, at 1:02 PM, V20 (CNA) stated R18 does not eat much and she usually eats 25%. On April 14, 2026, at 2:00 PM, V23 (R18's Attending Physician) stated if the resident does not eat or if the resident's blood sugar is below 150 mg/dL, then insulin should not be given. V23 further stated the nurse should make sure there is oral intake before giving insulin. V23 stated R18 not eating may be a contributing factor since Insulin Lispro is short-acting and it peaks between 15 to 30 minutes up to two hours after administration. On April 14, 2026, at 2:29 PM, V24 (Pharmacist) stated rapid-acting insulin should be administered 15 minutes before eating. V24 also stated if a resident eats 0 to 25% of their meals, the physician should be notified and there should be hold parameters. V24 further stated the combination of R18 not eating and the administration of the insulin was the contributing factors for the hypoglycemic event. V24 further stated if the resident had eaten, he would not expect the blood sugar to drop that low. The package insert of Lispro shows change in meal pattern as a factor which may increase the risk of hypoglycemia.

Based on observation, interview, and record review, the facility failed to perform hand hygiene in between tasks during provisions of care and failed to wear complete PPE (Personal Protective Equipment) when providing care to a resident who is under EBP (Enhance Barrier Precautions). This applies to 3 of 23 residents (R3, R7, R90) reviewed for infection control in the sample of 23. The findings include: 1. R90 has multiple diagnoses including diabetes mellitus and presence of gastrostomy tube. On April 13, 2026, at 4:44 PM, V5 (Nurse) checked the gastrostomy tube (g-tube) placement of R90 and administered R90's medications via g-tube. After administration, V5 removed her gloves, touch other surfaces, and donned new set of gloves without hand hygiene then she proceeded to check R90's blood glucose level. 2. The EMR (Electronic Medical Record) shows R3 has multiple diagnoses including type 2 diabetes mellitus with foot ulcer and end stage renal failure (ESRD). R3 receives dialysis from Monday through Friday and has a dialysis access port in the right upper chest. R3's Care Plan shows R3 is at high risk for infection secondary to dialysis and left foot wound. This same care plan shows interventions which includes wearing PPE (Personal Protective Equipment) during high contact resident care activities such as dressing, bathing transferring, changing linens, providing hygiene, changing briefs/toileting etc. During observations from April 13 through April 15, 2026, there was a signage of Enhance Barrier Precautions (EBP) on R3's bedroom door. R3 was also observed for wound care on April 15, 2026, at 10:01 AM. R3 has an arterial wound in her left foot. On April 15, 2026, at 9:39 AM, V32 (Certified Nursing Assistant/CNA) entered R3's bedroom wearing only a pair of gloves and without wearing a gown. V32 turned R3 from side to side to check for incontinence and removed the mechanical lift sling underneath R3. Afterwards, V32 straightened R3's bedding, and left the room without hand hygiene. On April 15, 2026, at around 2:45 PM, V2 (Director of Nursing/DON) stated staff must perform hand hygiene before starting care to resident, in between tasks from dirty to clean and before leaving the room. The staff must also change gloves and do hand hygiene before donning new gloves. If a resident is on EBP, the staff must wear complete PPE including gloves and gown. These are to be done to prevent potential spread of infection. Facility's Policy and Procedure for Hand Hygiene dated January 2025, shows: The purpose of this policy and procedure is to provide guidelines on proper and appropriate hand washing and hygiene techniques that will aid in the prevention of the transmission of infections. It also shows the use of gloves does not replace hand hygiene and hand hygiene is always the final step after removing and disposing of personal protective equipment (PPE). The Policy and Procedure of Enhance Barrier Precaution (EBP) dated April 28, 2025 shows: The purpose of this policy and procedure is to reduce the transmission of novel and targeted multi-drug-resistant organisms (MDRO). This same policy shows the EBP requires the use of gown and glove during high contact resident care activities. EBP may apply to residents with a wound (chronic wounds) or similar dressing or indwelling device (e.g. central line), even if the resident is not known to be infected or colonized with MDRO. 3. According to the Electronic Medical Record (EMR), R7 had multiple diagnoses, including generalized muscle weakness, a disorder of muscle, unspecified hypertensive heart disease with heart failure, and unspecified lack of coordination. R7's MDS (Minimum Data Set) dated March 23, 2026, showed R7 had impairments to upper and lower extremities and was dependent on the staff for toileting hygiene. On April 14, 2026, at 12:50 PM, V27 (Certified Nursing Assistant/CNA) brought a bowl of soup to R7's room. R7 was sitting up in bed with a bedside table in front of R7. There was a urinal containing some urine on R7's bedside table. V27 placed the bowl of soup on R7's bedside table next to the urinal containing urine. V27 grabbed the urinal containing urine with her bare hands without wearing gloves and went to empty the urine in R7's toilet. V27 left R7's room without washing her hands and without using hand sanitizer. V27 went to the hallway and pulled out one meal tray from the tray cart parked in the hallway. V27 looked at the items on the tray and returned the tray to the cart. V27 then walked to the nurses' station. Immediately after V27 left the tray cart area, R50 was in the wheelchair, wheeling herself in the hallway. R50 went to the tray cart and pulled out the same tray V27 touched. R50 looked at the items on the tray and returned the tray to the cart. On April 15, 2026, at 9:00 AM, V2 said V27 should have removed the urinal from R7's table prior to placing the bowl of food on the table. V2 said V27 should have worn gloves when grabbing the urinal containing urine. V2 said V27 should have performed hand hygiene with soap and water immediately after emptying the urinal and before touching any other surfaces to prevent the spread of infection and potential cross-contamination. The facility's policy titled Policy and Procedure Hand Hygiene, dated January 1, 2020, with a review date of January 2025, showed, Purpose: Provide guidelines on proper and appropriate hand washing and hygiene techniques that will aid in the prevention of the transmission of infections. Washing Hands with Soap and Water: 1. Staff will perform hand hygiene by washing hands for at least twenty seconds with antimicrobial or non-antimicrobial soap and water should be performed under the following conditions: . e. After handling items potentially contaminated with blood, body fluids, or secretions.

Based on observation, interview, and record review, the facility failed to provide peri-care in a manner that would prevent urinary tract infection (UTI), failed to ensure indwelling urinary catheter is secured, and failed to apply barrier cream after an incontinence care. This applies to 3 of the 4 residents (R13, R78, R90) reviewed for incontinence and catheter care in the sample of 23. The findings include:1. The electronic medical record (EMR) showed R90 is [AGE] years old who has multiple medical diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cholecystitis, stage 3 chronic kidney disease. On April 13, 2026, at 5:11 PM, V33 (Certified Nursing Assistant/CNA) rendered incontinence care to R90 who was saturated with urine. V33 used wet towels to wipe R90's groins and outer labia. However, V33 did not open and clean the inner area of the labial folds and the urethra, and proceeded to clean the back perineum. V33 finished the incontinence care without ensuring that the whole perineum was completely cleaned. Facility's Policy and Procedure for Perineal/Incontinence Care dated January 2026, shows: Purpose: To provide cleanliness and comfort to the resident, prevent infections and skin irritation, and observe the resident's skin condition. Procedure: Cleanse the resident's perineal area using an approved no-rinse incontinence cleansing product. For female residents, separate labia and cleanse on side, then the other, then the center of the labia towards the rectal area. 2. The EMR showed R13 is [AGE] years old who has multiple medical diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R13's Physician Order Summary (POS) dated August 7, 2024, shows Moisture Barrier Cream/Ointment to buttocks and groins as needed. CNA may apply. On April 14, 2026, at 1:34 PM, V12 and V13 (Both CNA) transferred R13 from wheelchair to bed and rendered incontinence care. R13 said that he had been sitting on his feces for about an hour. During incontinence care R13's fecal matter was dry and pasty with R13's skin flushed/red. V13 said that R13 just came back to facility after going out with friends. V13 cleaned R13 from front to back of the perineum, applied clean incontinence brief, and transferred R13 back to wheelchair without applying barrier cream to his perineum. On April 15, 2026, at 1:02 PM, V11 (Wound Care Nurse) stated that R13 has an order of barrier cream because he is incontinent of urine and bowel. The barrier cream needs to be applied for protection of skin against moisture of urine and feces. 3. The EMR showed R68 is [AGE] years old who has multiple medical diagnoses including muscle disorder, neuromuscular dysfunction of the bladder, abnormalities of gait and mobility, and muscle weakness. Minimum Data Sheet (MDS) dated [DATE], showed R68 is alert and oriented and requires assistance with toileting hygiene. On April 15, 2026, at 12:21 PM, V26 (CNA) transferred R68 from wheelchair to bed and then provided peri-care. R68 has an indwelling urinary catheter. The urinary tube was not secured to R68, it was dangling/moving loosely and getting pulled while R68 was being transferred, repositioned, and being cleaned. While V26 was providing perineal care, R68 asked V26 to secure the urinary tube to her thigh. When R68 was asked why she wanted the urinary tube to be secured to her thigh, R68 replied that it had been loose for several days and every time she was being assisted or moved, the inner catheter tube moved a lot inside her ureter causing pain and discomfort. R68 added, no staff attempted to secure it after it became loose. On April 15, 2026, at around 2:40 PM, V2 (Director of Nursing/DON) stated that indwelling urinary catheter tube must be always secured to prevent accidental pulling, tension, and/or trauma to the ureter and bladder. V2 also said when staff provides incontinence or peri-care the staff must ensure that the whole perineum is clean to prevent potential infection or urinary tract infection. The Facility's Policy and Procedure for Catheter Care dated January 2026, shows: Indwelling catheters will be secured to prevent trauma and tension.

Based on observation, interview and record review, the facility failed to follow orders and therapy recommendations to apply upper extremity devices for residents that have functional limitations on one side.This applies to 2 of 3 residents (R1 and R90) reviewed for range of motions in the sample of 23. The findings include:1.R90's face sheet included multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, wrist drop, right wrist, paraplegia, other lack of coordination. R90's quarterly MDS (minimum data set) dated April 2, 2026, showed that R90 was cognitively intact and had functional limitation in range of motion due to impairment on one side. R90's POS (Physician Order Summary) showed to apply RWHFO (Right Wrist-Hand-Finger-Orthosis) before breakfast and remove after lunch 4-6 hours/daily as tolerated. Check for skin breakdown and maintain brace hygiene (revised October 6, 2025). On April 13, 2026, at 11:16 AM, R90 was sitting propped up in bed. R90's right arm appeared flaccid resting on R90's abdomen and R90 had no devices on right arm. R90 stated My right hand is weak. I don't get much exercise on my right hand. On April 13, 2026, at 3:55 PM, R90 was visited at bedside, and no devices were on R90's right arm. When asked whether staff put any devices on right arm, R90 stated that staff haven't put them on recently.On April 14, 2026, at 9:18 AM, R90 was in bed and there were no devices on R90's right arm.On April 14, 2026, at 9:45 AM, V6 CNA (Certified Nursing Assistant) stated I don't put any devices on. Only Restorative staff and Therapy put it on. When asked if R90 has any devise for her right hand, V6 responded, not that I know of.On April 14, 2026, at 10:45 AM, V14 (Restorative Nurse) stated that the right-hand splint devise is put on after breakfast by restorative aides. When told that the hand devise was observed not on R90's right hand for two consecutive days, V2 responded I don't know why they were not put on.On April 14, 2026, at 4:02 PM, at 3:05 PM, V16 (Restorative Aide) stated that R90 has splint devices for upper extremity, and the staff usually put it on after breakfast. V16 stated that she was not here yesterday, and she did not put it on today. R90's care plan revised December 27, 2023, included that R90 would benefit from participation in the following restorative programs: Splints due to generalized weakness, limited range of motion. Interventions included: Splint Schedule: Apply RWHFO before breakfast and remove after lunch 4-6 hours/daily as tolerated . 2.R1's face sheet showed diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, disorder of muscle, cognitive communication deficit, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, dorsalgia, other lack of coordination.R1's quarterly MDS dated [DATE], showed that R1 was moderately impaired in cognition and had functional limitation in range of motion due to impairment on one side.R1 did not have an order for any devices on POS. POS included 'Patient to be discharged from skilled OT (Occupation Therapist) services effective February 20, 2026' signed by V15 (Occupational Therapist). On April 13, 2026, at 11:59 AM, R1 was seated in her wheelchair, and her left arm was immobile and appeared flaccid. R1 was not wearing any devise on her left hand. When asked to open her fingers on her left hand, R1 was unable to do so. R1 stated that she has received therapies. On April 14, 2026, at 9:23 AM, R1 was in her room seated in her wheelchair and was not wearing any devices to left hand.On April 14, 2026, at 12:28 PM and 1:30 PM, V15 (OT) stated that she had followed R1 for Occupational Therapy and R1 was wearing a palm mitt all day to left hand at that time. V15 stated that R1 had a little bit of grasp' in her left hand. V15 stated that when she discharged R1, she recommended palm mitt to left hand to be placed overnight, and this is to prevent contractures. V15 stated that she does not enter the order in but sends it over to Restorative to follow up. V15 provided Therapy to Nursing Recommendations dated February 20, 2026, that showed left upper extremity palm mitt overnight. On April 14, 2026, at 1:17 PM, V14 (Restorative Registered Nurse) stated that she did not receive any orders from therapy for any devices. V14 stated that the restorative aides apply the devices and do the range of motion exercises for the residents. On April 14, 2026, at 3:05 PM, V16 (Restorative Aide), stated that R1 does not have any splint devices and that the restorative staff do range of motion for her. Restorative care plan created September 19, 2025, included that the resident would benefit from participation in the following restorative programs: Walking and AROM (Active Range of Motion) due to: Generalized weakness, Limited ROM (Range of Motion). Interventions included: AROM exercises RUE (Right Upper Extremity) and RLE (Right Lower Extremity) extremities as tolerated x 15 Reps (Repetitions). Encourage daily participation or as tolerated. Report pain or changes in ROM to nurse.

Based on observation, interview and record review, the facility staff failed to perform hand hygiene, and did not use PPE (Personal Protective Equipment) while providing care for residents in EBP (Enhanced Barrier Precautions) and failed to educate visitors regarding contact TBP (Transmission Based Precautions). This applies to 7 of 7 residents (R2, R3, R4, R7, R8, R9, R10) reviewed for infection control practices in the sample of 10. The findings include: 1. R2's medical record showed R2 was admitted to the facility on [DATE], with multiple diagnosis including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, chronic obstructive pulmonary disease, dysphagia, gastrostomy status, diabetes mellitus with chronic kidney disease, paroxysmal atrial fibrillation, and major depressive disorder, recurrent. R2's MDS (Minimum Data Set) dated February 9, 2025, showed R2 was cognitively intact and required assistance with ADLs including moderate assistance with oral hygiene, personal hygiene, upper body dressing and bed mobility, substantial assistance with coming to a sitting position in bed, with chair to bed and tub transfer and lower body dressing, and dependent on staff for eating and toilet hygiene. R2's care plans were reviewed. R2 has a care plan initiated on August 6, 2024, is at a higher risk for infection secondary to feeding tube and indwelling foley catheter and will receive enhanced barrier precautions with interventions that included, wash hands before entering and leaving the room and wearing PPE during high contact activity including changing linen, dressing, and bathing. On February 18, 2025, at 2:54 PM, there was a sign on R2's door for EBP, Enhanced Barrier Precautions. R2 stated she wanted to be repositioned because the sun was in her eyes. V10 (RN) entered the room to assist the resident to reposition without donning a gown and repositioned R2. R2's physician order summary showed R2 had an order for Enhanced Barrier Precautions initiated on July 1, 2024. 2. The medical record showed R3 was admitted to the facility on [DATE], with multiple diagnosis including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, aphasia, dysphagia, acute and chronic respiratory failure with hypoxia, tracheostomy status, gastrostomy status, and moderate protein-calorie malnutrition. R3's MDS dated [DATE], showed R3 was severely cognitively impaired, and required assistance with ADLs, including substantial assistance with oral hygiene and upper body dressing and dependent on staff eating, bathing, toileting, lower body dressing, bed mobility and transfer. R3's care plans were reviewed. R3 had a care plan initiated on February 3, 2025 of being at risk for infection secondary to feeding tube, tracheostomy and wound and will receive enhanced barrier precautions with an intervention that showed PPE to be worn during high contact activity including gown and glove and use of face mask when risk of splashing is present .and wear PPE during high contact activities during changing linens, and wash hands before entering a room and after leaving the room. R3's room had an Enhanced Barrier Precaution sign posted on the door. On February 18, 2025, at 3:00 PM, V4 (Speech Language Pathologist) provided treatment that included covering R3's tracheostomy with a speaking valve. V4 stated she was also trying to have R3 follow one step commands. V4 was not wearing a gown while providing direct contact with R3's tracheostomy tube. On February 18, 2025, at 3:54 PM, V10 (RN) entered R3's room, did not wash hands before entering, adjusted R3's linen and covered R3 with bare hands. V10 exited R3's room without washing hands. On February 19, 2025, at 11:45 AM, V9 (CNA) entered R3 and R9's room that had the EBP sign on the door. V9 served R9 his meal tray. V9 then turned to R3 and wearing the same pair of gloves touched R3's left arm, top sheet linens and straightened them to cover R3 without changing gloves or perform hand hygiene. R3's physician order summary showed an order for Enhanced Barrier precautions dated February 3, 2025. R9's physician order summary showed an order for Enhanced Barrier Precautions dated January 22, 2025. 3. The medical record showed R8 was admitted to the facility on [DATE], with multiple diagnosis including other toxic encephalopathy, enterocolitis due to clostridium difficile not specified as recurrent, frostbite with tissue necrosis of abdominal wall, lower back, pelvis and left foot, local infection of the skin and subcutaneous tissue unspecified, paroxysmal atrial fibrillation, rhabdomyolysis, neuromuscular dysfunction of the bladder, and unspecified fall subsequent encounter. On February 19, 2025, at 11:35 AM, R8 had a sign on the door for EBP. V7 (Nurse Aide in training) entered the room without performing hand hygiene to deliver a meal tray to R8. Upon leaving the room V7 did not perform hand hygiene. V7 was asked about the sign on R8's door and what precautions staff should take according to the sign for EBP. V7 stated she should have performed hand hygiene prior to entering the room and leaving the room but she forgot. R8's physician order summary showed an order for Enhanced Barrier Precautions dated February 18, 2025. 4. On February 19, 2025, at 11:25 AM, V5 (CNA) entered R10's room, which had an EBP sign on the door, without performing hand hygiene. V5 served R10's meal tray and left the room without performing hand hygiene. V5 then went to the meal tray cart and removed R7's meal tray. R7 had an EBP sign on the door. V5 entered R7's room without performing hand hygiene, delivered R7's meal tray, and exited R7's room without performing hand hygiene. On February 19, 2025, at 11:50 AM, V10 (RN) entered R7's room to give R7 medication without performing hand hygiene before entering the room or upon leaving the room. V10 was unsure why R7 had the EBP sign on the door. V10 stated she did not perform hand hygiene before entering R7's room because she had washed her hands after using the bathroom, before preparing R7's medication. R10's physician order summary showed an order for Enhanced Barrier Precautions initiated on January 31, 2025. R7's physician order summary showed an order for Enhanced Barrier Precautions initiated on January 27, 2025. 5. On February 18, 2025, at 3:10 PM, a contact precautions sign was observed on R4's door. R4 was sitting in her bed and there were 2 visitors, V17 (R4's son) and V18 (R4's daughter in law) in R4's room. V17 and V18 did not have gloves or a gown on. V17 was lying on top of the second bed in R4's room. V18 was sitting in the chair in the room. The visitor log, reviewed with V1(Administrator) showed V17 and V18 had signed in at 2:25 PM. Prior to 3:45 PM, after it was brought to V6 (LPN) attention, there was no evidence that V17 and V18 had received education regarding contact precautions. V5 was in the hall and asked about the sign for contact precautions on R4s door. V5 stated that means we must wear gloves and gown before entering the room. During the entrance conference on February 18, 2025, V1 (Administrator) identified R4 as being in contact TBP precautions for C Difficile infection. R4 physician order summary showed an order for contact isolation for C Difficile infection until March 30, 2025, at 23:59, initiated on February 17, 2025, and entered by V3 (ADON, IP). R4s medical record showed R4 was admitted to the facility on [DATE], with multiple diagnosis including metabolic encephalopathy, dysphagia, diverticulitis of the large intestine, dysphagia, adult failure to thrive, chronic diastolic congestive heart failure, primary osteoarthritis, primary pulmonary hypertension, hypokalemia, and enterocolitis due to clostridium difficile. R4's MDS (Minimum Data Set) dated February 7, 2025, showed R4 was cognitively intact and required assistance with Activities of Daily Living including set up assistance for eating, supervision for oral hygiene, substantial assistance with bathing, upper body dressing, personal hygiene, and bed mobility, dependent on staff assistance for toileting, lower body dressing and transfer. R4's care plans were reviewed. R4 had a care plan for C Diff positive infection on contact isolation precaution initiated on November 19, 2024. Interventions included: All staff will follow PPE use, Observe, assess for signs /symptoms of infection .maintain infection control standards. The EBP sign used by the facility showed Everyone must clean their hands before entering and when leaving the room and 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 central line, urinary catheter, feeding tube, tracheostomy, and wound care, any skin opening requiring a dressing. The Contact precaution sign used by the facility showed Everyone must clean their hands before entering and when leaving the room and providers and staff must also put on gloves before room entry and discard gloves before room exit, put on a gown before room entry and discard gown before room exit, do not wear the same gown and gloves for the care of more than one person. The facility provided a list of residents and criteria who are on Enhanced Barrier Precautions dated February 18, 2025. The list included: R2 for indwelling medical device, R3 for indwelling medical device, R7 for indwelling medical device, R8 for indwelling medical device, R9 for indwelling medical device, and R10 for indwelling medical device. On February 19, 2025, at 2:27 PM V3 (ADON, IP Nurse) and V12 (LPN IP in training) were interviewed together. Neither V3 or V12 were able to identify what resource or policy should be referenced to determine when TBP should be implemented or discontinued. V3 and V12 stated they would refer to a resident's laboratory culture results or hospital recommendation regarding when TBP were needed. V3 and V12 both stated hand hygiene should be performed when entering or exiting a room identified with EBP sign on the door. V12 and V3 stated when placing a speaking valve on a tracheostomy tube would be considered handling a medical device and would warrant the use of both gloves and gown during that provision of care. V12 and V3 agreed that before entering a room to give oral medications to a resident in EBP precautions hand hygiene would need to be performed. V12 and V3 also agreed that glove and gown should be worn when repositioning a resident on EBP precautions and hand hygiene performed and gloves changed between providing care to two residents. The facility's policy titled Enhanced Barrier Precautions dated, August 15, 2024, showed Purpose .Reduce the transmission of novel or targeted multi drug resistant organisms (MDRO) .Procedure .1. Enhanced barrier Precautions require the use of gown and glove during high contact resident care activities .changing linens .device care or use .feeding tube .tracheostomy .6. Adhere to other infection control practices such as Hand Hygiene . The facility's policy titled Infection Control dated January 2024, showed Procedure .14. All facility personnel are required to routinely wash hands and use appropriate barrier precautions to prevent transmission of infections .15. All facility personnel shall adhere to the Infection Control Program in the performance of their daily assigned tasks .16, The facility shall assure the necessary training, equipment and supplies are maintained to carry out an effective Infection Control Program .17. Hand washing is essential .18. Contact precautions in addition to standard precautions will be initiated as specified in the specific isolation policy.

