Every finding on record at Avantara Evergreen Park

Based on observation, interview, and record review the facility failed to ensure eye drops were available for administration as ordered, failed to administer medications timely in accordance with prescriber orders, and failed to ensure the prescriber was notified when medication was not available for administration. This failure affected 5 of 5 (R3, R6, R7, R8, R9) residents reviewed for medication administration in the sample of 9. The Findings include:1. On 06/26/2026 at 12:05pm, R3 stated sometime in May 2026, the nurses would tell her they did not have her eye drops in the med cart. R3 stated she did not know their names. R3 stated she had cataract surgery, and she has glaucoma. R3 stated she was supposed to get eye drops with green cap on both eyes in the morning and purple cap in the evening, but the nurse said they could not find her eye drops.R3's (05/2026) MAR (Medication Administration Record) documented that R3 had missed medication doses from 05/26/2026 through 05/31/2026 which also documented that V7 (Licensed Practice Nurse/LPN) and V8 (Registered Nurse/RN) were assigned to R3 when R3 missed doses of her medication. On 06/26/2026 at 1:42pm, V7 (LPN) stated she did not see her medication in the med cart; she needed a refill, and she reordered the medication in the electronic health record platform. V7 stated that when she identified it was missing, she reordered the medication right away.On 06/26/2026 at 2:15pm, V7 stated she informed the nurse supervisor, but she did not document she informed the supervisor. V7 stated she did not notify R3's Health Care Provider.On 06/26/2026 at 1:55pm, V8 (RN) stated when she found that the medication was not available she informed the unit manager that the med is unavailable, and she called the pharmacy. V8 stated she sent the order and the medication arrived that day she reordered it after her shift.On 06/26/2026 at 2:18pm, V8 stated the Nurse Practitioner (NP) was in the room with her (R3) and she (R3) reported to the NP that the facility was missing the eye drops. V8 stated she did not document in the chart that the Nurse Practitioner was aware R3's medication was missing.R3's (Date Range: 05/25/2026 - 06/01/2026) Progress notes were reviewed with no documentation of notification of Provider for missed medications on 05/26/2026 - 05/31/2026. 2. On 06/26/2026 at 10:30am, during the medication administration task with V4 (Agency LPN), V4 opened the EHR/electronic health record; some residents are still on red. V4 stated the residents are still in the red because the morning medications are not administered yet. V4 stated the residents who have not received their morning meds are (R6, R7, and R8) and she just administered R9's medications.R9's Medication Audit report dated 6/26/2026, showed R9 was prescribed Aricept 5 mg (milligrams) scheduled to be administered at 8:30 am, multiple vitamin and ascorbic acid 500 mg scheduled to be given at 09:00 am. These medications were documented as administered at 10:38 am. R9 also had ketotifen fumarate ophthalmic 0.035% solution, 2 drops to be instilled in both eyes, scheduled to be administered at 6:00am and 6:00 pm. The documentation showed R9's eye drops were administered at 7:10 am and 8:05 pm on 6/26/2026. 3.R6's medication audit report dated 6/26/2026, showed R6 had gabapentin 100 mg prescribed to be given three times per day, metformin 500 mg, 2 tabs, to be given twice per day, baclofen 10 mg to be given three times per day and senna 8.6 mg, 2 tablets, to be given every 12 hours.R6's medication audit report showed gabapentin was scheduled to be given at 8:30 am, 1:30 pm and 5:30 pm, and was administered at 11:21 am, 12:43 pm and 5:57 pm on 6/26/2026.R6's medication audit report showed metformin 200 mg, 2 tablets was scheduled to be administered at 8:30 am and 5:30 pm and was administered at 11:21 am and 5:57 pm on 6/26/2026.R6's medication audit report showed baclofen 10 mg was scheduled to be given at 8:30 am, 1:30 pm, and 5:30 pm, and was administered at 11:21 am, 12:34 pm and 5:57 pm on 6/26/2026.R6's medication audit report showed senna 8.6 mg, 2 tablets was scheduled to be administered at 9:00 am and 9:00 pm and was administered at 11:18 am and 8:26 pm on 6/26/2026. 4. R7's medication audit report showed R7 was prescribed docusate sodium 100 mg