Based on observation, interview, and record review, the facility failed to properly label/date/store food items and scoops, remove expired items, clean walk-in cooler, and wear hair restraint while serving food from facility kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated [DATE] documents the total census was 79 residents. On [DATE] at 11:29 AM, V1 (Administrator) said there are 3 NPO (Nothing By Mouth) residents; all other residents eat from the facility kitchen. On [DATE] starting at 10:16 AM, the facility kitchen was toured in the presence of V16 (Dietary Manager) and the following was found: In walk-in cooler: 1. A large empty silver bin on top shelf under the fan with crusted dirt and dust in it and a dead dusty black house fly. V16 said the bin is kept on the top shelf to catch water dripping off the fan. Surveyor did not observe any water dripping from fan. 2. Medium sized bin labeled gravy with expiration date of [DATE]. 3. Small sized silver bin of leftover fish fillets with expiration date of [DATE]. 4. Medium sized clear bin of cut up fruit with no label or date. V16 said they were peaches. 5. Medium sized silver bin of leftover Spanish rice with no label or date. In the kitchen: 6. A medium sized clear bin of powdered mashed potatoes with no date. 7. A 20 gallon large white plastic bucket labeled thickener, not dated and scoop stored inside the thickener. 8. A 20 gallon large white plastic bucket labeled flour, not dated and scoop stored inside the flour. 9. On [DATE] at 11:14 AM, V17 (Cook) was observed serving lunch on the tray line in the kitchen with a hair net only covering the back half of her head. V17's bangs and top front of head were not restrained in hair net. On [DATE] at 10:18 AM, V16 (Dietary Manager) said all food items in the kitchen should be labeled and dated for food safety so the staff know when the food expires and when to throw the food away to prevent serving it and making the residents ill. V16 said the expired food items should be thrown away by the end of the day on the expiration date. V16 said the walk-in cooler should be cleaned twice a day on morning shift and afternoon shift. V16 said this includes cleaning the shelves in the walk-in cooler and sweeping/mopping the floor. V16 said the scoops for the flour and thickener should not be stored inside the food item/bin because it is an infection control contamination risk after staff touch the handle of the scoop and place it back in the bin. V16 said kitchen staff should wear their hair restraints covering all their hair to avoid hair falling into resident food causing contamination. The facility's policy titled, Dietary Personnel- Hygienic Practices and Personal Cleanliness dated ,d+[DATE] states, Purpose: To establish standards for employee dress, personal hygiene and hand washing practices. Standards: 2.d. Hairnets, coverings or caps shall be worn at all times in the Dietary Department and applied appropriately to keep hair from contacting exposed food, clean utensils and single service/use items, if unwrapped . The facility's policy titled, Storage of Refrigerated/Frozen Foods last revised [DATE] states, Policy: Refrigerator and freezer food items will be properly stored to keep foods safe and preserve flavor, nutritive value, and appearance. Procedure: Refrigerated Foods: Refrigeration units are routinely cleaned and free from garbage and other waste . The facility's policy titled, Date Marking and Labeling last revised [DATE] states, Policy: All foods that are stored will be properly dated and labeled to ensure food safety. Procedure: 1. Date marking is an identification system that helps identify the name of the food, when the food was prepared, and when it is to be discarded. 2. When to date mark: b. The food requires refrigeration c. A commercially prepared food item is opened e. When potentially hazardous (PHF/TCS) foods are stored f. When leftovers are stored .3. When to discard: b. The item has expired according to the manufacturer's expiration date c. When foods are mixed together, the date of the oldest food becomes the new discard date for the mixed food . 5. Items should be marked with the name of the item and the discard date. The facility's policy titled, Food Storage dated ,d+[DATE] states, Purpose: Protect food from contamination, the ensure wholesomeness, and to prevent the spread of infections and communicable disease . The facility's policy titled, Storage of Dry Foods/Supplies last revised [DATE] states, Policy: Dry foods and supplies will be properly stored to keep foods safe and preserve flavor, nutritive value, and appearance. Procedure: .Dry bulk foods are stored in plastic containers with tight containers with tight covers or bins which are easily sanitized. Containers are clearly labeled, and scoops are stored separately in a covered, protected area, which are washed and sanitized at least weekly .

Based on observation, interview, and record review, the facility failed to provide care with dignity to 3 of 3 residents (R12, R56, R22) reviewed for dignity in a sample of 25. The findings include: 1. On 01/14/25 at 12:47 PM V6 ADON (Assistant Director of Nursing) was observed during lunch standing over R22 while assisting with feeding R22. On 1/16/2025 at 12:50 PM V2 (DON) said V6 should not be standing over R22 while feeding her for dignity and respect. 2. On 01/14/25 at 11:35 AM, V7 and V8 CNAs (Certified Nurses Assistants) were providing incontinence care and giving a bed bath to R12 and R12's curtain was left open. R12's entire body was exposed. R13 (R12's roommate) was in the room at the time. On 01/16/25 at 01:30 PM R12 said he wants his door and his curtain closed when staff are providing care for him for privacy. R12 said that he usually has to tell staff to close his door and curtain when they are providing care for him. R12 said that it makes him feel uncomfortable when they leave them open. R12 said that the staff always leave the door open, and it makes him cold. On 1/16/25 at 12:50 pm V2 (DON) said her expectations are the staff pull the resident's curtains for privacy. 3. On 01/16/25 at 10:35 AM V3 and V4 CNAs (Certified Nurses Assistants) were providing catheter care and incontinence care for R56. The staff did not close the door or pull the curtain while providing care to R56. R56's perineal and buttocks were exposed to any persons in the hallway. On 1/16/25 at 10:52 AM V3 CNA said she forgot to close the door and pull the curtain. V3 said she should do it for dignity and privacy. On 01/16/25 at 12:50 PM V2 DON (Director of Nursing) said her expectations are that the staff close the door, and curtain when providing catheter and incontinence care for privacy and dignity. The facility's Contract Between resident and facility (no date) showed that resident shall not be deprived of any rights including right to always respect for bodily privacy and dignity especially during care and treatment. The facility's Dignity policy dated 12/24 shows each resident shall be care for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The policy showed; residents should be always treated with dignity and respect, residents will be assisted in maintaining and enhancing his/her self-esteem and self-worth, residents' private space will be always respected, staff shall promote, maintain, and protect residents' privacy including bodily privacy during assistance with personal care and during treatment procedures.

Based on interview and record review, the facility failed to provide written notice of reason for transfer to resident and/or their representative before resident transferred to hospital and failed to send a copy of transfer notice to the Ombudsman. This applies to 3 residents (R62, R69, and R37) reviewed for hospital transfers in a sample of 25. The findings include: 1. R62's Face sheet shows an admitted [DATE]. R62's nursing progress note dated 1/8/25 at 15:33 shows R62 was transferred and admitted to hospital with diagnosis of pneumonia and acute cystitis. There is no documentation of written notice of transfer being provided to resident or their representative, or the Ombudsman. 2. R69's Face sheet shows an admitted [DATE]. R69's nursing progress note dated 1/14/25 at 11:34 AM shows R69 was transferred to hospital for gastrostomy and jejunostomy tube evaluation. There is no documentation of written notice of transfer being provided to resident or their representative, or the Ombudsman. On 1/15/25 at 3:50 PM, V1 (Administrator) said the facility does not notify the resident or their representative, or the Ombudsman in writing of reason for resident transfer to hospital. On 1/16/25 at 1:17 PM, V2 (Don/Director of Nursing) said she did not know the resident and/or resident representative and the Ombudsman were supposed to be notified in writing of reason for resident transfers. 40054 3. The clinical records of R37 showed that diagnoses included cirrhosis of the liver, hemiplegia, type 2 diabetes, urinary tract infection, cardiac diseases, and hepatic encephalopathy. The current Minimum Data Set, dated dated dated ,d+[DATE]//2024 indicated that R37 is cognitively moderately intact. R37 was transferred and admitted to the hospital on 01/13/2025 for high level ammonia. The progress report review for R37 showed R37 was transferred to the hospital on 05/09/2024, 06/09/2024,10/11/2024, and 01/13/2025 related to comorbid conditions and complications. The R33's clinical records lacked the documentation of providing in writing R37 or representative the notification of discharge with the reason for transfer/discharge to the hospital and sending a copy to the ombudsman.

Based on interview and record review, the facility failed to provide written bed hold policy to resident and/or their representative prior to resident transfer to hospital. This applies to 3 residents (R62, R69, and R37) reviewed for hospital transfers in a sample of 25. The findings include: 1. R62's Face sheet shows an admitted [DATE]. R62's nursing progress note dated 1/8/25 at 15:33 shows R62 was transferred and admitted to hospital with diagnosis of pneumonia and acute cystitis. There is no documentation of bed hold policy being provided to resident prior to transfer to hospital. 2. R69's Face sheet shows an admitted [DATE]. R69's nursing progress note dated 1/14/25 at 11:34 AM shows R69 was transferred to hospital for gastrostomy and jejunostomy tube evaluation. There is no documentation of bed hold policy being provided to resident prior to transfer to hospital. On 1/15/25 at 3:50 PM, V1 (Administrator) said the facility does not have any documentation of bed hold notices being provided to residents prior to their transfers to hospital. On 1/16/25 at 1:17 PM, V2 (DON/Director of Nursing) said the residents are not provided written documentation of bed hold policy, including reserve bed payment, upon their transfers to the hospital because she did not know the facility was supposed to be providing it. The facility's policy titled, Bed Hold Policy last revised July 2024 states, Federal Standards: Federal regulations require each facility provide written information to the resident and/or legal representative that specifies the duration of the bed hold policy under the Medicaid state plan during which the resident is permitted to return and resume residence in the facility. This notice shall be provided during the admission period and at the time of a transfer to notify the resident and/or representative concerning bed hold rights and promote appropriate return to the facility .Purpose: To ensure the residents are informed of the bed hold and reserve bed payment policy before and upon transfer to a hospital . 40054 3. The clinical records of R37 showed that diagnoses included cirrhosis of the liver, hemiplegia, type 2 diabetes, urinary tract infection, cardiac diseases, and hepatic encephalopathy. The current Minimum Data Set, dated dated dated ,d+[DATE]//2024 indicated that R37 is cognitively moderately intact. R37 was transferred and admitted to the hospital on 01/13/2025 for high level ammonia. The progress report review for R37 showed R37 was transferred to the hospital on 05/09/2024, 06/09/2024,10/11/2024, and 01/13/2025 related to comorbid conditions and complications. The R33's clinical records lacked the documentation of providing R37 or representative and the Ombudsman with written notice to be aware of a facility's bed-hold and reserve bed payment policy to R37 before and to the Ombudsman upon transfer to a hospital.

Based on observation, interview, and record review, the facility failed to assess and provide necessary treatments and services for skin impairment, which caused a resident severe itching and discomfort. This applies to 1 of 3 (R33) reviewed for skin impairment in a sample of 25. Findings Include: R33 is an [AGE] year-old female with diagnoses including chronic respiratory problems with hypoxia dependent on supplemental oxygen, acute kidney disease, cerebral infarction, a chronic obstructive pulmonary disease with polyneuropathy, depression, and anxiety disorder. Minimum Data Set, dated dated dated [DATE] showed R33 was cognitively moderately intact and required one person to assist with activities of daily living (ADL), transfers, and bed mobility. On 01/14/2025, R33 was in her room scratching both arms. Redness, scratch marks, dry skin, and scabs were observed on both arms and the right chest area. R33 was interviewable and said the itching has been happening for at least a month and the staff knows about it. R33 said she doesn't know whether her skin conditions and itching could be due to her medication, food, or bedding. R33 said the continuous itching is annoying. R33 said V14 (Certified Nursing Assistant) showered her last week, and because of her itching, V14 checked her bedding and changed her linens to ensure there were no issues with her bedding. On 01/15/2025 at 12:45 PM, V14 (Certified Nursing Assistant) said R33 has had rash and itching issues for a while and she provided a shower to the resident on 01/06/2025. V14 completed the form titled, CNA skin attention form and notified the nurse (V13) on duty about R33's known skin condition. The writer asked V14 to assist R33 in showing her entire body for the skin conditions and noted R33 also has rashes on her back and right buttocks with itching and scratch marks in addition to her arms and chest. On 01/15/2025 at 1:00 PM, V15 (Certified Nursing Assistant) said he was new and over the weekend he noticed skin issues with R33 during his hygiene care and notified the V13 (Licensed Practical Nurse). On 01/16/2025 at 10:00 AM, V13 (Licensed Practice Nurse) said she should have assessed R33 for her skin conditions and notified the physician for further evaluation and treatment. On 01/16/2025 at 11:45 AM and 1:30 PM, V6 (Infection Preventionist) and V2 (Director of Nursing), respectively, said the nurse should be checking the CNA skin attention form, assessing the residents, signing off on the form, and notifying the wound care nurse and the physician for evaluation and treatment. A review of CNA skin attention dated 01/06/2024 showed V14 marked as a known skin condition, and the nurse evaluation was not completed. The facility policy, titled Wound Care, revised dated 11/2023 under assessment, in part, stated that the nurse should review the nurse's aide's completed shower sheet form for the impairment, the shower sheet should be given to the designee for follow-up, and the Director of Nursing should review the shower sheet weekly.

Based on interview and record review, the facility failed to provide restorative therapy services as care planned. This applies to 1 resident (R68) reviewed for restorative services in a sample of 25. The findings include: R68's Face Sheet shows he was admitted to the facility on [DATE] and has the following diagnoses: need for assistance with personal care, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, muscle weakness (generalized), unsteadiness on feet, history of falling, and difficulty walking. R68's POS (Physician Order Sheet) shows order entered on 8/8/23 that resident may participate in restorative services. R68's MDS (Minimum Data Set) dated 12/14/24 shows his cognition is intact and he requires substantial/maximal assistance to roll right and left in bed. R68's Care Plan last revised on 11/30/22 shows he has a self-care deficit (Activities of Daily Living/Mobility) related to generalized weakness, left hemiparesis/hemiplegia, impaired balance, limited range of motion, multiple comorbidities, left knee pain, and physical limitations. Care Plan goal states resident will improve/maintain highest level of function with participation in therapies and/or restorative programs through next review. R68's Care Plan dated 1/12/23 shows he would benefit from participation in Bed Mobility Restorative Nursing Program due to impaired mobility, physical limitations, decrease in strength, endurance, balance and lack of coordination, and at risk for fall related to: stroke with hemiplegia and hemiparesis affecting left dominant side, generalized weakness, and cognitive impairment. Care Plan interventions state R68 was placed on ADL Bed Mobility restorative nursing program and document restorative minutes in point of care for each individual task, documenting time spent working with resident on each program on your shift. Additional Care Plan also dated 1/12/23 shows R68 would benefit from participation in AROM/AAROM (Active Range of Motion/ Active Assisted Range of Motion) Restorative Nursing Program due to impaired mobility, physical limitations, decrease in strength, endurance, balance and lack of coordination related to: stroke with hemiplegia and hemiparesis affecting left dominant side, and generalized weakness. Care Plan goal shows R68 will be able to participate in AROM/AAROM exercises to all extremities 20x2 reps daily as tolerated through next review date and interventions show R68 was placed on ADL (Activity of Daily Living) AROM/AAROM restorative nursing program and document restorative minutes in point of care for each individual task, documenting time spent working with resident on each program on your shift. R68's Point of Care Task for AROM states R68 will be able to participate in AROM/AAROM exercises to all extremities 20x2 reps daily as tolerated through next review date. Over the past 30 days, facility staff have documented AROM program participation for R68 9 times. There has been no documentation of resident refusal. R68's Point of Care Task for Bed Mobility states R68 will be able to turn from side to side of the bed with limited to extensive assist of one daily as tolerated through next review date. Over the past 30 days, facility staff have documented Bed Mobility participation for R68 9 times. There has been no documentation of resident refusal. On 1/14/25 at 2:26 PM, R68 said he no longer receives restorative nursing services. On 1/16/25 at 11:25 AM, R68 said he does turn side to side in bed when the staff assist him to get changed about 3 times a day. R68 said it has been weeks and weeks since restorative therapy has worked with him or has done any range of motion exercises with him. On 1/16/25 at 9:55 AM, V5 (Restorative Nurse) said R68 is on Bed Mobility and AROM Restorative Programs. V5 said the restorative staff is not doing Bed Mobility Program with R68 because he should be turning side to side with incontinence care. V5 said the Restorative staff is doing the AROM Program with R68 3-4 times a week, not daily as it is recommended. V5 said the Restorative staff do not document when they work with R68 in the POC (Point of Care) task as stated in the Care Plan. On 1/16/25 at 1:17 PM, V2 (DON/Director of Nursing) said R68's care plan needs to be followed and Restorative Nursing participation should be documented in the point of care task daily. V2 said restorative nursing programs should be done daily for R68 as they were assessed as needed so R68 can maintain, and not decrease, his abilities with mobility and strength. The facility provided policy titled, Restorative Nursing Program dated 9/14 states, Purpose: The facility promotes restorative nursing to attain or maintain the highest practicable physical, mental, and psychosocial well-being .Restorative Nursing is available seven days a week and is provided for residents with assessed needs according to program criteria. The Restorative Nursing Program is designed to: preserve function, promote optimal improvement, increase independence, self-esteem and dignity, promote safety, and minimize deterioration within the limits of normal aging . Components and Types of Restorative Nursing Programs: . Contracture Prevention and Management- .AAROM and AROM . Mobility Programs- Bed Mobility .

Based on observation, interview, and record review, the facility failed to provide appropriate urinary catheter care to prevent UTI (Urinary Tract Infection). This applies to 2 out of 3 residents (R56, R67) reviewed for urinary catheter care in a sample of 25. The findings include: 1. R67's Face Sheet documents he was admitted to facility on 9/26/2022. R67 has a urinary catheter for diagnosis of neuromuscular dysfunction, BPH (Benign Prostatic Hypertrophy), and Obstructive Uropathy. Currently, R67 has diagnosis of UTI and is on Ceftriaxone Sodium Injection Solution. 1 gram intravenously in the afternoon for UTI for 10 Days. R67 started his antibiotic on 1/13/2025 and will end on 1/24/2025. On 1/15/2025 at 9:33 AM, during skin check, R67 was noted to have a small amount of bowel movement on his incontinent briefs. V9 (CNA- Certified Nurse Assistant) proceeded to provide incontinence care. R67's urinary catheter was observed to have dried up debris on the tubing close to the base. V9 wiped the urinary catheter tubing by wrapping the tubing with a wet towel and wiping the tubing sideways to remove the debris. While wiping the tubing, V9 did not attempt to hold the catheter steady to avoid pulling on it. V9 did not attempt to wipe the rest of the tubing. V9 continued to provide incontinent care. On 1/16/2025 at 10:02 AM, morning care provided to R67 by V10 (CNA) and V12 (CNA) was observed. V10 provided catheter care. Dried debris were observed on R67's urinary catheter tubing. V10 wiped the urinary catheter tubing towards the body three times. While wiping the tubing, V10 did not attempt to hold the catheter steady to avoid pulling on it. V10 continued providing incontinence care to R67. On 1/16/2025 at 12:51 PM, V2 (Director of Nursing) said urinary catheter tubing should always be wiped away from the body to prevent UTI (Urinary Tract Infection). V2 said staff should attempt to clean the tubing of any dried debris and inform the nurse so the nurse can assess the catheter and change it if needed. 41384 2. R56's electronic health record showed that R56's has diagnoses including history of UTI (urinary tract infection), anemia, adult failure to thrive, malnutrition, and is under Hospice care at the facility. On 01/16/25 at 10:35 AM V3 and V4 CNAs (Certified Nurses' Assistants) were providing catheter care for R56. R56's urinary catheter was observed with a hard brown substance on the tubing near R56's urethral meatus. V3 with gloved hands grabbed the catheter with her right hand and wiped the catheter tubing towards R56's urethral meatus twice. After V3 was done cleaning R56's perineal area and ureteral catheter, V3 removed her gloves and put on new gloves not cleaning her hands and began cleaning in-between R56's legs, removing a brown substance. Then V3 cleaned R56's rectal area. R56's had 2 open pressure ulcers on her buttocks with dressings on them. After V3 finished cleaning R56's rectal area, V3 removed the dirty brief from under R56 and then changed gloves but did not clean her hands. V3 then put a new brief under R56, then changed gloves again and applied barrier cream to R56's buttocks and thighs again without cleaning her hands. V3 then removed her gloves, put on clean gloves, did not clean her hands, and preceded to attach R56's brief, adjust R56 in her bed, adjust R56's pillow and linen, and adjusted R56's bed, all with uncleaned gloved hands. On 01/16/25 at 12:50 PM V2 DON (Director of Nursing) said staff should always clean/wipe the tubing on the catheter away from the insertion site for infection control to prevent UTIs. V2 said staff should have cleaned their hands after removing their gloves when going from dirty to clean for infection control. The facility's Catheter Care policy dated 11/2023 showed that the guidelines are established to reduce the risk of or prevent infections in resident with an indwelling catheter. The policy standards show that hand washing shall be performed before and after touching any part of the urinary catheter drainage system, and encrustations on the Foley catheter should be removed from the meatus outward. The facility's Hand Hygiene policy dated 11/8/2022 showed proper and appropriate hand washing hygiene techniques will aid in the prevention of the transmission of infections. The policy showed that staff perform hand hygiene before applying gloves and after removing gloves, after contact with body fluids secretions, mucous membranes, or non-intact skin, after handling items potentially contaminated with body fluids or secretions, and before moving from a contaminated body site to a clean body site during resident care; example: after providing peri-care, before applying moisture barrier or other treatments, and after providing direct resident care.

Based on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to hand hygiene. This applies to 2 of 7 residents (R9, R12) reviewed for infection control in the sample of 25. The findings include: 1. On 01/14/25 at 12:38 PM V5 (Restorative Nurse) was observed getting up from feeding R9, moving R45, who was in her wheelchair, closer to the table and then, without cleaning her hands, returned to feeding R9. V5 then got up from feeding R9 and picked up R5's dirty lunch plate and put the plate on the food cart and then went back to R9, and without cleaning her hands first, picked up R9's sandwich off of her plate and fed it to R9. 2. On 01/14/25 at 11:35 AM, V7 and V8 CNAs (Certified Nurses Assistants) were providing incontinence care and a bed bath for R12. V8 with gloved hands picked up the garbage can and moved it closer to V7, then with the same dirty gloved hands went to R12's bedside and began providing care for R12 without removing her gloves and cleaning her hands. V7 had gloves on her hands and after cleaning every body part including face, arms, legs, abdomen, penis and rectal area of R12, V7 would remove her gloves and put on new gloves but would not clean her hands. After V7 was done with the incontinence care and bed bath, V7 with dirty gloved hands and V8 with uncleaned gloved hands put a new brief on R12, put R12's pants and shirt on him, put a lift sling under him, removed the soiled linen from R12's bed, and then transferred R12 from his bed to his wheelchair without removing their gloves, cleaning their hands and putting on clean gloves. On 1/16/25 at 12:50 PM V2 (DON) said staff should be cleaning their hands after removing gloves and before putting on new gloves for infection control and cross contamination. V2 said when staff are going from dirty to clean, they are to remove their gloves, clean their hands, and put on new gloves. V2 said that it is her expectations that staff clean their hands after touching another resident or resident's object for infection control. The facility's Hand hygiene policy dated 11/8/2022 showed proper and appropriate hand washing hygiene techniques will aid in the prevention of the transmission of infections. The policy showed that staff perform hand hygiene before applying gloves and after removing gloves, after contact with body fluids secretions, mucous membranes, or non-intact skin, after handling items potentially contaminated with body fluids or secretions, and before moving from a contaminated body site to a clean body site during resident care; example: after providing peri-care, before applying moisture barrier or other treatments, and after providing direct resident care.

Based on observation, interview and record review the facility failed to store medications in accordance with manufacturer guidelines. This applies to 5 of 5 (R9, R11, R13, R35 and R39) residents in a sample of 21. The findings include: On March 19, 2024, at 9:50 AM, the 2nd floor south medication cart was reviewed, with V7 (LPN) and V6 (ADON Assistant Director of Nursing) with the following observations: R9's Trelegy ellipta (100 mcg/62.5 mcg/25 mcg) inhaler was dated as being opened on 12/6, was in the drawer of the medication cart. R11's Breo ellipta (200/25) inhaler was dated as being opened 12/23, and in the drawer of the medication cart. R13 unopened vial of Lispro insulin had a label on the box, refrigerate if not opened was in the drawer of the medication cart. R35's unopened vial of Aspart insulin had a label on the box, refrigerate if not opened was in the drawer of the medication cart. R39's unopened vial of Lispro insulin had a label on the box, refrigerate if not opened was in the drawer of the medication cart. V7 removed the 3 unopened insulin vials and stated they should not be in the medication cart, they are supposed to be in the refrigerator. V6 reviewed the Medication Expiration Dates document provided by the pharmacy dated January of 2022, and stated R11's Breo Ellipta inhaler expires 42 days after opening and should be removed from the cart and reordered from pharmacy. On March 19, 2024, at 12:30 PM, V6 provided documentation from the pharmacy, manufacturer guidelines for R9's Trelegy inhaler that showed the inhaler expires 42 days after opening and stated it should be removed from the cart and reordered from the pharmacy. R9's EMR (Electronic Medical Record) showed R9 had diagnoses of chronic obstructive pulmonary disease and a physician order for Trelegy Ellipta inhalation powder, 1 puff daily initiated on October 23, 2023. R9's March 2024 MAR (Medication Administration Record) showed R9 was administered Trelegy Ellipta daily. R11's EMR showed R11 had a diagnosis of chronic obstructive pulmonary disease and a physician order for Breo Ellipta aerosol powder, 1 puff orally, one time a day, initiated on December 1, 2020. R11's March 2024 MAR showed R11 was administered Breo Ellipta daily. R13's EMR showed R13 had a diagnosis of type 2 diabetes mellitus and a physician order for Lispro insulin in accordance with sliding scale, 4 times per day initiated on September 8, 2023. R13's March 2024 MAR showed Lispro insulin was administered multiple times per day. R35's EMR showed R35 had a diagnosis of type 2 diabetes mellitus with neuropathy and a physician order for Aspart insulin 7 units before meals (three times a day) initiated on March 18, 2024. R35's March 2024 MAR showed Aspart insulin was administered 7 times between March 18 and March 21, 2024. R39's EMR showed R39 had a diagnosis of type 2 diabetes mellitus and 2 physician orders for Lispro insulin, Lispro insulin inject 5 units before each meal (three times a day) initiated on January 25, 2024, and Lispro insulin administer in accordance with sliding scale three times per day also initiated on January 25, 2024. R39's March 2024 MAR showed R39 has been administered Lispro insulin three times per day every day. On March 19, 2024, at 9:50 AM V6 (ADON) stated unopened insulin vials should be refrigerated and expired medications should be removed from the medication cart and reordered from the pharmacy. The facility's policy Storage of Medications dated May 1, 2018, showed Temperature . A. Medications and biologicals are stored at their appropriate temperatures and humidity according to the United States Pharmacopeia guidelines for temperature ranges and Expiration Dating .G. No expired medication will be administered to a resident .H. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner.

Based on observation, interview and record review, the facility failed to serve portions of chicken nuggets and diced pork as shown on the menu spreadsheet. This applies to 8 of 8 residents (R21, R30, R31, R34, R54, R57, R90 and R196) reviewed for dining in the sample of 21. The findings include: During initial tour of the facility kitchen on March 18, 2024 starting at 9:45 AM, V13 (Food Service Manager) stated that since Sunday (March 17, 2024) was St Patrick's day, the lunch menu from Sunday is served for the lunch on Monday. Lunch menu prepared for March 18, 2024, showed Chicken Nuggets, French Fries, Seasoned Mixed Vegetables, sugar cookie. Facility daily menu spreadsheet for week 1 Sunday included Chicken Nuggets (7 each= 3 oz/ounce protein). On March 18, 2024 at 11:32 AM, V13 was platting the lunch meal at the tray line service in the facility kitchen and served 5 pieces of chicken nuggets to each of the residents on Regular diets. Residents observed to receive the same included R21, R30, R34, R57, R90 and R196. On March 18, 2024 at 11:44 AM, when V13 was asked why the residents received only 5 pieces of chicken nuggets when the spread sheet showed 7 pieces, V13 responded, It shows 5 pieces on the box. V13 added that the size of the nuggets varies depending on the kind purchased. On March 19, 2024 at 11:47 AM, during lunch tray line service, V13 used a #10 scoop to serve diced pork to the residents on Renal diets and R31 and R54 received the same. Facility daily menu spreadsheet for week 1 Tuesday showed to serve 4 oz=2 oz protein of no salt added diced pork for Renal diets. On March 19, 2024 at 11:52 AM, when asked, V13 stated that the Renal diets are supposed to receive 4 oz of diced pork, but they (facility) did not have the scoop (#8) to serve the same. On 03/20/24 at 10:33 AM, V22 (Registered Dietitian) stated that 7 pieces of chicken nuggets should have been served to obtain 3 oz of protein [21 grams protein]. V22 added that a #8 scoop should have been used instead of the #10 scoop to get 4 oz serving. Facility Scoop and Ladle Equivalents chart showed that #10=3 1/4 oz and #8 =4 oz. The label on the box for Chicken Chunk Fritters showed that serving size of 5 pieces =17 grams of protein. Resident diets on Physician order sheet showed that R21, R30, R34, R57, R90, R196 were on Regular consistency diets and R31 and R54 were on Renal diets.

Based on observation, interview, and record review, the facility failed to administer medications as ordered by the physician. There were 26 medication opportunities with 8 errors, resulting in an 30.77% medication error rate. This applies to 3 of 3 residents (R33, R80, R87) reviewed in the sample of 21. The findings included: 1. R33's EMR (Electronic Medical Record) showed R33 was admitted to the facility on [DATE] with diagnoses that included muscular dystrophy, acute and chronic and chronic respiratory failure with hypoxia, pneumonia, chronic bronchitis, heart failure, olecranon bursitis left elbow, and hypertension. On [DATE] at 9:15 AM, V17 (LPN/Licensed Practical Nurse) prepared R33's morning medications. R33 was given: 1. Norco ,d+[DATE] mg (milligrams). Give one tablet. 2. Vitamin D 500 mg. Give one tablet. 3. Vitamin C 500 mg. Give one tablet. 4. Divalproex 125 mg. Give one tablet. 5. Iron 325 mg. Give one tablet. 6. Furosemide 20 mg. Give one tablet. 7. Hydroxyzine HCL (Hydrochloric Acid) 25 mg. Give one tablet. 8. Duloxetine HCL 30 mg. Give three tablets. 9. Potassium Chloride 10 meq. (milliequivalents) ER (Extended Release). Give one tablet. 10. Folic Acid 400 mcg (microgram). Give two tablets. 11. Multivitamin. Give one tablet. 12. Vitamin B-complex. Give one tablet. 13. Probiotic one pill (was not counted as an opportunity) After all medications were placed into a medication cup. V17 was asked to count the number of pills in the cup. V17 counted and said there were 16 pills in the medication cup. On [DATE] at 1:00 PM, medication reconciliation showed three medications were missed during the morning medication pass. 1. Capsaicin External Cream 0.025% apply to effected area 2. Fluticasone Salmeterol inhaler, give 1 puff every 12 hours 3. Metoprolol 12.5 mg, in morning and at bedtime R33's POS (Physician Order Set) showed the following three medications were to be administered every morning: 1. Capsaicin External Cream 0.025% (Capsaicin) apply to effected area topically two times a day for pain. 2. Fluticasone-Salmeterol inhalation aerosol powder breath activated ,d+[DATE] mcg/act (micrograms/One puff orally every 12 hours for wheezing. 3. Metoprolol Tartrate Tablet, give 12.5 mg (milligrams) by mouth every morning and at bedtime for beta blocker. On [DATE] at 1:14 PM, V17 (LPN) said she gave R33 her Fluticasone Salmeterol inhaler and rubbed the Capsaicin cream on R33's elbows after the surveyor left but was unsure of the time. V17 said she gave the Metoprolol during the surveyor's observation of her medication pass. V17 was asked if she remembered counting the pills in her medication cup and she said yes there were 16 pills. Surveyor said 16 was what was written down and matched the number in her medication cup. Had the Metoprolol been given, there would have been 17 pills in the cup. 2. R80's EMR (Electronic Medical Record) showed R80 was admitted to the facility on [DATE] with diagnoses that included congested heart failure, cardiomegaly, and hypertensive heart and chronic kidney disease with heart failure. On [DATE] at 8:30 AM, V3 (RN/Registered Nurse) prepared R80's morning medications. R80 was given: 1. Vitamin C - 500 mg. Give one tablet. 2. Aspirin 81 mg, chewable. Give one tablet. 3. Bumetanide 2 mg. Give one tablet. 4. Escitalopram 20 mg. Give one tablet. 5. Iron 325 mg. Give one tablet. 6. Farxiga 5 mg. Give one tablet. 7. Glimepiride 1 mg. Give one tablet. 8. Loratadine 10 mg. Give one tablet 9. Spironolactone 25 mg. Give one tablet. 10. Multiple vitamins. Give one tablet. 11. Pantoprazole 40 mg. Give one tablet. After all medications were placed into a medication cup. V3 was asked to count the number of pills in the cup. V3 counted and said there were 11 pills in the medication cup. On [DATE] at 12:55 PM, medication reconciliation of R80's morning medications showed one medication had been missed. 1. Metoprolol 25 mg, take one tablet twice a day for PVCs (Premature Ventricular Contractions). On [DATE] at 1:21 PM, V3 (RN) said she held R80's blood pressure medication (Metoprolol) because V80's blood pressure was low. V3 said her blood pressure was ,d+[DATE]. When asked what the parameters were to hold the medication, V3 said there weren't any physician ordered parameters, but that she held the medication because her systolic blood pressure (top number) was less than 110. 48308 3) On [DATE], at 5:05 PM, V5 (RN) prepared and administered R87's scheduled medications via gastrostomy tube. V5 prepared the following medication: 1. Cholestyramine powder 4 gm (gram) 1 packet mixed with 200 ml. (milliliter) of water 2. Atorvastatin 40 mg.(milligram) 1 tablet crushed into powder and mixed with 200 ml. water 3. Xarelto 2.5 mg. 1 tablet crushed into powder and mixed with 200 ml. water 4. Metoprolol tartrate 100 mg. 1 tablet crushed and mixed with 200 ml. water V5 turned off the jejunostomy tube feeding that was infusing through the same port and flushed the gastrostomy tube port with 30 ml of water. V5 then administered each medication including the 200 ml. of water with each medication, by gravity bolus and did not flush the tube between medications. V5 then flushed the gastrostomy tube with an additional 175 ml. of water. On [DATE], at 3:57 PM, V2 stated when doing a medication pass the nurse should hand sanitize, have MAR (Medication Administration Record) available, check order, check medication against the physician order, place the medication into a medication cup, make sure house stock is not expired. V2 stated staff should check vital signs, explain to resident what they are going to do, explain what medications are to be given, perform hand hygiene after, and document on the MAR. V2 explained a nurse should never hold a medication without talking to the physician or nurse practitioner and the nurse also needs to know the reason the medication was ordered. V2 stated she had already spoken with V3 (RN/Registered Nurse) regarding the medication V3 held that was a blood pressure medication, but it was ordered for PVCs (Premature Ventricular Contractions) and V3 had no parameters to hold it. V2 stated when administering medications by G-tube (Gastrostomy) the nurse needs to check G-tube placement by listening for air when administering an air bolus, check residuals, crush medications one at time, take crushed pill and add it to ,d+[DATE] cc of water, flush 30 cc of water prior to administering any medications, administer the medication and flush with 10 cc of water in between, repeat this process with each medication until all medications are given and then flush with 30 cc of water. V2 stated, using 200 ml with one medication during administration is way too much water, to then repeat 200 ml with 3 other medications for a total of 800 ml, and then administered a flush of 175 ml for a total of 975 ML at one time is unheard of and should not be done. The facility's Policy and Procedure Administering Medications last issued on [DATE] showed Purpose: To ensure safe and effective administration of a medication in accordance with physician orders and state and federal guidelines.

Based on observation, interview and record review, the facility failed to provide specialized cup for drinking for residents that were at risk for aspiration with dysphagia and could not use straws. This applies to 2 of 3 residents (R18, R87) observed for dining in the sample of 21. The findings include: R87's face sheet included diagnoses of dysphagia, oropharyngeal phase, paraplegia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R87's quarterly MDS (minimum data set) dated December 19, 2023, showed R87 was cognitively intact. R87's POS (Physician Order Sheet) showed diet order of General diet, Mechanical Soft texture, Regular Thin Liquids consistency, chop vegetables, gravy added to meat. No straw during TL (thin liquid) related to dysphagia, oropharyngeal phase. On March 18, 2024 at 04:23 PM, R87 in bed with tube feeding running. On R87's bedside table, there was a straw in a cup of brownish tinged water with a bottle of 16.7 oz/ounces soda placed next to it. R87 stated, I just drank my soda with a straw. The water is from the ice that melted. It was also noted there were multiple straws in a cup on the nightstand. V19 (Licensed Practical Nurse) who was in the area, was not sure if R87 is able to use straws with liquids. On checking the diet order that showed, no straw during TL. V19 did not know what TL abbreviation meant. Nursing progress note dated March 18, 2024 17:06 (5:06 PM) included, Came to the room and noted straw in resident's cup of water. Made resident aware that she is not to use straw when drinking as it can make her cough and possibly aspirate. Resident verbalized understanding and allowed this writer to remove the straw and the unopened ones at bedside. On March 19, 2024 at 2:51 PM, V4 (Speech Language Pathologist) stated she just picked R87 back up on her case load. V4 stated she had previously recommended no straw for R87 as R87 demonstrates high risk for aspiration as she has dysphagia. V4 added larger volumes of liquids can be ingested with straws and cause higher risk for aspiration. V4's discharge summary dated November 9, 2023 included as follows: To facilitate safety and efficiency, it is recommended the patient use the following strategies during oral intake: chin tuck. general swallow techniques/precautions, rate modifications, no straws . 2. R18's face sheet included diagnoses of dysphagia, oropharyngeal phase, communicating hydrocephalus, other cerebral palsy, adult failure to thrive, abnormal weight loss, mild protein-calorie malnutrition. R18's POS included diet order of General diet, Mechanical Soft texture, Regular Thin Liquids consistency, Thin Liquids in Provale cup only; Whole milk all meals related to other cerebral palsy. On March 19, 2024 at 12:14 PM, R18 received a meal tray in the dining room with thickened water in a cup and an 8 oz carton of whole milk (regular consistency). Diet card showed, thin liquid Provale cup. V16 (CNA/Certified Nursing Assistant) who was passing out trays stated that previously a blue cup used to be sent up on the tray by dietary but recently she has not seen it. V14 (Dietary Aide) who had brought up the tray cart stated the residents take it to their rooms and the dietary does not have any more Provale cups. On March 19, 2024 at 2:57 PM, V4 stated R18 was also on her caseload. V4 stated that on her last recommendations on February 22, 2023 she recommended R18 should have thick liquids but can have thin liquids with Provale cup only. V4's discharge recommendations dated February 22, 2023 showed liquids Provale cup during TL intake to decrease signs and symptoms of aspiration.

Based on observation, interview, and record review the facility failed to provide ADLs (Activities of Daily Living) care to residents identified as requiring assistance with ADLs. This applies to 2 of 6 residents (R40, R58) in the sample of 21. The findings included: 1) R40's EMR (Electronic Medical Record) showed R40 was admitted to the facility on [DATE], with diagnoses that included aftercare following joint replacement surgery, presence of left artificial hip joint, muscle weakness, and need for assistance with personal care. R40's MDS (Minimum Data Set) date February 7, 2024, showed R40 was cognitively intact and required substantial/maximal assistance for showers/bathing and partial/moderate assistance for personal hygiene. R40's care plan showed R40 had a self-care deficit (ADLs/Mobility) due to generalized weakness, impaired balance, multiple comorbidities, pain, and physical activity. Interventions included one assist with dressing/hygiene tasks, encourage as much self-performance as safely available. On March 18, 2024, at 11:17 AM, R40 was in bed wearing a hospital gown and bath robe. There were several chin hairs/whiskers noted. R40 said she would like to be shaved. R40 said no one has offered a shower or bed bath, she said all they do is clean her bottom when they change her incontinence brief. On March 19, 2024, at 8:17 AM, R40 said she is wearing the same gown and bath robe as she has had on for days. R40 said she would really like to be shaved. R40 said she could not remember any time a staff asked her if she would like to take a shower or get cleaned up. On March 20, 2024, at 8:50 AM, R40 still in same gown and robe as Monday and Tuesday. R40 said no one has offered to shave her or clean her up. On March 20, 2024, at 8:59 AM, V25 (CNA/Certified Nurse Assistant) said all CNAs are to fill out a shower sheet after providing a shower or bed bath. The CNA will give the shower sheet to the nurse, then it is placed in a bin to be picked up by the scheduler or V2 (DON/Director of Nursing). On March 20, 2024, at 9:03 AM, V2 DON was asked to provide shower sheets for R40. On March 20, 2024, at 10:00 AM, V2 DON said she is learning that shower sheets are not being done so we have no proof is the care is being provided or if the resident has refused. 48308 2) R58's EMR (Electronic Medical Record) showed R58 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, heart failure, dementia, and muscle weakness. R58's MDS dated [DATE], showed R58 had moderate cognitive impairment and needed substantial assistance with bathing and personal hygiene. On March 18, 2024, at 10:38 AM, R58 was lying in bed, taking a nap, with long facial hair present. On March 19, 2024, at 9:05 AM, with V20 (CNA-Certified Nurse Aide) present, R58 remained with long facial hair, in need of shaving and R58 requested to be shaved. On March 20, 2024, at 9:20 AM, with V17 (LPN-Licensed Practical Nurse) present, R58 remained with long facial hair, in need of shaving and again R58 requested to be shaved. R58's care plan initiated on November 14, 2023, showed R58 needed assistance of 1 staff with dressing and hygiene ADL (Activities of Daily Living) task. The facility was unable to provide documentation that R58 had received a shower, which included shaving, during the month of March 2024. On March 20, 2024, at 10:05 AM, V2 (DON) stated it is the expectation for staff to complete documentation on the shower sheet form when a shower or bed bath is given or when the resident refuses a shower or bath. V2 stated residents are scheduled for showers twice a week and the expectation of grooming facial hair should be included during the shower or when needed. V2 stated she did not have documentation of shower sheets for either R40 or R58. The facility's policy Activities of Daily Living (ADL's) dated November 2022, showed the Purpose .to preserve ADL function, promote independence, and increase self-esteem and dignity .and Bathing .washing and drying the body, including full body sponge bath and Grooming .maintaining personal hygiene .combing and/or styling hair, face and hands, brushing teeth, shaving or applying makeup, oral hygiene, self-manicure (safety awareness with nail care) and/or application of deodorant or powder.

Based on observation, interview and record review, the facility failed to follow manufacturer's instructions for a pressure reducing/relieving mattress. This applies to 2 of 7 residents (R15, R87) reviewed for pressure ulcers in the sample of 21. The findings include: 1.R15's EMR (electronic medical records) showed R15 was admitted on [DATE] with diagnoses including cognitive communication deficit, other reduced mobility, pressure ulcer of sacral region, stage 2. R15's care plan revised on February 11, 2024 included R15 has an alteration in skin integrity and is at risk for additional and/or worsening of skin integrity issues related to impaired cognition, impaired communication, incontinence of bladder, incontinence of bowel, impaired mobility status, impaired nutritional status, comorbidities, cancer, failure to thrive. Interventions for the same included pressure reducing/relieving mattress as needed. R15's weights and vitals section in EMR showed R15 was 89.2 pounds on March 1, 2024. On March 18, 2024 at 10:57 AM, V19 (Licensed Practical Nurse) stated she is unsure if R15 has pressure sore on sacral area. V19 added, She has a dressing. The wound nurse does the treatments. On March 19, 2024 at 10:34 AM, R15 was lying in a low bed had a pressure relieving mattress. The control knob was switched ON at low pressure and had the label for Proactive Medical Products with weight dial set at 320 lbs. for weight in pounds. When asked, R15's nurse V3 (Registered Nurse) stated she is not aware of what the settings should be. V3 stated, The housekeeping does the setting for the air pressure on the mattress. On March 19, 2024 at 10:37 AM, V2 (Director of Nursing) was shown the above setting on R15's air mattress. V2 stated, V12 (House Keeping Director) puts it (control setting) on. I am not sure if V11 (Wound Care Nurse) lets him (V12) know about the setting. V2 added she will refer to the manufacture's guidelines for the same. On March 19, 2024 at 10:39 AM and 11:18 AM, V11 stated, I check it (mattress) sometimes to see if the pressure is low or high but never do any adjustments. I don't know anything about the setting. She (R15) had a pressure sore on admission but currently it is healed. Currently I do protective treatment on her sacral area. On March 19, 2024 at 10:42 AM, the control knob for the weight dial on R15's pressure relieving mattress was noted changed to 350 lbs. for weight in lbs. V12 stated he adjusted it a few minutes earlier to make sure there is enough air in the mattress. V12 added he thinks the adjustments are related to the weight but is not sure. Proactive Medical Product's operation manual instructions for the pressure redistribution mattress showed as follows: Step 6. Determine the patient's weight and set the control knob to the weight setting on the control unit. 2. R87's EMR showed R87 was admitted on [DATE] with diagnoses including paraplegia, unspecified, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, oropharyngeal phase. R87's quarterly MDS (Minimum Data Set) assessment dated [DATE], showed R87 was cognitively intact. R87's care plan revised on September 12, 2023, included R87 has an alteration in skin integrity and is at risk for additional and/or worsening of skin integrity issues related to immobility, admitted with pressure injury to sacrum, tube feeding, respiratory trach, incontinence, advancing age. Interventions for the same included pressure reducing/relieving mattress as needed. R87's weights and vitals section in EMR showed R87 was 126.0 pounds on March 1, 2024. On March 18, 2024 at 9:10 AM, R87 was seated up in a wheelchair and stated she had had a wound on her sacral area, and she gets dressing change every morning by V11. R87 was not sure if the wound was still present. On March 19, 2024 at 10:29 AM, R87 was lying in bed had a pressure relieving mattress showing the control unit labeled Drive with power switch switched on. The pressure adjust knob was set at 350 firm setting. R87 stated, I have had this (pressure) mattress ever since I have been here since last August. Nobody ever adjusts it. They don't even look at it. On March 19, 2024 at 10:38 AM, V2 was also shown the above setting on R87's air mattress. V2 added she will refer to the manufacture's guidelines for the same. On March 19, 2024 at 11:18 AM, V11 stated R87 had a stage 3 pressure sore on here sacral area, and it is currently healed. V11 added she does routine preventive treatments on the area to prevent it from reopening. Drive operation's manual instructions for alternating pressure low air loss mattress showed as follows: Step 6. Determine the patient's weight and set the control knob to the weight setting on the control unit. On March 19, 2024 at 12:23 PM, V2 stated per operations instructions shown both in the Proactive Medical Products and Drive manuals, the setting for the pressure relieving mattress is based on (patient) weight. On March 21, at 10:02 AM, V26 (Drive Representative) stated it is recommended the control knob is set to the patient's weight as if its set too low the mattress will be soft and if set too high the mattress will be too firm.

Based on interview and record review, the facility failed to ensure a resident received physician ordered ventilation therapy. This failure resulted in R1 requiring hospitalization for worsening cough and dyspnea (shortness of breath). This applies to 1 of 3 residents (R1) reviewed for improper nursing care in the sample of 5. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility in April 2020. R1 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS (Minimum Data Set) dated February 10, 2021 shows R1 is cognitively intact, requires supervision for eating and locomotion on and off the unit, extensive assistance with personal hygiene, dressing, and bed mobility, and is totally dependent on facility staff for transfers between surfaces, toilet use, and bathing. R1 has an indwelling urinary catheter and is always incontinent of stool. On March 5, 2021, V3 (NP-Nurse Practitioner) documented he assessed R1 for shortness of breath due to nursing staff concerns. V3 assessed the resident, ensured inhalers and breathing treatments were administered and documented to monitor R1. On March 5, 2021 at 9:35 PM, V5 (RN-Registered Nurse) documented R1's roommate notified V5 that R1 was complaining of experiencing shortness of breath. R1 was assessed by V5. V5 documented R1 had no signs and symptoms of shortness of breath, however, V10 (Spouse of R1) insisted R1 be sent to the local hospital. V5 documented R1 was taken to the local hospital by private ambulance at 10:35 PM. Hospital documentation shows R1 was admitted to the local hospital on March 5, 2021 for dyspnea (shortness of breath). V11's (Physician/Pulmonologist) assessment of R1 dated March 6, 2021 at 2:13 PM shows, multiple concerns, including: Worsening cough, dyspnea suspect related to mucous plugging given nonadherence to [R1's] home regimen of nocturnal VPAP (Variable Positive Airway Pressure), chest PT (Physiotherapy) and cough assist. Chronic respiratory failure supposed to be managed on nocturnal VPAP, however, per [V10] (Spouse) not performed at the facility, ALS with multiple complications including chronic respiratory failure, dysphagia (difficulty swallowing), [CONDITION(S)], aspiration risk and history of DVT. Plan: Continue close monitoring of respiratory status . Resume home respiratory regimen including nocturnal VPAP, chest PT and cough assist - will need to ensure these are arranged and functional at facility prior to discharge. The EMR shows an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing documentation on the TAR (Treatment Administration Record) and nursing progress notes for February and March 2021 shows R1 did not receive the physician-ordered ventilation therapy on multiple dates. The facility did not have nursing documentation to show R1 received any alternative treatment or equipment to provide the ventilation therapy when equipment was malfunctioning. Nursing documentation shows the following: March 5, 2021 by V5 (RN) - IVAPS not working. March 4, 2021 by V5 - IVAPS not working, message sent to Respiratory Therapist to come check machine. February 24, 2021 by V7 (RT-Respiratory Therapist) - IVAPS from home missing power cord. The cord has still not been found. I set him up on [CONDITION(S)] (Bilevel Positive Airway Pressure) in the meantime for nocturnal support until the power cord is located or replaced. I have instructed him to use it. He understands and agrees to. Plan: Locate or replace power cord for home unit. February 23, 2021 by V5 - IVAPS not working. Respiratory Therapy notified. Will be here in the morning to check. Nursing documentation also shows R1 did not receive the physician-ordered ventilation at bedtime due to missing machine parts and waiting for respiratory therapy to set up R1's IVAPS machine on February 5, 7, 9, and 14, 2021. Nursing documentation shows R1 refused the ventilation therapy at bedtime on February 17, 18, 19, 21, 22, 23, 24, 28, 2021, and March 1, and 3, 2021. The facility did not have documentation to show R1 received education by nursing staff regarding possible outcomes of not using the ventilation therapy, nor did the facility have documentation to show R1's physician was notified each time R1 refused the treatment. On March 9, 2021 at 12:39 PM, R1 was sitting in motorized wheelchair in room. R1 said, As for the breathing machines, sometimes they are missing a cord, sometimes a mask, other times the water chamber. I will refuse to wear the machine at night if it is not functioning correctly. Who wants to wear a mask on their face if it is constantly beeping and the nurses don't know how to fix it? I've only refused to wear it when the machine is broken. On March 9, 2021 at 12:56 PM, V2 (DON-Director of Nursing) said, [R1] needs a new machine. The chamber is broken so he doesn't get a tight fit. The company has been called to see if he qualifies for a new machine. We haven't gotten a response from them yet. The nurses didn't know how to call the breathing machine company for trouble shooting when a red light comes on. It is lack of knowledge and follow through and a critical thinking component. I told them if there is a red light on, you pick up the phone and call the 1-800 number. The nursing staff did not provide the respiratory therapy because the machine wasn't working right. The nurses need better training. The refusing hasn't been frequent. If we are not able to resolve the situation with the staff we have here, then we can call his wife and involve her. The whole facility needs to get better on involving social work, and others, to document and work on educating the resident. I don't see that we have anyone involved here with [R1] resisting care. On March 9, 2021 at 3:26 PM, V5 (RN) said, The [CONDITION(S)] at night was not working right. The charting said it was not working so that means the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The plan of care was to put it in the progress notes. There was no other plan of care for him refusing care. When I called the respiratory therapist to come in, it took time for him to come fix it. Respiratory never comes the same night we call. On March 9, 2021 at 4:47 PM, V7 (RT) said, I am a consultant for the facility for respiratory therapy. I am not there every day. Only when they call me to come. I set up different devices for [R1]. He currently has a temporary device because his own device had a water chamber that no longer sits inside the machine. The seal is worn. When the cord was missing from his equipment, the facility should have seen that the cord was missing and put him on a temporary unit until they could order the new cord. I never guarantee when I can get there. I can't always get there the next day. His current IVAP machine is worn out. At one point I got a call for malfunctioning equipment, and I went there and the equipment was working fine. I trained a bunch of staff back when he was admitted in April 2020, but I would say that if they have new staff since that training, they have not been trained by me. On March 9, 2021 at 3:06 PM, V3 (NP-Nurse Practitioner) said, The breathing machine is absolutely necessary for [R1] at night. I know there is a machine in his room right now that turns on and appears to work, though I did not check to see if the settings were correct or if the mask fits [R1] correctly. I do have concerns about the resident going to bed without the breathing machine. It is important that he has the machine on during bedtime because he has ALS. I agree that his recent hospitalization for shortness of breath and mucous plug were caused by not using the IVAPS at night. These failures escalated to the point where [R1] needed hospitalization , especially due to his ALS diagnosis. The facility's policy entitled [CONDITION(S)]/[CONDITION(S)] (Continuous Positive Airway Pressure) dated 4/14 shows: Policy: [CONDITION(S)]/[CONDITION(S)] therapy will be administered by a Respiratory Therapist or Nurse upon order of a physician. Procedure: 1. The Respiratory Therapist or Nurse will fit the patient for the proper headgear and mask. 2. The Respiratory Therapist will give the initial in-service to the nursing staff, and demonstrate how to set IPAP (Inspiratory Positive Airway Pressure), EPAP (Exhalation Positive Airway Pressure), MODE settings and operate the unit. 3. If the nursing staff has been previously trained and is knowledgeable on the equipment, they will be responsible to set IPAP, EPAP, and MODE setting per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN or LPN (Licensed Practical Nurse) is responsible for placing the resident on the [CONDITION(S)]/[CONDITION(S)] unit daily per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview and record review the facility was found to have the following failures related to COVID-19: 1) Failed to follow their policy for screening visitors and facility staff for COVID-19 symptoms and exposure prior to entering the facility. 2) Failed to follow their policy for screening facility staff at mid-shift for fever and other symptoms of COVID-19. 3) Failed to have a system in place to track facility staff present in the building and ensure staff had been screened for COVID-19 symptoms and exposure upon entrance to the facility and mid-shift. 4) Failed to post signage to identify a resident unit as a COVID-19 unit and resident rooms as isolation rooms, including type of isolation and type of PPE (Personal Protective Equipment) required to enter the unit/resident room. 5) Failed to ensure COVID-19 positive residents are kept separate from non-COVID residents. 6) Failed to have designated staff to care for COVID-19 positive residents. These failures resulted in Immediate Jeopardy. The immediate jeopardy was noted to begin on November 16, 2020 at 12:50 PM, when V11 (Receptionist) was observed allowing visitors to enter the facility without performing COVID-19 screening. This applies to all 88 residents residing at the facility. V1 (Administrator) was notified of the Immediate Jeopardy on November 20, 2020 at 2:40 PM. V1 was provided with the Immediate Jeopardy Template outlining the failures. Although the immediacy was removed on November 23, 2020 the facility remains out of compliance at a Severity Level II due to the need to evaluate the implementation of policies and procedures and Quality Assurance monitoring. The findings include: The Facility Data Sheet dated November 16, 2020 shows the facility census as 88 residents. On November 16, 2020 at 12:50 PM, V11 (Receptionist) was sitting at the desk at the front entrance of the facility. V11 allowed this surveyor to enter the building without performing COVID-19 screening, including checking body temperature and screening for COVID-19 exposure or symptoms. At 1:00 PM, V1 (Administrator) said V11 should screen everyone entering the building for body temperature and COVID-19 exposure/symptoms. V1 instructed V11 to screen this surveyor. V11 used a thermometer to check this surveyor's body temperature and then proceeded to put a checkmark in the no column of the screening tool, for all COVID-19 symptoms without asking this surveyor if any of the symptoms were present. V11 said all visitors and employees entering the building are supposed to be screened for COVID-19 symptoms and body temperature. V11 said, I am the only receptionist working here, the other two quit. I don't follow up with employees to make sure they get screened for COVID before they start work or during their shifts. They are on the honor system. I just put the forms in a pile on my desk and clip them together. I don't keep track of them. I don't know who looks at them. On November 16, 2020 at 1:20 PM, screening sheets were reviewed with V11 (Receptionist). V11 said she did not have screening sheets to show the employees currently working in the facility had been screened for body temperature or COVID-19 exposure and symptoms prior to their shift or mid-shift. The facility's Daily Staffing schedule dated November 16, 2020 shows, V14 (RN-Registered Nurse), V15 (RN), V16 (LPN-Licensed Practical Nurse), and V20 (LPN) were scheduled to work from 7:00 AM to 3:30 PM, and V7 (CNA-Certified Nursing Assistant), V17 (CNA), V18 (CNA), V19 (CNA), V21 (CNA), V22 (CNA) were scheduled to work 6:30 AM to 2:30 PM. On November 16, 2020 between 1:25 PM and 2:00 PM, V14 (RN), V26 (LPN), V15 (RN), V21 (CNA), and V20 (LPN) said they all started their shift between 6:30 AM and 7:00 AM and did not get screened for body temperature, COVID-19 exposure or symptoms prior to starting their shifts or midway through their shifts. V15 had a blank screening sheet in his hand and said he did not complete the screening prior to his shift. V20 said, There was no receptionist at the desk when I came in, so I didn't do the screening. The facility's policy entitled Coronavirus 2019, revised on July 12, 2020 shows: Facilities: h. Screen staff: Screen all staff for respiratory symptoms and check temperatures at the beginning of the shift and again at mid-shift. If a COVID-19 respiratory symptom or fever is present, the staff member should be sent home Employees: c. All employees should be pre-screened for fever and other symptoms prior to shift and at mid-shift.Fever (>100.0 degrees Fahrenheit) · New or worsening cough · Shortness of breath · Sore throat · Chills or shaking w/chills · Muscle pain · Headache · New loss of taste or smell If employee answers YES to any of the screening questions the employee should not work. The employee should self-isolate at home. Contact the supervisor and infection prevention. Infection Prevention should notify the local health department. Visitors: b. If there is community-wide transmission of COVID-19, facility will consider screening visitors at entry to the facility. Only essential visitors will be permitted entry to the facility. Essential visitors are defined as relatives who have loved ones who are critically ill, medical providers and practitioners that are essential to provide care and services to manage health and well-being. d. (As of 4/17/2020 for Illinois facilities) Essential professionals, such as those providing legal services, advising residents of their legal rights, and assisting with matters in which residents may be aggrieved should be allowed reasonable access to patients/residents at facilities. Essential professionals will be screened as facility staff. On November 16, 2020 at 12:50 PM, V1 (Administrator) said, The second floor is our designated COVID unit. On November 16, 2020 at 1:44 PM, and November 19, 2020 at 1:25 PM, observations were made of the second floor of the facility. No signage was present at the entrance to the unit, via the elevator or stairway, to show the second floor was a designated COVID unit. On November 19, 2020 at 1:30 PM, V16 (LPN) said, Most of this floor is COVID residents. There are no signs posted to show that. We wear masks at the nurse's station and in the hallways but if you go in the room of a COVID positive resident, then you need to wear everything. V12 (LPN), said, You just have to look at the signage on the resident's rooms to see what kind of PPE (Personal Protective Equipment) is needed in each room. Some residents I am caring for have COVID, and some don't. We don't have dedicated staff for the COVID residents. The facility provided an undated list of residents with current positive COVID-19 infections on November 19, 2020. The list shows, R3, R9, R10-R22 have COVID-19 infections. None of the rooms occupied by R3, R9, R10-R22 had signage to show the residents were in isolation, the type of isolation, or the type of PPE to be worn prior to entering their rooms. On November 19, 2020 at 1:30 PM, R7, R17, R24 and R25 resided in the same room. The facility's undated list of residents with positive COVID-19 infection shows R17 as positive for COVID-19. The facility's EMR (Electronic Medical Record) shows R7, R24 and R25 had orders to discontinue isolation for COVID-19 on November 17, 2020. On November 19, 2020 at 1:30 PM, R7, R24 and R25 remained on the COVID-19 unit, in the room with the COVID positive resident R17, despite their previous room at the facility remaining empty. On November 23, 2020 at 10:48 AM, V1 (Administrator) identified V2 (DON-Director of Nursing) as the facility's Infection Preventionist (IP). On November 23, 2020 at 10:56 AM, V2 (DON/IP) said, I was the interim DON. I worked from the end of October 2020 through November 20 in that capacity. I don't know why the residents who were cleared of COVID isolation were left up on the COVID unit. The facility was supposed to make a COVID unit and as the unit got smaller, have a dedicated wing and barrier it off from the other residents to make it a COVID unit. We had discussed it, and the plan was (V27) (Nurse Consultant), (V23) (Former Administrator) and (V1) (Administrator) would barrier off the unit and make it a COVID unit. They were also supposed to have dedicated staff there. I was out on leave from early November until November 16, 2020. When I came back, (V27) and (V1) were discussing the room moves while I was catching up on everything else. I don't know why the residents were not moved. Once the residents came off isolation they would be moved back to their room, that was always the plan. The facility did not want to keep people in isolation once the isolation was discontinued. There was supposed to be signage to identify the unit as a COVID unit. There was also supposed to be signage on all the resident rooms as well. I did tell them they had to have dedicated staff in the building. Also, they were supposed to be announcing halfway through the day to get staff to be screened for COVID symptoms and fever. On November 23,2020 at 11:50 AM V28 (Disease Specialist DuPage County Health Department) said, Our advice to the facility is to always make sure they have a COVID unit set up with cohorted staff and make sure they are using proper PPE (Personal Protective Equipment). They should be screening their staff twice a day for COVID symptoms, and if they work two shifts in a row, then twice in every eight hours they work, including when they enter the building for the first time. We recommend they put up notification of entering a COVID unit. We would recommend the residents go back to the normal floor if they are cleared from isolation. If the facility has the room, they should move the residents out of the COVID unit. The facility had some questions for the health department on Friday, November 20. They had some residents that were positive for COVID and some residents that were cleared. We said they should move the residents, cleared of isolation, back to the normal unit when they are cleared from isolation if they had room. Absolutely, the staff and visitors should be screened upon entering the building. The staff should be screened twice in every eight hours they work. Through observation, record review, and interviews conducted on November 24, 2020, the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation: Re-education on Systems: Dates initiated and dates to be completed · All visitors/associates and employees will be screened for COVID-19 symptoms and exposure prior to entering the building and include a system for tracking employees who fail to be screened prior to entering the building. o Education initiated 11.20.2020 and completed 11.23.2020, by Midnight o All staff educated via phone will be re-educated prior to the beginning of the next shift worked and will sign education sheets o New hires will be educated during orientation o 5 random screening tools a week are being audited by the Administrator and/or designee to ensure compliance. The audits will continue for 4 months. · Staff /associates will be screened at midshift, if in the facility longer than four hours, for COVID-19 symptoms. This will include a system for tracking employee/associates who fail to complete the screenings at midshift (four-hour). o Education initiated 11.20.2020 and completed 11.23.2020, by Midnight o Staff that work double will have 4 screens completed (beginning of the shift and midshift for each shift worked) o All staff educated via phone will be re-educated prior to the beginning of the next shift worked and will sign education sheets o New hires will be educated during orientation o 5 random screening tools a week are being audited by the Administrator and/or designee to ensure compliance. The audits will continue for 4 months. System: Ensure all employees who show up to work get checked for COVID-19 symptoms and ensure body temperatures are taken mid-shift (four hours) after their shift starts The pre-checker will check visitors/associates and employees for COVID-19 symptoms and exposure prior to entering the building and will not allow visitors/associates or staff into the building. The designated staff member/pre-checker will follow up to ensure employees will be checked at the midshaft (four-hour) mark after the shift starts. If issues are identified with education or compliance staff will be re-educated immediately. · Screening forms are updated, per CDC/IDPH and DCHD guidelines when changes occur. The Administrator and/or Designee will ensure forms are current. · Signage posted informing all residents, staff, and visitors/associates at all entrances to the COVID-19 unit and required PPE to be worn while on the unit o Completed 11.20.2020 o A weekly audit for appropriate signage is being completed by the Administrator and/or Designee to ensure compliance · Signage posted outside resident rooms to inform all residents, staff and visitors/associates of residents in isolation for communicable diseases such as COVID-19 and PPE worn to enter the resident's room o Completed 11.20.2020 o A weekly audit for appropriate signage is being completed by the Administrator and/or designee to ensure compliance · Separate COVID-19 positive residents from non-COVID residents to designated unit o All staff education initiated 11.20.2020 and completed 11.23.2020, by Midnight o All staff educated via phone will be re-educated prior to the beginning of the next shift worked and will sign education sheets o New hires will be educated during orientation o Room moves completed 11.20.2020 o Designated COVID-19 unit is 1 North o A weekly audit for appropriate signage is being completed to ensure compliance. The audit is being completed by the Administrator and/or designee · Dedicated staff is assigned to the COVID-19 unit o All staff education initiated 11.20.2020 and completed 11.23.2020 by Midnight o The scheduler will assign dedicated staff to the COVID-19 unit o A weekly audit has been put into place to ensure dedicated staff is assigned to the COVID-19 unit o The audit is being completed by the Administrator and/or designee All audits will be analyzed and reviewed in monthly QAPI. This is overseen by the medical director and administrator. Audits will continue for no less than 4 months. QAPI will determine if the audits will continue at that time.

Based on observation, interview and record review the facility failed to supervise a resident and failed to ensure the alarm on an emergency exit door was working, resulting in a resident ,with dementia, leaving the facility through the unalarmed door on October 25, 2020 without staff knowledge. This applies to 1 of 3 residents (R4) reviewed for safety and supervision in the sample of 12. The Immediate Jeopardy began on 10/25/20 when R4 eloped from the facility through an unalarmed Emergency Exit door. The Immediate Jeopardy was identified on 10/30/20. V1(Administrator) was notified of the Immediate Jeopardy on 11/3/20 at 11:00AM. The Surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 11/3/20; however, noncomplaince remains at a Level Two because additional time is nneded to evaluate the implementation and effectiveness of the in-service training. The findings include: R4's Minimum Data Set of 10/24/20 shows that R4 has Severely Impaired Cognitive Skill for Daily Decision Making and short and long term memory problems. R4's physician's orders [REDACTED]. R4's Elopement Risk assessment dated [DATE] shows that R4 has a history of wandering/elopement and /or verbalizes a strong desire to leave, responds poorly to staff redirection when roaming into areas that are off-limits or unauthorized, and is considered at risk to elope and should be placed on the Elopement Risk Protocol. R4's Progress Notes dated 10/26/20 at 12:55AM state, Physician notified of resident being in (Hospital ER). There is no documentation related to R4's elopement from the facility. On 10/30/20 at 10:40AM V10 (Licensed Practical Nurse- Wound Nurse) stated, I was on the second floor and I got a call from the police department. They asked if we had a resident by the name of (R4- first name), I said, (R4's full name). They said she was found outside and she had had a fall. I told them I was not the nurse in charge of her. They asked to speak to whoever was in charge but I told them they could just speak to me. They said she was going to the hospital. I ran downstairs to let V11 ( Registered Nurse (RN) Agency Nurse) on the Homeward Bound Unit know. When I found (V11) she did not know that (R4) was not in the building. She said, It's your building. So I called V2, (Director of Nursing) and V1 (Administrator). The staff on the unit said the last time they saw (R4) was around 8:30PM. Everyone that works on that unit is from an Agency. I got statements from V11 and V12, (Certified Nursing Assistant- CNA). I was so upset. I was kind of on an [MEDICATION NAME] rush- I ran around and tested all the doors. The patio door alarm went off but the end of the hall door did not alarm when I opened it. I ran around the entire building and tested the doors. I called the hospital to check the status of (R4). We have never had a dementia unit before. That unit was created for our COVID residents. On 10/30/20 at 11:30AM, V11 stated, I'm not sure how she (R4) got out. It is supposed to be a locked unit. She has dementia and she kept packing her bags and we kept redirecting her to her room. Then, we went in to care for 2 other residents. This is supposed to be a locked unit. I guess she went out the emergency door in the back of the unit. It had to be this door. We saw her last about 8:00-9:00PM. Then (V10) came and told me that (R4) was found outside. I had never worked at the facility before and I have not worked there since. On 10/30/20 at 11:45AM V12 stated, She (R4) was in the front foyer area. She was ready to leave and had been packing her bags all night. It is a locked unit. Residents shouldn't be able to get out. These are patients with Dementia. We went in to give care to 2 other residents about 8:30PM and we didn't hear any alarms go off. After caring for the other gentlemen, we came out and (R4) wasn't there. I didn't think anything of it. I thought it was a locked unit. They are pretty independent back there. They said she went out the back door but it never alarmed while I was back there. On 10/30/20 at 2:00PM V2 stated, I got a phone call from (V10) that (R4) had gotten out of the building. I asked (V10) to check the doors and V1 called the emergency number to arrange for the repair of the door that did not alarm. I asked (V10) to call the hospital and check on the status of (R4), call the doctor and get statements from (V11 and V12) on the unit. Then I followed up in the AM with the hospital and (V1) told me the door was secure. When (V10) had tested the door that night the door did not alarm. I did not have a part in the investigation. I just kept having (V10) check on (R4's) status in the hospital. The nurses are supposed to document in Risk Management when we have an incident and that is not part of the medical record. V11 said she called R4's facmily. I don't know if she documented it anywhere. On 10/30/20 at 12:00PM V1 stated, The door was fixed by (Repair Company). The panel has a battery and the battery was dead so he changed out the battery so the alarm will go off. The doors are fixed now. There is supposed to be a 15 second egress on the doors. Surveyor and V1 then went to the unit to check the doors. V1 stated, We did not use agency until this unit opened. This unit had been closed for 3 years. Then I got a call on a Wednesday night that they were going to admit 15 residents from another facility on Thursday, so we quickly got this unit in order. Surveyor and V1 checked Foyer/patio door inside unit. Door released and alarmed when pushed open. Then Surveyor and V1 checked the End of hall emergency door (door that was repaired following R4's elopement) V1 pushed on door release and the alarm sounded, however the door would not release. V1 put in the code and door released and did not alarm. V1 stated, The door is supposed to have a 15 second egress. V1 called V13, ( Maintenance) and explained to him what was happening. V1 then stated, (V13) is calling the guy now- this is not good. This Emergency Exit Door has a Door Guardian System and a Magnet Lock. Therefore the door has 2 different keypad panels with separate codes, 2 different locks, and 2 different alarms. At 1:50PM, V1 stated, The service company did not put a 15 second egress on the door, so they are coming back on Monday to fix it. If the fire alarm goes off, the door will automatically release. The Facility Incident Report dated 10/25/20 states, (R4) was reported missing on the evening of 10/25/20. Immediate Action Taken: 1. The resident was found missing by non-facility staff and notified police, 2. Police notified facility at approximately 10:15PM, 3.The resident was determined to have been unauthorized to leave the facility at the time the resident went missing, 4.Resident was taken to the ER by emergency personnel, 5. The resident was reported missing to the treatment nurse who immediately notified the Administrator, 6. A count of all residents in the facility was conducted, No other residents were reported missing, 7. Physician notified, 8. The resident's family was notified, 9. All doors and door alarms checked. Facts Determined by Facility: 1. Facility Protocol regarding missing resident followed, 2. Resident was found by police, 3. Resident was taken to the ER and no new injuries immediately noted. Analysis and Conclusion: 1. Resident admitted to facility from another Skilled Nursing Facility on 10/15/20. Resident's [DIAGNOSES REDACTED]. Resident is oriented to self only due to diagnosis, 2. Resident was redirected by staff several times, 3. Resident's care plan will be updated upon readmission, 4. Resident to be monitored upon readmission by facility staff for any behaviors that can trigger a repeat occurrence, 5. Plan discussed between administrator and family and family is happy with plan. Written statements from V11 and V12 are included with this Incident Report. V11's written statement dated 10/25/20 reads, (R4) was last seen by the nurse around 8:30PM. She was confused, kept talking about leaving. Redirected several times before helping (V12) put 2 other residents down for the night. V12's written statement also dated 10/25/20 reads, Right before 8:30PM (V11) and myself were collaborating on giving patient {care}, considering I'm the only CNA on the unit. Patient was last seen down the hall in front of her room. The unit is a locked unit. I'm not aware of how the patient escaped. On 11/2/20 at 10:00AM V14 (R4's daughter) stated, I got a call from the ER at 11:45PM on 10/25/20. I tried to call the facility all night and no one answered the phone. I was told they don't have a receptionist at night, but they are getting one. I called the facility at 7:40AM and spoke with a nurse on the unit but she didn't know anything about the situation. I finally got a call on 10/26/20 at 11:17AM from V1 and V2. They kept apologizing to me over and over and said that the facility had blown a fuse and that is why the alarm did not go off when my (R4) opened the door and that is how she got out. The ER said she was dressed in jeans, a sweatshirt and tennis shoes and she was carrying a garbage bag with her clothes. They said she had 2 black eyes, a cut on her forehead, a cut on her cheek, 2 skin tears on her arm- one was old because it was bandaged and her knee was swollen. They did a CT because they didn't know if she hit her head and that was negative. They admitted her with a Urinary Tract Infection and she tested positive for COVID-19. They told me her body temperature was low but did not give me a number. They said they had her wrapped up like a burrito and had heat lamps on her. The facility told me that they had a back -up plan so this would not happen again, but I never told them I was happy with their plan. They knew I was mad. The facility did not even know she was gone until the police called them. R4's emergency room Report dated 10/25/20 states, Stated complaint: Fall, Hypothermia. [AGE] year old woman with a history of Dementia brought in by ambulance. She had reportedly eloped from the extended care facility was found outside face down in the cold. Face is bruised, unknown how long she has been there for. Unknown how long she has been missing . This same report shows that R4 arrived at the emergency room at 10:30PM and her rectal temperature was 96.2 degrees Fahrenheit (Equal to 95.2-95.7 degrees Fahrenheit- orally) According to Wunderground.com (Weather Underground) accessed on 11/1/20, the temperature in Naperville, Illinois on 10/25/20 between 8:00PM and 11:00PM ranged from 40-42 degrees Fahrenheit. The Immediate Jeopardy that began on 10/25/20 was removed and on 11/3/20 when the facility took the following actions to remove the immediacy : 1. System to determine if door alarms are functioning properly. Doors on the unit to be checked and signed off twice daily by the facility. Audit initiated on 10/26/20 ( Doors fixed and working appropriately on 11/3/20 at 3:10PM) 2. Staff have been trained and are familiar with identifying resident behaviors showing risk for elopement. Inservice on elopement policy and procedure completed 11/3/20. 3. Detailed and thorough investigation of the event completed 11/3/20 4. Audits will be analyzed through monthly QAPI. All audits will be analyzed and reviewed in the monthly QAPI. This is overseen by the medical director and administrator. Audits will continue for no less than 4 months. QAPI will determine if the audits will continue at that time. Staff will not be allowed to work until education is completed.

Based on interview and record review, the facility failed to ensure that a resident's medication was administered as ordered by the Physician for a resident with [MEDICAL CONDITION] Arthritis. This failure resulted in a severe flare up of pain, swelling, and immobility with admission to the emergency room . This applies to 1 of 3 residents (R1) reviewed for medication administration in the sample of 8. The findings include: On 10/10/19 at 2:56 PM, V4 (Social Service, Hospital) stated that R1 was admitted to the ER (emergency room ) on 10/08/19 at 5:00 PM. V4 stated that it was noted by V6 (ER Physician) that R1's medications were not given at facility. V4 stated that R1 had gone to see V5 (Rheumatologist) at noon earlier that day and per her notes, R1 had a flare up of his RA ([MEDICAL CONDITION] Arthritis) because of R1's medication mismanagement at the facility. V4 stated that V5 then sent R1 to the ER. V5's progress notes included the following: 10/08/19 Acute Visit: (R1) was discharged from (hospital) 9/25/19 after receiving IV (intravenous) steroids and 1/2 [MEDICATION NAME] 1000 mg (milligrams) IV. He was supposed to be on 25 mg weekly [MEDICATION NAME] with 1 mg of folic acid daily, [MEDICATION NAME] 1500 mg bid (twice daily), [MEDICATION NAME] 200 mg bid and [MEDICATION NAME] 40 mg daily. He presents a med (medication) list today that does not include any of this medication. I called and spoke with V2 (Director of Nursing) who confirmed that his (R1's) last dose of [MEDICATION NAME] was 10/6/19 and [MEDICATION NAME] 200 mg this morning. However he is not being given his 40 mg of [MEDICATION NAME] daily or his 1500 mg bid of [MEDICATION NAME], he (V2) states this is because his document is only 5 pages long. When I asked him if he meant that he was missing pages 6 and 7, he said no this document says page 5 of 5, indicating that his particular discharge document was only 5 pages long.(R1) showed up unexpectedly today and unfortunately has severe swelling of multiple joints with inability to move, or do any ADLs (activities of daily living), including transfer easily from his wheelchair. He is crying out in pain at this time. He is having severe flaring of his [MEDICAL CONDITION] arthritis apparently due to some miscommunication about discharge medications. I recommend that he go to the (ER) and receive IV Solu-[MEDICATION NAME]. V6's ER progress notes included the following: 10/8/19 at 5:39 PM History: 46 -year old male with history of [MEDICAL CONDITION] arthritis brought in by (paramedics) from nursing home for acute on chronic pain. Patient apparently was recent hospitalized a few weeks ago. When discharged back . patient's medications not correctly restarted. Patient states the pain is acute on chronic. He complains of diffuse arthralgia pain, his neck, hands, wrists, knees, feet, ankles. He did not know of any fever but did have a fever of 101 (degrees Fahrenheit) here. He states he has been having intermittent left-sided chest pain. Physical Exam: Looks very uncomfortable, moaning and wincing in pain. Patient has decreased range of motion of his upper and lower extremities due to his joint pain. Primarily pain to both wrists which look [MEDICAL CONDITION] also his hands diffusely. Diffuse hand [MEDICAL CONDITION], his knees are tender with some limited range of motion . Both ankles are swollen, right looks slightly worse, or mild lateral [DIAGNOSES REDACTED]. His feet are having diffuse [MEDICAL CONDITION] as well. Psychiatric: He has a normal mood and affect. His behavior is normal. Judgement and thought content normal. V7's (Nurse Practitioner) progress notes included the following: 10/14/2019 at 12:18 PM Patient is a [AGE] year old male who was seen today due to readmission from (hospital) on 10/12/19 after being sent out on 10/8/19 due to increased joint pain and discomfort. Patient was recently readmitted from the hospital on [DATE]. He has been stable since (current) admission. He was supposed to be on [MEDICATION NAME] 40mg daily and [MEDICATION NAME] upon discharge from recent hospitalization but has not been taking these medications resulting in worsening symptoms of his RA On 10/15/19 at 11:35 AM and 12:20 PM, V3 (Assistant Director of Nursing) stated that R1 had a hospital stay from 9/19/19-9/25/19 related to RA flare up and upon readmission to the facility on [DATE], the paramedics dropped off the hospital discharge papers to the reception. V3 stated that the receptionist then scanned the discharge papers. V3 stated that since the papers were scanned out of order, page 4 was missed of total 5 pages for the medication list. V3 stated that [MEDICATION NAME] 1500 mg bid and [MEDICATION NAME] 40 mg daily were listed on page 4 and therefore were not entered into the facility electronic medical records listed under the POS (Physician order [REDACTED]. V3 stated that usually she (V3) or V2 (Director of Nursing) reconcile the admitting medications but did not do so for R1's readmission on 9/25/19. V3 stated that due to this error, R1 did not receive [MEDICATION NAME] (used to treat [MEDICAL CONDITION] arthritis) 1500 mg bid and [MEDICATION NAME] (is a corticosteroid which is used as an anti-[MEDICAL CONDITION] medication) 40 mg daily for treatment of [REDACTED]. On 10/15/19 at 2:55 PM, V2 verified that he failed to check or reconcile the medication list, and stated that there was a mixup of medication discharge paperwork pages from the hospital on re-admission of R1 to the facility (on 9/25/19) and one page was missed. On 10/10/19 at 11:48 AM, V8 (R1's Primary Care Physician) stated that R1 missing medications ([MEDICATION NAME] 1500 mg bid and [MEDICATION NAME] 40 mg daily) was not warranted and can cause a flare up of [MEDICAL CONDITION] Arthritis. R1's discharge medication list from hospital (printed on 9/25/19 4:44 PM) included the following: [MEDICATION NAME] 500 mg tablet, delayed release. Take 3 tablets by mouth 2 (two) times daily. Dose: 1,500 mg. [MEDICATION NAME] Tablet 20 mg tablet. Take 2 tablets by mouth daily. Dose: 40 mg.

Based on observation, interview and record review, the facility failed to ensure a resident had adequate assistance and interventions in place to prevent residents falls. This failure resulted in a resident (R8) sustaining left tibia/fibula [MEDICAL CONDITION] leg from the fall. This applies to two of six (R8 and R284) residents reviewed for falls in the sample of 18. Findings include: 1. R8's face sheet showed R8 was admitted on [DATE] with [DIAGNOSES REDACTED]. R8's progress note written on 1/14/18 at 2:45 PM, showed the following: V4 (nurse) heard a thump noise and R8 was yelling for help. Upon entering the room V4 saw R8 had fallen out of the bed, was on the floor and yelling for help. Further assessment by V4 showed R8 complained of discomfort on the left lower extremity upon range of motion. R8 was placed in bed with lifting equipment, bed bolsters, bed alarm and bed in lowest position was implemented. V4 informed V2 (Director of Nursing), V21 (physician) and family of fall. V21 gave orders for stat X-ray of the left femur and pelvis and a urine analysis. R8's Progress notes on 1/14/18 showed the following sequence of events: 2:45 PM R8 fell out of bed - unwitnessed fall 4:26 PM R8 complained of leg pain 6:26 PM R8 received an X-ray 10:24 PM V26 (nurse) called for results 11:06 PM Results returned classified as suspicious fracture 11:09 PM V26 received orders to send R8 to hospital for further evaluation 12:17 AM R8 transported to hospital via ambulance R8's care plan initiated on 7/13/17 stated Resident requires use of bilateral bed bolsters . The approach stated to assess resident's response to bilateral bed bolsters, equip the resident with a device that monitors attempts to arise and place the bed lower to the floor and surround the bed with a soft mat. R8's care plan initiated on 7/18/17 stated (R8) is at risk for fall . The approach stated to evaluate for bed/chair alarm and to increase staff supervision with intensity based on resident's need. On 01/31/18 at 11:00 AM, V4 (Nurse) stated that he was in the hallway when he heard a thump and R8 was yelling for help. He responded and found R8 on the floor. R8 was not wearing mittens, no bolster was in place and did not have a mat on the floor at the time of the fall. On 2/1/18 at 10:15 AM, V21 (Physician) stated she was sure that the fall caused the fractures to the left legs. R8's progress note on 1/18/18 at 11:20 AM showed R8 was readmitted to the facility from the local hospital with [DIAGNOSES REDACTED]. The policy and procedure titled Fall Management effective 8/12 showed the facility observes the physical and cognitive function of each resident to identify them at risk for falling. A care plan is developed defining those risks and interventions are implemented. 2. According to the Electronic Health Record (EHR), R284 has [DIAGNOSES REDACTED]. The Initial Admission Care Plan dated 01/22/18 showed R284 had [MEDICAL CONDITION] precautions to avoid injury with interventions included to keep the bed in the lowest position. Admission Fall Risk assessment dated [DATE] shows R284 was a high fall risk due to diminished mental status, medications of antihypertensives, anticoagulants and diuretics, and [MEDICAL CONDITION]. A care plan shows R284 needs a total mechanical lift for transfers using two staff members. On 01/29/18 at 9:50 AM R284 was lying in bed leaning to the left side against a padded half side rail. The bed was in a high position approximately 35 inches from the top of the mattress to the floor. R284 was awake with some confusion, and able to answer some simple questions At 12:04 PM R284 remained lying in the bed in the high position. On 01/30/18 at 10:54 AM R284 was in bed awake but not responding to any questions asked, and moving feet back and forth against mattress. R284's bed was not in the lowest position.

Based on observation, interview and record review, the facility failed to implement preventative measures, follow physician's orders for pressure ulcer treatment and failed to provide wound and incontinence care to prevent infection, promote healing and prevent facility acquired pressure sore from worsening. This failure resulted in R1 acquiring a stage 2 pressure ulcer in the facility on the right gluteal cleft which progressed into an unstageable pressure ulcer after nine days of developing a stage 2 pressure ulcer. This applies to 2 of 4 residents (R1 and R5) reviewed for pressure ulcers in the sample of 17. The findings include: 1. R1 is a [AGE] year old resident admitted to the facility on [DATE]. R1's POS (Physician Order Sheet) for the month of March 2016 showed [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) dated [DATE] and December 11, 2015 showed that R1 required extensive to total assistance for bed mobility, transfers, hygiene and incontinence care for bowel and bladder elimination. The MDS also showed that R1 was cognitively intact and was not identified with mood or behavior episodes. The Braden Scale Skin assessment dated [DATE] showed that R1 scored 17 (at risk for pressure sore development). R1's Braden Scale as of December 16, 2015 showed a score of 12 (High Risk). The Wound Summary showed that on October 28, 2015, two weeks after R1 was admitted , R1 developed a stage 2 pressure ulcer on the right gluteal cleft. On November 06, 2015, 9 days after developing a stage 2, this pressure ulcer worsened to an unstageable pressure ulcer. The pressure ulcer was unstageable for long period until January 18, 2016. The pressure ulcer turned into a stage 3 on January 25, 2016. The care plan dated January 12, 2016 showed non specific interventions to address R1's worsened pressure sore. Some interventions included utilizing pressure relieving mattress for pressure relief, assist to turn reposition at least every hour and as needed, treatment as ordered by physician, provide incontinent care including moisture barrier to prevent maceration of skin. The review of R1 ' s POS showed a physician ' s order dated February 10, 2016 to cleanse the wound (right gluteal pressure sore) with saline and pat dry. Apply skin prep and allow to become tacky. Fill wound with collagen alginate and cover with foam dressing. Change daily and PRN (if needed) if loose or soiled. There was also an order dated November 12, 2015 for R1 to be turn and reposition every hour for off loading pressure. On March 06, 2016 at 10:00 A.M., R1 was in bed lying on her back. R1 stated I have pain on my behind, I'm still waiting for the nurse to apply my dressing. I had a very good bed bath last evening, the dressing got wet, (E12, CNA, Certified Nurse Assistant) removed the dressing, and up to now, my dressing was not on. I felt so soaked now, it sting. I also need my diaper changed. It takes a while before my diaper was changed and not always turned as often. I would like to get up but my therapy ran out. At around 10:20 am, E5 (Licensed Practical Nurse) and E9 (CNA) checked R1 ' s skin. R1 was lying on a under inflated pressure relieving mattress, her buttocks/gluteal were not offloaded from pressure. R1 was also noted with a disposable brief and an incontinent cloth pad and a sheet on a low air low mattress. R1 was heavily soaked with urine. The absorbent padding from the brief had turned into a gel like consistency due to heavy saturation of urine. It was also noted that the urine had leaked through the brief onto the incontinent cloth pad. There was no dressing on the pressure sore to the right gluteal cleft. The pressure sore was exposed to the smeared feces and urine. The pressure sore on the right gluteal cleft was approximately an inch or 1.5 inch deep, 1 x1 inch wide and length. There was redness around the sacrum. While providing incontinence care E9 further exposed the pressure sore to fecal material. E5 also did not completely apply skin prep around the wound. Furthermore, E5 did not cover the wound when she applied the alginate dressing and allowed E9 to change the bed linen before covering the wound. E9 stated that she had provided incontinence care and repositioned R1 at 6:30 A.M. on 3/6/2016. E9 also stated that she noted there was no dressing on the right gluteal pressure sore. E9 also added that she did not inform E5 regarding R1 ' s pressure sore not having any dressing. For three and half hour R1 was not repositioned for pressure relief and incontinence care was not provided. On March 07, 2016 at 3:30 P.M., E12 (CNA) stated that she had removed the pressure sore dressing at around 8:30 P.M. on 3/6/2016. E12 also stated that she informed E13 (Nurse on 3/7/2016 evening shift) regarding R1's requiring pressure sore dressing. E12 also added that at 10:30 P.M. that evening, R1 still had no dressing on the pressure sore. E12 added, I guess (E13) was busy. As a result of R1's stage 3 pressure ulcer was exposed to urine and feces for 13 and 1/2 hours that might cause infection of the pressure sore and will not promote healing. R1 was not turned and reposition every hour as observed on 3/6/2016 at 12:50 P.M., 1:00 P.M. and on 3/7/2016 at 11:20 A.M., 12:20 P.M., 2:10 P.M., 3:18 P.M. During this time of observations, R1 was lying on her back, with her sacrum/buttocks and heels not offloaded. On 3/7/2016 at 4:10 P.M., E6 (Wound Care Nurse) stated that R1 should be turned and reposition every hour for offloading of pressure, and R1 should be kept clean and dry from incontinence. E6 also added that there should be no added linen padding on the air mattress such as the incontinent cloth pad since it would defeat the purpose of relieving the pressure. As E6 added, the skin prep should be applied as ordered by the physician since the skin prep would help prevent further skin damage. 2. On 3/06/2016 at 10:30 A.M., E10, (CNA, Certified Nurse Assistant) provided incontinence care to R5. It was noted that R5's sacrum area had some redness. R5 was moderately soaked with urine. After the incontinence care, there was no skin barrier applied. There was also no protective dressing on the sacrum for pressure ulcer prevention. R5's heels were noted with foam dressing with a date label of January 28, 2016. For 5 weeks the same foam dressing was on R5's heels. On 3/7/2016 at 4:00 P.M., together with E8 (License Practical Nurse) and E12 (CNA), R5's heels were checked. R5 has the same foam dressing on her heels with a date label of 1/28/2016. E8 stated that the foam dressing was for pressure ulcer prevention since R5 is a high risk for developing pressure ulcer. The POS for the month of March 2016 showed a physician order dated 1/28/2016 for R5 to have foam dressing on bilateral heels for pressure ulcer prevention. The order also showed to check the heels every shift and change the dressing every week. There was also an order to apply foam dressing on the sacrum for pressure ulcer prevention. As observed on 3/6/2016 during the incontinence care, there was no foam dressing on the sacrum. On 3/7/2016 at 4:10 P.M., E7 and E6 (Wound Care Nurses) had no explanation how come the date label was still 1/28/2016 and how could nurse be checking every shift and had not noticed the date label as to when the dressing was last changed. E6 and E7 also stated that the dressing was labeled with a date to show when the dressing was last changed. The POS also showed that R5 has [DIAGNOSES REDACTED].

br>Based on interview and record review the facility failed to provide safe care to prevent a fall which resulted in a fracture. This applies to R1, one of two residents reviewed for falls in the sample of three. The findings include: According to the MDS (minimum data set) dated 08/03/15 in the medical record R1 requires extensive assistance for bed mobility with 2 plus persons to assist. According to an incident report dated September 18, 2015, R1 was being provided morning care by E1, CNA, (Certified Nurses Aid) without the assistance of another staff member. E1's statement noted while giving R1 a bed bath E1 rolled R1 away from her. R1 rolled out of the bed falling to the floor ending up on her back. R1 complained of right hip pain and was sent to the hospital for further assessment. X-rays completed at the hospital found a fracture through the greater trochanter of the proximal right femur. R1 remains in the hospital where surgical repair of the hip was performed. On September 22, 2015 E2, DON (Director of Nursing) stated R1 should have been assisted by more than one staff member while care was being given. E2 stated E1 was remorseful and knew she was wrong by not asking another staff member to help her with R1's care. E3, ADON (Assistant Director of Nursing) documented in her statement the following, Asked CNA (E1) specifically if anyone else was in the room at the time and she stated No I was by myself. I' m sorry. Z1, attending physician stated on 09/23/15 he was notified by the facility when the incident occurred. Z1 said he is currently seeing R1 at the hospital and was aware R1 had been given morning care by only one staff person when the fall incident occurred. E1 said based on R1's clinical condition and assessments she should have been receiving care by more than one staff member when the fall occurred.

Based on record review, interview and observation the facility failed to provide nursing services by not performing ongoing thorough and accurate pain evaluations of one resident's (R1) continued complaints of pain, failed to follow their own policy and procedure on assessing pain and failed to have a plan of care in place to manage the pain for one of 3 residents for complaints of worsening pain following a fall. The facility also failed to renew an antidepressant for one resident (R1) with a long standing history of depression, upon return from the hospital. These failures contributed to R1 experiencing pain ranging from 3-10 on a scale of 10 for 26 days following a fall from a lift on 10/18/13 and contributed to R1 displaying increased signs and symptoms of depression. The finding includes: A Final (Investigation) Report dated November 18, 2013 states during a mechanical body lift transfer on October 18, 2013 the double straps on the lift tore, resulting in R1 ([AGE] years old) falling to the floor and sustaining a left humeral neck fracture. (Per Minimum (MDS) data set [DATE], R1 weighs 152 pounds.)The report states R1 was noted to have persistent swelling and complaints of pain to the left knee following the fall to the ground on October 18, 2013. The (left) leg, upon initial event of 10/18/13, noted with swelling and foot rotation. On November 15, 2013 R1 underwent surgical repair for an acute left tibial metaphysis fracture with anterior displacement. This report states R1 has extensive history of [MEDICAL CONDITIONS], osteopenia and previous fractures of this area. Also per this report, R1 is receiving a medication "to assist with bone turnover again noting severe risk for fracture." An H & P (history and physical) exam dated 11/13/13 from the hospital states R1 "had a left femur fracture in 10/2012, treated with an intramedullary rod. She went on to have 2 fractures in her left upper extremity a few months ago." This report indicates the facility was aware that R1 was at high risk for fractures. E1 (administrator) stated on 11/16/13 at 10:15 am via phone that the lift straps on the hoyer sling separated. When R1 came back from the hospital on [DATE], she had a fractured humerus and left swollen knee. E1 stated the rotation of the left leg seemed to be increasing and she complained of pain upon transfer in addition to all over body pain. E1 said staff wanted to keep R1 in bed but she wanted to get up. It wasn't until R1 went to the hospital on [DATE] that the fracture to the left leg was diagnosed . E6 (certified nurses aide) stated on 11/16/13 at 12:45pm she (E6) was the one transferring R1 on 10/18/13 when R1 fell from the lift. E6 said R1 was very particular about who could help her but R1 liked E 6 and she (E6) was one of R1's regular cnas. E6 said R1 didn't complain of pain that much before the fall, just in her shoulder sometimes. E6 said after R1 came back from the hospital after the fall on 10/18/13, she (R1) complained of pain to the left leg during transferring. And when R1 was in bed, she complained of pain when being repositioned or turned, R1 said that hurt too. E6 said "the more you moved her as the days went on she had more pain in bed." E6 stated R1's "left leg was swollen and red in the knee area and the calf." E6 said R1 even started to refuse to get up in the morning and that wasn't like her because she loved to be up in her wheelchair for breakfast. Following R1's return from the ER visit after the fall on 10/18/13, there is random documentation in the nurses notes of R1 experiencing increasing pain in the left leg upon movement until 11/13/13, when R1 was discharged to the hospital for further evaluation. The NP (nurse practioner) E3, documented on 10/18/13 after the fall, that R1 had left proximal tibia swelling/tenderness and extreme pain to the left upper and lower extremities. To ER for evaluation. The NP note from 10/21/13 identifies the internal rotation of the left lower extremity and ankle. Nurses notes (NN) 10/18/13: R1 returned from the hospital at 10:45pm. [DIAGNOSES REDACTED]. Leg remains swollen and R1 was medicated for pain. (There was no mention of the left leg having been evaluated.) The NP ordered for an orthopedic appointment. The 10/19/13 NN document complaints of left leg pain, swelling and the left foot turned inward. E5, wound nurse, documernted on the Skin Alteration assessment dated [DATE] that R1 was noted with bruising to (left) foot with [MEDICAL CONDITION]. On 11/16/13 at 12:00pm E3 (assistant director of nurses) provided copies of the xrays taken after R1's fall on 10/18/13 and confirmed the left lower extremity had not been xrayed in the ER. POS dated 10/19/13 orders an xray for increased pain and swelling. E2 provided a portable xray (in the facility at bedside) report taken 11/20/13 stating there is a long intramedullary rod stabilizing an old distal femur fracture. Left total knee replacement. Old deformity to left distal tibia. No new fracture is seen. NN continue to document complaints of pain to the left lower extremity and on 10/20/13 state R1 is moaning when turning and changing diaper. This NN states twice that the pain is upon movement. Nurses note document on 11/5/13 at 3 am, R1 rated her pain at 10/10 when being moved for a dressing change. Review of nurses notes through the end of October and up until November 13, show R1 continues to have increasing complaints of pain. R1's October 2013 MAR (medication administration record) shows R1 had been receiving 1000 mg Tylenol Extra Strength every 12 hours prior to her fall on 10/18/13. On 11/16/13 at 11:45am, E4 (adon) stated R1 was administered this medication for complaints of general body pain from her arthritis and pain to her left arm from a fracture sustained several months ago. This was the only medication for pain R1 was administered prior to the fall on 10/18/13. This MAR shows that R1 had a new order for [MEDICATION NAME] 5/325 one tab by mouth every 6 hours as needed that began on the day of the fall, 10/18/13. Review of R1's October and November MAR and her Controlled Drug Record for the [MEDICATION NAME] shows R1 received the [MEDICATION NAME] at least 29 times between 10/18/13 and 10/31/13 and 33 times from 11/1/13 through 11/13/13, when R1 was a direct admit to the hospital for evaluation of the ongoing pain in the left leg and subsequent surgery. E2 stated 11/20/13 at 10:40am she could not locate the Controlled Drug Record for 10/18/13 through 10/23/13, indicating how many times [MEDICATION NAME] had been signed out for R1 on those days. A facility Pain Evaluation performed on the day R1 was dropped from the lift, 10/18/13, is non-specific to R1's complaints of pain. It consists of 10 generalized categories (such as mental status, communication, etc) and the responses are numeric based with no further instructions or analysis. R1's quarterly pain assessment dated [DATE] is the pain assessment for non-verbal/cognitively impaired residents, neither of which R1 is based on R1's interview of 11/20/13. In addition, the information is incorrect, stating R1's routine pain meds are effective and she (R1) has not had any recent accident that may be causing pain. The facility's Pain Management policy and procedure has not been followed which states to utilize non-verbal pain evaluation on residents who are unable to respond or have a cognitive deficit. When asked for a comprehensive pain assessment that documents and identifies specific risk factors for fractures, location of pain, pain type and characteristics and effects of the pain on activities of daily living, E4 stated the MAR reflects R1's pain level every shift. E4 also stated there is no nursing documentation showing the staff was monitoring the circumference, color, [MEDICAL CONDITION] or inward rotation of the left leg following the incident on 10/18/13. E4 stated R1's pain assessments are the daily levels of pain (scale of 1 -10) found on the MAR and on the back side of the MAR. The reasons documented by nursing on the back of the MARs vary from generalized discomfort to left arm pain with no mention of left leg pain as the reason for pain medication. In addition, not all the instances in which R1 was administered [MEDICATION NAME] are documented on the back of the MAR. In addition to receiving Tylenol 1000 mg twice a day and [MEDICATION NAME] 5/325 one tab by mouth every 6 hours as needed during this time period (10/18/13 - 11/13/13), R1 was prescribed additional Tylenol 500 mg twice a day as needed on 11/1/13 per nurses notes dated same. [MEDICATION NAME] .25 mg at bedtime was prescribed on 10/22/13, per physician order [REDACTED]. R1 went to an ortho appointment on 10/22/13. The report from this consultation dated 10/22/13 shows the physician did not examine the left leg, only the left arm where a fracture to the humerus had been confirmed. There is a statement in this report that R1 has chronic left leg pain, however there was no documentation in the medical record or mention of such obtained during staff and family interviews supporting that R1 had chronic left leg pain prior to the fall on 10/18/13. Following R1's return from this ortho appointment, nurses note on 10/22/13 state R1 is transported via stretcher, "(no) complaints of pain but yells out to movement/transfer." E4 provided R1's entire care plan on 11/16/13 and there was no plan of care identifying interventions or their effectiveness to address R2's pain based on a resident-specific assessment for R1's pain post fall, 10/18/13. The facility's pain policy also directs staff to develop the care plan based on the evaluation regarding pain and pain relief. E4 confirmed on 11/16/13 at 3:10pm there was no such plan of care for R1. R1 had a second bedside portable xray performed on 10/30/13 of the left tibia, fibula and ankle. It states "Examination reveals some soft tissue swelling with some demineralization and arthritic changes and an old fracture deformity of proximal and distal tibia with vascular calcifications. There is revision total knee replacement prosthesis with some flexion deformity of the knee. Clinical correlation is requested." E4 was asked if the clinical correlation had been completed as suggested in this report and E4 provided a progress note done by R1's attending physician (and facility's medical director) dated 11/1/13 does not indicate R1's left leg was examined, only that the xray shows an old fracture. Z1 (R1's orthopedic surgeon) stated on 11/21/13 at 5:35pm that he (Z1) would have sent R1 back to the ER for evaluation for complaints of the on-going pain even though the portable xrays were negative. Z1 stated portable xays are not as good as the ones in the hospital and the people taking the xrays are usually not as skilled as the technicians in the hospital. Z1 said R1's left leg was swollen and contracted and that clinical assessment based on a portable xray would be difficult due to R1's underlying contractures. Z1 stated there was a screw navigating from a previous surgery that was in the knee. Z1 said the fracture could have started as a stress fracture when R1 was dropped and that the contractures, [MEDICAL CONDITION] and fall all worked together to cause the fracture. Z3 (family member ) stated on 11/21/13 at 7:30pm he saw R1 the day after the fall, 10/19/13, and noticed her left leg was pointed inward at about a 45 degree angle. Z3 said "I tried to get her to move it and she no, it's sore." Z3 said that several days later, maybe about a week, R1 complained of throbbing and burning pain to the left lower leg. Staff thought it might be a blood clot but the test was negative. All the while her foot was turned inward. Z3 said she was in a lot of pain when being transferred saying, 'Ow ow, it hurts." Z3 said that when Z2 (POA and family member) arrived (11/8/13) they both began asking staff including E2, why R1's foot was turned so far inward. Z3 said R1 couldn't straighten her leg because of contractures. Z3 said he and Z2 wondered how the facility could have gotten an accurate xray because R1 could not have been positioned well. Z3 said all the facility kept doing was to give her more pain medication until we (Z2 and Z3) finally insisted she (R1) be sent back to the hospital for more evaluation. Z2 (POA and family member) stated on 11/20/13 at 10:10am R1 began complaining of pain to her left leg immediately after the fall on 10/18/13 over the phone. (Z2 lives out of state.) Z2 stated she was on the phone multiple times with E2 from 10/19/13 until she arrived 11/8/13, telling E2 about R1's continued complaints of pain to the left leg. Z2 stated R1's left leg and foot were huge when she saw it on 11/8/13. Z2 said she told the NP (E3) over the phone starting a day or two after the fall that R1 does not stop complaining of pain to the left leg. Z2 said she (Z2) watched staff transfer R1 to bed (upon arrival on 11/8/13) and every inch they moved her, R1 would cringe and cry, Z2 couldn't even watch. "It was incredible pain for her," said Z2. Z2 stated she sat in on R1's care plan conference on 11/12/13 and insisted R1 go to the hospital, that this level of pain is not normal. "I asked them why are we still monitoring the pain, there is something wrong." Z2 was told there would be a palliative care evaluation and that a [MEDICATION NAME] for pain was going to be tried. Z2 stated on 11/12/13 she insisted to E2 that R1 be sent to the ER and E2 talked her into waiting until the next day, 11/13/13, until after the hospice or palliative evaluation. A hospice provider assessment dated [DATE] states R1 fell [DATE] "and after fall left leg has been causing (R1) pain. (R1) describes pain as burning over the entire leg and she rates pain a 5-7/10 on the numeric scale. (R1) states pain comes and goes and hurts more with movement of extremity. On [MEDICATION NAME] 5/325mg. Per (R1) [MEDICATION NAME] not helping with pain control. Radiology reports of left leg negative to date and time. Being sent to hospital this afternoon for further evaluation of LLE (left lower extremity)." On November 15, 2013 R1 underwent surgical repair for an acute left tibial metaphysis fracture with anterior displacement. On November 20, 2013 at 4:35 pm R1 was observed in the hospital to be lying in bed. R1 was lying on her right side with her left leg contracted at a right angle. R1 stated she is unable to straighten her leg any further and that it's been like that for years. R1 began to cry stating that it took the staff at the facility "more than 3 weeks to figure out which bone in my leg was broke. My leg and foot were so swollen. It was such horrible pain when I moved. I couldn't sleep for more than 1 or 2 hours at a time. It kept getting worse and worse. I wanted to stay in bed and they made me get up." R1's Medical Administration Record (MAR) for February 1 - 8 th (date of discharge to hospital) 2013 shows R1 had been receiving [MEDICATION NAME] 30 mg at bedtime while in the facility. Review of MAR for Feb. 14, 2013 (date of readmission) shows R1's [MEDICATION NAME] was not renewed upon return from the hospital. E4 stated on 11/16/13 at 2:50pm R1's [MEDICATION NAME] was renewed on 6/4/13, 3 1/2 months after readmission from the hospital. E4 did not reply when asked why the medication was not prescribed upon readmission from the hospital on [DATE]. E2 provided a typed statement dated 12/3/13 noting that R1 has a long history of being on antidepressants and that upon return from the hospital, R1's physician (and facility medical director), Z4, discontinued the antidepressant when in the hospital for abdominal surgery. When asked for documentation as to why Z4 felt R1 no longer needed the medication upon readmission, E2 stated there is no such documentation, only the medication was not prescribed upon readmission on 2/14/13. A geriatric psych consult dated 6/28/13 states that R1 "appears flat, sad looking, causually groomed and tense. Her speech is monotonal. ... Demeanor is sad. Body posture and attitude convey an underlying depressed mood. Slowness of physical movement helps reveal depressed mood." Diagnosis: [REDACTED]. E2 stated on 12/4/13 at 12:10pm she could not locate any previous psychiatric evals prior to R's hospitalization on [DATE]-[DATE]. Social Service note dated 2/28/13 states R1 "voiced out feeling tired and trouble sleeping at times" displays...mild depressive symptoms. Social service note dated 5/23/13 states R1 has sad affect at times and voices little energy and trouble sleeping at times. Identified mild depressive symptoms. Z2 stated on 11/20/13 at 10:10am that R1 has had a long history of depression and has been on antidepressants for years. Z2 said she (Z2) began suspecting R1 was becoming depressed in March and it seemed to be getting worse. May and June were very hard for R1 said Z2, R1 was very weepy and not engaging in her usual daily patterns. That's when Z2 began asking about R1's antidepressant and was told R1 had not been receiving it. Physician telephone order shows that [MEDICATION NAME] 10 mg every day was ordered for R1 on 6/4/13 and then increased to 20mg every day on 6/14/13. E2 stated on 12/5/13 that R1's [MEDICATION NAME] had been discontinued while in the hospital for abdominal surgery in February 2013 and was not renewed until June 4, 2013. E2 gave no expalnation given as to why the antidepressant was not renewed until 3 1/2 months later other than the physician did not reorder it.

Based on observation, interview and record review, the facility failed to identify the correct (a) location (sacrum versus coccyx) and (b) Stage (Stage III from Unstageable) of R 12 ' s pressure ulcers. The facility also failed to analyze R 12's tissue tolerance in order to develop and implement a more specific repositioning plan to promote healing , to stabilize or reduce R 12's underlying risk factors and co morbidities. The facility failed to evaluate and revise R 12 ' s care plan based on the identified needs and outcome. This applies to one (R 12) of two residents reviewed for pressure ulcer in the sample of 24. These failures resulted in the decline of R 12's pressure ulcers on her (1) coccyx from Stage III to Unstageable and (2) R 12's right hip from a Deep Tissue Injury to Unstageable pressure ulcer. Findings include: On 03-27-13 at 1:00 PM, R 12 was observed during [MEDICAL TREATMENT] treatment sleeping. The [MEDICAL TREATMENT] staff identified R 12 as alert and oriented X 3 (with no cognitive problem), able to verbalize needs and needing the assistance of two during transfer using a mechanical lift. The staff stated, " We reposition her if she asks. She can verbalize her needs. " Review of the pressure ulcer report listed R 12 with three pressure ulcers (1) coccyx (2) right hip and (3) right medial toe. On 03-28-13 at 3:00 PM, R 12 said, " The sores started in the hospital but it didn't help here neither. It's healing too slowly and they (staff) can't heal the one in my behind. " The Administrative Staff (Director of Nursing/E 2 and the Nurse Consultant/E 1) claimed R 12 has multiple pressure ulcers when she was re- admitted in the facility (from the hospital on 03-09-13). E 1 and E 2 were unable to identify which admitted s did R 12's pressure ulcers were initially noted. The most recent re- admission resident -data collection (re admission form) dated 03-09-13, under skin condition section showed the following instructions: Using the diagram provided, indicate all body marks such as old/recent scars (surgical and other), bruises, discolorations, abrasions, pressure ulcers or questionable markings. Indicate size depth (in cms (sic)), color and drainage. These instructions were not followed. The diagram showed a line drawn pointing at R 12's sacral and abdominal area,. the left shin and a perma cath on the right chest. Comments reads: sacral wound Stage III, abdominal folds fungal infection, buttocks, left shin wound and right groin -hematoma. There was no other documentation found in R 12's clinical record or presented by the facility to show a thorough assessment was conducted until 03-11-13. There was no record/documentation the wounds or other skin alterations were measured including a description of each upon admission. These findings were discussed with the Administrative staff (E 2 and E 3) on 03-28-13 at 4:10 PM. On 03-28-13 at 1:30 PM, skin assessment was conducted with the Treatment Nurse (E 3). E 3 claimed R 12 has multiple pressure ulcers but all developed from the hospital. E 3 identified and describes the following pressure ulcers: (1) Coccyx - measured at 2.1 cm X 1.4 cm x 0.6 cm with 1.0 cm undermining at 12 o ' clock and 1.0 cm at 3 o ' clock. E 3 stated " with 100% yellow slough, this is a Stage III. " This pressure ulcer was incorrectly staged. The National Pressure Ulcer Advisory Panel (NPUAP) reads: Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined ... The re- admission (resident-data collection) form dated 03-09-13 showed no skin alteration on R 12 ' s coccyx. Based on the initial assessment conducted on 03-11-13 (the nurses progress notes skin alteration assessments) this pressure ulcer on R 12 ' s coccyx (initially identified as sacrum) progressed in size (from 2.4 cm X 1.7 cm X 0.9 cm, undermining at 3:00 1cm to 12:00 0.5 cm) and is now an unstageable pressure ulcer (from Stage III) measured at 2.1 cm X 1.4 cm x 0.6 cm with 1.0 cm undermining at 12 o ' clock and 1.0 cm at 3:00. . On 03-29-13 at 11:06 AM, E 1 stated " the Treatment Nurse called the wound doctor and upgraded the wound to Stage IV and also order a change in treatment. " (2) Right Hip - measured at 1.0 cm X 1.5 cm. E 3 stated " it ' s covered with yellow slough, this is unstageable. " The re- admission (resident-data collection) form dated 03-09-13 showed no skin alteration on R 12 ' s right hip (upon admission). The initial assessment conducted on 03-09-13 (the nurses progress notes skin alteration assessments) this pressure ulcer on R 12's Right hip was identified as a Deep Tissue Injury and now identified as Unstageable pressure ulcer. R 12's pressure ulcer care plan for a deep tissue injury located on the right hip showed that this " problem starts on 03-18-13. " R 12 was re admitted in the facility on 03-09-13. E 1, E 2 and E 3 on several days of the survey were unable to present a comprehensive assessment to show the facility analyzes and address R 12's risk factors and co morbidities. Review of R 12 ' s Pressure ulcer Care Area Assessment (#16) was blank. The Minimum Data Set Coordinator (E 5) stated on 03-29-13 at 11:45 AM, E 5 confirmed the finding and stated " Yes, there's nothing in there (blank). They should have done one for her because she has a pressure ulcer. " R 12's coccyx care plan was not individualized and based on R 12's needs. The interventions were developed since 12-24-12. No revision was done and no repositioning plan developed. On 03-29-13 at 10:40 AM, E 1 and E 2 confirmed that they had not assessed R 12 for tissue tolerance test. E 1, E 2 and E 3 on several days of the survey were unable to present a comprehensive assessment to show the facility analyzes and address R 12's risk factors and co morbidities. Review of R 12 ' s Pressure ulcer Care Area Assessment (#16) was blank. The Minimum Data Set Coordinator (E 5) stated on 03-29-13 at 11:45 AM, E 5 confirmed the finding and stated " Yes, there's nothing in there (blank). They should have done one for her because she has a pressure ulcer. " R 12 ' s coccyx care plan was not individualized and base on R 12's needs. The interventions were developed since 12-24-12. No revision was done and no repositioning plan developed. On 03-29-13 at 10:40 AM, E 1 and E 2 confirmed they had not assessed R 12 for tissue tolerance test.

Based on observation, interview and record review, the facility failed to provide a more dignified manner of assisting one of one sampled resident (R 12) during toileting needs in the sample of 24 This failure resulted in mental and psychosocial distress to R 12. R 12 claimed, " it's humiliating, demeaning and depressing " to have a bowel movement while in bed and on side lying position. Findings include: On 03-28-13 at 12:50 PM, R 12 was observed sitting on her wheelchair alone in the unit -dining room. R 12 was identified by staff as alert and oriented, can verbalize needs and transfer via a mechanical lift with two person assistance. At 1:00 PM, R 12 was taken to her room for dressing change, R 12 told the staff " I want to do #2 (bowel movement). " R 12 was observed transferred from her wheelchair to bed using a total mechanical lift. She was turned on her left side and was told by the two CNAs, " Let us know when you ' re done. " At 3:00 PM, R 12 stated, " That's one of my problems here., They get up so early, dress me up right away and if I had to have # 2 (BM) they even hurry you up. It's demeaning and very humiliating to do #2 while in bed. It is very hard to do that (do # 2 while in bed." On 03-28-13 at 10:25 AM, R 12 claimed, " They make me do # 2 while in bed. They don' t take me to the bathroom: If I wanted to use the bathroom they put me back to bed. They lie me down and turn me on the side. I have diaper on so they told me to just do it in my diaper. It is embarrassing. At the beginning it's very hard on me. I can't do it specially doing it while you're side lying? They said I can't use the toilet because of my sore in my tail bone. I'm telling you it's depressing and humiliating. It's very hard but what could I do? " On 03-29-13 at 2:25 PM, the Director of Nursing (E 2) and the Nurse Consultant (E1) was notified about R 12's statement and concern: E 2 stated, " She's a mechanical lift transfer. We put a disposable pad underneath her. " When the Administrative staff (E1 and E 2) were asked if there was a Physical Therapy referral done to evaluate appropriate system to assist R12 in her toileting needs, E 2 stated, " No, there were no referrals done and no, we didn't evaluate her for other alternatives. " On 03-29-13 at 10:30 AM, the Physical Therapy Aide (E 21) was informed about these findings (the assigned Physical Therapy person was on vacation at this time), E 21 stated she would discuss this information with the other Rehab staff and will evaluate R 12. At 1:25 PM, the Physical Therapy person stated, " We evaluated her and prescribed a bariatric bed pan for her. I think this would be better for her because it' softer for her back and more flexible. "

Based on observation, record review and interview the facility failed to ensure, E6 the Certified Nurse Aide (CNA) used gait belt and bed was locked and secured when transferring R16 to prevent him from falling. this is for one sampled resident (R16) in the sample of 24. Findings include: The facility documented an incident on [DATE] at 7:15 am indicating R16 was found his 'buttocks on floor, back up against wheel chair foot rest.' It is noted in the incident report 'R16 stated he is non-compliant with safety practices, transferring himself from the bed to the wheel chair and he slipped.' On [DATE] at 10:45 am E6 assisted R16 from his wheel chair to toilet without using a gait belt. R16 has unsteady gait. After R16 was done using toilet E6 transferred him to wheel chair brought him to his bed side to transfer him to his bed. As E6 transferred R16 from wheel chair to bed, the bed slid and it stopped only because his room mate's bed blocked his bed from sliding farther that prevented him from falling. E6 stated she should have used gait belt and did not know why his bed was not locked. The investigation of R16's [DATE] 7:15 am incident of falling did not rule out if the unlocked bed contributed for his falling. Based on record review and interview the facility failed to supervise and develop an individualize plan of care to address one of one supplemental sampled resident( R 26) who was known to sit up while sleeping These failures resulted in R 26 being found on the floor unresponsive and expired. Findings include: Review of nursing note dated [DATE] states at 3:00am, 2 nurse's aides came to nurse (E19) and reported R26 was found on the floor, vitals not detectable including respiration or blood pressure and pupils were dilated. There was blood noted from the right ear. Review of most recent quarterly Minimum Data Set ((MDS) dated [DATE] shows R26 is [AGE] years old with [DIAGNOSES REDACTED]. R26 has been a resident at the facility for 7.5 years. This MDS shows R26's cognition is severely impaired and requires extensive physical assist with activities of daily living. The MDS also states R26 has not had any falls which is incorrect as review of 2 incident reports dated [DATE] and [DATE] shows R26 was found on the floor next to her bed. Several direct care staff stated in interviews on [DATE] at 2:30pm (in person, E25 and E26, nurse's aides) and [DATE] (via phone, E19 at 9:30am, E2 at 1:50pm, nurses) R26 would sleep sitting up in bed without the aid if the head of the bed being raised. E25 and E26 stated that staff would try to lay R26 down but she would just sit up again. E25 and E26 also stated R26 could stand up on own and would attempt to do so from bed or chair occasionally. E25 stated R26 could walk a little but only with hands on assistance of one person and was at risk for falls. E2 stated on [DATE] at 2:00pm that R26 had fallen out of bed before. E2 (dir of nursing) stated on [DATE] at 2:50pm R26 did exhibit this behavior of sitting up while sleeping. At 3:20pm, E2 confirmed this behavior had not been care planned for and no assessments had been conducted for appropriate devices to be utilized in bed to prevent injury related to this behavior. E2 also stated no incident report or investigation had been completed to assist in analyzing the circumstances surrounding R26's incident and subsequent death. Interview with E22 (nurse's aide) stated on [DATE] at 1:50pm she was the person who discovered R26 on the floor at around 3:00am. E22 also said R26's alarm was on the bed but was not alarming when she (E22) walked into the room. E22 stated R26 was observed face down with her bottom in the air, lying on the floor mat. R26 had blood coming from her ear and a small amount dripped onto her neck. E22 notified the nurse immediately who called for the charge nurse on 1st floor to come assist. E22 stated the nurses were unable to obtain vital signs and determined R26 was unresponsive. E22 stated 4 staff assisted in rolling R26 onto a bed sheet and placed her back into bed. E22 and 2 other aides cleaned up R26. E22 also said that the staff would get R26 up last in the morning because she would fall forward in the chair because she was so sleepy. When sitting at a table, staff would place something soft in front of R26 so she would not hit her head on the table due to her jerky movements. E 23 (nurse)stated on [DATE] at 11:40am she was called and told R26 had passed away was asked to come to the 2nd floor to assist on [DATE] at around 3:00am. E23 said R26 was lying on her left side in a semi-fetal position and her color was pale, not normal color. E23 assessed R26 for vitals signs and found none. R26 was placed back in bed using a sheet. E23 said that afterwards, she spoke to E2 (director of nursing) by phone and was told to call the family and tell them R26 passed away. E23 stated she told the family R26 had been found unresponsive during rounds and did not tell the family R26 had been found on the floor. Based on observation, interview and record review, the facility failed to supervise: (1) R 21 with known history of verbal and physical aggression towards other residents, (2) R 14 who was identified with dementia with behavioral disturbance, (3) R20 who was identified roaming in and out of other resident's rooms and lying on the beds. This is for four sampled residents R8,R14,R20 and R21 and one supplemental sampled resident R25 in the sample of 24 This resulted in multiple physical altercations involving R21, R8, R14 and R25 and R14 sustaining dark blue discoloration and swelling of her 4th and 5th fingers. Review of final report of resident to resident altercation dated [DATE] shows R21 (age 89) and R8 (age 87) were sitting in front of the nursing station when R21 propelled herself over to R8 and hit R8 on the hand unexpectedly and without provocation. R8 responded by slapping R21 on the face. The facility concluded both residents are confused and unable to effectively communicate with each other. This incident is noted on R21's care plan and states it was witnessed by staff. A second care plan dated [DATE] states R21 had an unwitnessed episode of hitting another resident that was reported by a peer. It is unclear if there was a second incident involving R21 or if this was inaccurately care planned. On [DATE] in the 2nd floor dining room at 12:20pm, R21 displayed verbal and physical aggression toward a surveyor after R21 observed the surveyor in a conversation with another resident. R21 picked up a utensil from the table and attempted to approach the surveyor while in her wheelchair but was unable to do so because the wheelchair was locked. Several minutes later, R21 became very agitated and pushed the items off the table and onto the floor, including a cup of coffee. Review of Behavior section of most recent full Minimum (MDS) data set [DATE] shows assessment of R21 ' s behavioral symptoms : Put R21 at significant risk for physical injury. Significantly interfere with R21 ' s care. Significantly interfere with R21 ' s participation in activities or social interactions. R21 ' s behavioral symptoms have an impact on others by: Putting others at significant risk for physical injury. Significantly intruding on the privacy or activity of others and disrupting the care or living environment. The results of this Minimum Data Set behavioral assessment indicates R21 is at risk for abuse. Review of incident summary dated [DATE] states that R14 is [AGE] years old with impaired cognition including impaired memory, comprehension and problem solving skills. R14 ' s medical history includes dementia with behavioral disturbance and anxiety. R 14 demonstrates impulsive behavior and hoards items. On [DATE] at 10:00am, R14 was noted to have dark blue discoloration and swelling of her 4th and 5th fingers. R14 was seen by the physician who ordered an Xray of the right hand. The report stated that the bruising and swelling was most likely due to impulsive behavior and accidentally bumping self on surface given that she exhibits anxiety tremors and is on Coumadin therapy. The summary concludes by stating R14 " Remains at risk for skin alteration due to risk factors and co morbidities. " Review of a prior incident report involving R14 and dated [DATE] shows on [DATE] at 7:50am, E19 (nurse) heard R14 screaming and asking for help. E19 checked immediately. E19 saw R25 and R14 fighting. R14 told E19 that R25 'hit me in the head and it hurts. He doesn't like me. Let him stay away from me.' After the incident, R14 complained of headache and noted pain at ,[DATE]. Review of the Final Report submitted to IDPH states there were no witnesses to this altercation and concludes the incident is related to both parties being confused and not being able to effectively communicate with one another. This is in contradiction to what the nurse documented on the Incident report stating she witnessed the 2 fighting. Also, review of R25's incident report shows R25 concedes he did strike R14 because she was taking something from him. In the summary portion of R14's incident report it states staff are to closely monitor and limit interaction between these two residents. However, this report states that during this investigation period, (on [DATE], 1 day after physical altercation) "it was noted that (R25) threw a cup of water on (R14) the day after the initial incident. It was noted (R14) continues to repeat the statement "he hit me" frequently throughout the day and evening, even though (R25) was not near her or even in the same area." Review of care plan dated [DATE] states that R14 " Has observed and perceived conflict with peers. (R14) perceives conflict with one particular male peer. Episodes of alleged physical altercation. Unwitnessed/not observed. No injuries noted. Verbal conflict observed and ongoing. (R14) is very persistent on this conflict. " On [DATE] at 10:40am, E2 confirmed abuse was not ruled out as a possible factor into the [DATE] incident to R14 and that no further interventions have been put into place to assist R14 in feeling safe. During the resident group meeting on [DATE] at 10:30am, 6 of the 8 residents in attendance voiced complaints of R20 roaming in and out of their rooms and responding with verbal aggression when asked to leave the rooms she does not belong in. Two of the residents stated they were concerned that R20 may get hurt by other residents due to wandering in and out of resident rooms and lying on the beds. Other residents are irritated by R20 ' s behaviors. These residents stated staff had moved R20 to the end of the hall, making it more difficult for staff to watch her. Review of most recent care plan dated [DATE], 3rd day of survey, (no prior care plan addressed this issue) states R20 is exhibiting a new behavior of wandering into other resident rooms and is in an adjustment period after a room change. The CAA dated [DATE] (care area assessment) states R20 has severely impaired cognitive deficits. R20 was moved from room 128 to room 123 (which is further away from the nursing station and at the end of the hall.) E2 (director of nursing) stated on [DATE] at 10:40am that she is unaware of the facility performing assessments to assist in identifying residents at risk for abusive behavior. E2 stated she would talk to the social service department to see if they did such assessments. None was provided by end of survey on [DATE].

Based on interview, record review and observation facility failed to monitor/supervise a newly admitted resident (R2) with a tracheostomy tube (trach), who was exhibiting anxious, agitated and restless behaviors. The facility failed to have trained staff and emergency tracheostomy care equipment readily accessible when (R2) removed her tracheostomy tube. These failures resulted in R2 requiring emergency hospitalization to reinsert the tracheostomy tube. This applies to 1 of 3 residents (R2) reviewed for tracheotomy tube care in the sample of 3. The findings include: R2's Nursing notes dated 1/21/13 5PM, show R2 was admitted to first floor medicare unit, alert and oriented and responsive, denies pain or discomfort. R2 was hallucinating and seeing people in her room, a bed and chair alarm were attached. On 1/21/13 at 5:30PM, R2 was noted to have severe anxiety attacks screaming and verbally aggressive to staff. R2's physician (Z4), was called and ordered new anti-anxiety medications. On 1/21/13 physician orders [REDACTED]. On 1/21/13 medication administration record (MAR), documents that R2 was administered Seroquel 12.5mg at 5PM and again at 9PM. On 1/21/13 at 9PM, R2 Nurses Notes document R2 was restless and a PRN medication was given. (R2's 1/21/13 MAR and nurses notes do not include documentation that a PRN was given for restlessness and the result of PRN administered). Nurses note continues to include "Resident noted to be a little restless". Resident noted to be anxious again after supper, she was assisted to bathroom, Certified Nurse Aide stated she left resident for 5 seconds to get the gown and saw patient with trach pulled out on her return. Z4 notified and ordered to send R2 to the hospital for evaluation. R2's transfer form to hospital includes "Resident pulled out trach and Z4 ordered to send to emergency room ", the form also documented R2 was at risk for falls. R2's 1/21/13 hospital emergency room report documents that R2 arrived in the emergency room at 9:45 PM. R2 accidentally pulled out her trach at 7PM tonight while pulling her shirt off. At 12:00AM Z5 (emergency room physician), attempted to reinsert the tracheostomy with respiratory therapy at the bedside, with moderate difficulty. At 12:20AM a #4.0 un-cuffed tracheostomy tube was placed and secured with trach ties by Z5. On 1/21/13 at 1:30AM, R2's nurses note document that R2 returned from hospital by ambulance. R2 was alert, verbally responsive with trach intact, size 4.0 with slight bleeding and appears tired wanting to go to sleep. On 2/15/13 at 11:00AM, E1 said that on 01/21/13 R2 was admitted to first floor , Medicare unit. R2 was agitated, restless, required one on one supervision by nursing staff. R2 was disruptive, setting off her chair alarm frequently and upsetting other first floor residents. Within two hours of admission, R2 was transferred from first floor to the second floor long term care unit. Shortly after transfer to second floor a nurse aide (E14), took R2 to the bathroom and left the resident alone on the toilet. E14 left R2 alone while E14 went to get some supplies. When E14 returned to the bathroom, R2 was observed with her trach tube extubated and resting in R2's hand. 911 was not called, we called physician and transferred R2 to hospital by ambulance. During a 02/15/13 1:00PM phone interview, E14 said the following; 01/21/13 was the first time she had ever worked with R2. At approximately 7PM, R2 was taken to the bathroom per R2's request. R2's gown was wet, so E14 left R2 in the bathroom, went out into the hall to get a clean gown from linen cart in the hallway. Upon return to bathroom R2 was observed with her trach tube in her hand. E14 immediately notified E10 (nurse), whom notified E9 (nurse). On 2/15/13 at 2PM, E10 said that E14 came to her with R2's trach saying that R2 pulled it out. E10 called E1 and Z4. E10 said there was no emergency equipment at R2's bedside. All extra trach's are kept in the supply room. E10 also said she was not familiar with care of trach's and all the different types of trach tubes. E10 said R2 was the first trach patient she had cared for since working at facility. E10 also said if a residents trach came out she would not re-insert one and E10 did not know if the registered nurses in facility would re-insert a new trach either. On 2/15/13 at 2:10 PM, E9 said that on 01/21/13 evening shift, E10 called for assistance with R2. R2 had pulled out her trach tube. E9 said Respiratory therapy sets up bedside trach supplies. All extra trach's are kept in the clean utility room. E9 said he did not know what emergency supplies for trach patients should be at the bedside. E9 said since date of hire in September 2012, he had not taken care of any residents with trach's. On 2/15/13 at 12:13PM, observation of the second floor clean utility room showed there were no bedside trach supply set-ups. Surveyor observed boxes of different sized trachs in bulk boxes, suction catheter kits in another box, suction machines on a cabinet behind a cart. The facilities 01/21/13 staffing schedule documents E9 and E10 were the second floor nurses on the 2:30PM - 10:30PM shift. On 2/19/13 at 10:05AM, E1 said E13 (Respiratory therapist), works one day a week at the facility on Thursdays and Z2 (Pulmonologist), also comes to facility on Thursdays. E1 also said the facility has a nurse practioner on staff Monday through Friday from 8:30AM to 5PM. R2's trach was extubated at 7PM on a Monday (1/21/13). E1 said that as of 2/18/13 the facility has one nurse on day shift (6:30AM-2:30PM) and one nurse on night shift (10:30PM-6:30AM), that are trained on re-inserting trachs. E1 said that facility currently has no one on PM shift (2:30PM-10:30PM), that is trained in re-inserting trachs. On 2/19/13 at 1:25PM, during a telephone interview, Z2 (R2's Pulmonologist), said the nurses at facility are not trained on re-inserting trach tubes in residents. This is why R2 required emergency room treatment 01/21/13. The 1/24/13 Pulmonologist progress note documents, R2 has failed nocturnal capping of her trach tube due to Hypercapnia. Needs #4 un-cuffed trach tubes, history of Aspiration Pneumonia, continue un-capped trach with humidification at night. The respiratory therapist initial evaluation dated 1/22/13 documents R2's trach was initially inserted 12/20/12. History of OSA (obstructive sleep apnea), Hypercarbic, Respiratory failure, diaphragmatic dysfunction. Facilities Tracheostomy Care policy and procedure includes : a sterile tracheostomy tube of the same size shall be readily available at the bedside. An obturator of the same size, suction equipment and supplies shall be maintained at the patients bedside at all times for emergency use.

Based on observation, interview and record review the facility failed to accurately and thoroughly assess 4 residents (R23, 41, 47 and 43) outside the sample and for 1 resident inside the sample (R19) of 21 residents having urinary incontinence. The facility also failed to develop and implement a bowel and bladder policy and procedure. This failure resulted in R23 expressing feelings of psychosocial and emotional distress as result of being told she cannot use the toilet and must void in her diaper sating she feels humiliated ans embarrassed about being told to void in her diaper. These failures also has the potential to affect all incontinent residents in the facility. Findings include: Review of 672 Resident Census and Condition shows that the facility has 56 residents who are occasionally or frequently incontinent of bladder and 49 residents who are occasionally or frequently incontinent of bowel. The 672 states that of the 56, 21 are on individual bladder training programs, and of the 21, 10 are on individual bowel training programs. When asked for the list of residents on a bowel and bladder program, E2 (director of nursing) provided a list dated [DATE] with 13 resident names. This is inconsistent with the 31 residents listed on the 672 as being in a program. E1 and E2 were asked on [DATE] at 10:55 am if the numbers needed to be revised and both declined, stating that E19 (restorative nurse) would explain the program and its number of participants. All B & B (bladder and bowel) assessments for the 31 residents listed in the program were requested on [DATE] and E19 (restorative nurse) presented 5 of the 31 on [DATE] stating she didn ' t have time to obtain the remaining 26 assessments. When asked to describe the facility ' s toileting program for the residents identified as being on individual toileting programs on the 672, E19 described a prompted toileting program in which involves toileting/prompting residents upon waking, before and after meals, before bed and as needed. This is not an individualized bladder training program. Review of care plans of residents on toileting programs show the facility has not developed individualized goals or implemented specific plans/interventions in order to prevent or minimize decline. Examples follow. Per E19 and review of incontinence assessments, the facility has not identified whether the causes of resident's incontinence are reversible or irreversible. R23 was observed to be sitting in a wheelchair in the second floor dining room on [DATE] at 9:40am. R2 stated she was having pain in her lower back and buttocks and needed to go to the bathroom. R23 stated she had not been to the bathroom since she was toileted upon rising this morning, a little before 7:00am. E15 (nurse's aide) stated on [DATE] at 9:55am R23 knows when she has to go to the bathroom and R23 is transferred onto the toilet via a sit-to-stand lift. E25 (nurse) assisted E15 in utilizing the lift and placing R23 onto the toilet in her bathroom. R23 was observed to have urine soaked through her diaper, onto her pants when lifted out of the wheelchair. Following concerns to facility regarding a lack of reassessment after an incident in which R23 was " lowered to the floor " while utilizing the sit-to-stand lift in [DATE], E2 (director of nursing) stated on [DATE] at 1:25pm that R23 had been reassessed and will now be transferred using a total body mechanical lift. Confidential interviews with direct care staff on [DATE] and [DATE] stated that R23 "absolutely knows when she has to go to the bathroom-she is alert enough to know." "She always tells us when she has to go." Now that R23 is a hoyer lift, "we can't get the hoyer lift into the bathroom." One direct care staff stated "I told her she has to go in her diaper now. She never poops in her diaper, she was so upset. We don't know how to address her when she says she has to go. That is taking away her dignity." R23 stated on [DATE] at 2:34pm that staff is telling her she has to go to the bathroom in her diaper and it makes her feel "humiliated and embarrassed." R23 said "I'm used to going to the toilet when I have to go." Review of medical record shows that R23 is [AGE] years old with [DIAGNOSES REDACTED]. Review of most recent Activities of Daily Living (ADL) Functional/Restorative Assessment and Progress dated [DATE] and provided upon request by facility states that R23 is oriented x2, requires one to two assist for transfers, is incontinent of bladder and continent of bowel and uses a bedpan for toileting. Most recent bladder and bowel assessment dated [DATE] contains contradictory information stating R23 is incontinent of urine, has the ability to go to the toilet and is aware when she is wet. R23 is identified to have functional incontinence in this assessment and concludes that R23 is poorly motivated to participate in the toileting program and therefore will not be in such a program. It is unclear what is meant by " poor motivation " as there is no documentation in the medical record supporting this statement and is contrary to what was observed by R23 requesting to be toileted during the survey. It is not supported by multiple staff interviews stating R23 knows when and asks to be toileted. The final section of this assessment is checked for R23 as requiring "dependent care: Resident is unable to be toileted. Care is focused on keeping resident clean and dry." R23's toileting care plan dated [DATE] is also contradictory and inaccurate stating R23 is incontinent of bladder and bowel due to poor motivation and refusal to participate in the program consistently. The goals are not specific or individualized stating R23 will " be clean, dry and odor free daily. " There is a 4 day bladder diary for R23 but the data is not analyzed to assist in determining a voiding pattern for R23. This was confirmed by E19 on [DATE] at 1:10pm. The following sample of B&B assessments were reviewed and found to have conflicting and inaccurate information following interviews with direct care staff: R41. E23 (nurse's aide) stated on [DATE] at 1:55pm that R41 is confused at times but knows when she has to go to the bathroom and will find one and go by herself. E23 said R41 stays dry most of the time. R41's B & B assessment dated [DATE] states R41 is incontinent of urine, has the ability to ask to go to the bathroom but wanders looking for the bathroom. The Summary section states that R41 cannot be in the program because of Dementia. This is not sufficient reason not to be in a B&B program. The plan is for R41 to be prompted to use the toilet. The voiding diary does not analyze the data to assist in determining a voiding pattern for R41. The incontinence care plan dated [DATE] states R41 " will toilet void in toilet upon rising, after meals, at HS and prn to establish a routine for urinary elimination. " E19 stated on [DATE] at 11:10am that there has not been a pattern established for R41. R47 E21 (nurse ' s aide) stated on [DATE] at 2:15pm that R47 knows when he has to go to the bathroom and takes himself despite the multiple alarms in place in his room. R47 is a high risk for falls E21 stated but R47 insists on using the bathroom most of the time even though he has a urinal. E21 said R47 knows how to turn off the alarms so he can get to the bathroom. B & B assessment dated [DATE] states R47 is incontinent of urine, has the ability to ask to go to the bathroom, uses a urinal at times . The Comment section states that R47 "is aware of his need to toilet but has difficulty at times getting there in time (urgency)." The quarterly summary dated [DATE] states " to continue prompting for toileting. " The voiding diary does not analyze the data to assist in determining a voiding pattern for R47. The incontinence care plan dated [DATE] states R47 will " participate in prompted toileting program. " E19 stated on [DATE] at 11:10am that there has not been a pattern established for R47. R43 E20 (nurse's aide) stated on [DATE] at 2:10pm that R43 is confused and uses a sit-to-stand lift to go to the bathroom. E20 said R43 says certain things like "It doesn ' t feel right" or tugs at her pants to let staff know she has to go to the bathroom. This information is not in her care plan or B & B assessment. The voiding diary does not analyze the data to assist in determining a voiding pattern for R43. B & B assessment dated [DATE] states R43 is incontinent of urine, has the ability to ask to go to the bathroom but cannot be in a B & B program because of her dementia and mood disorder. The Comment section states that R43 can state she feels like she has to go but it is "too late" by the time she asks. The plan is for R43 to be prompted to use the toilet. Review of facility's Bowel and Bladder Training policy and procedure states the B & B assessment will be used to assess reversible and irreversible causes of incontinence. Review of all the above care plans found none listed. The P & P only describes a policy for staff to take the resident to the toilet or provide a bedpan before breakfast and every 2 hours. Acello, Barbara RN MSN. The Long -Term Care Nursing Desk Reference HCPro, INC. 2005. Chapter 13 pg 215 states that "Most believe that toileting residents every 2 hours is the best means of keeping them dry, when in fact this is a dated and ineffective method. Effective urinary incontinence is management based and individualized to the resident. Incontinence management is a "catch" program that keeps residents dry. It is assessment-based, but it does not involve retraining or relearning. It involves toileting the resident at times in which he or she is most likely to eliminate. Many residents will not be able to participate in an active bowel and bladder retraining programs, but most will benefit from a regular, assessment based toileting schedule."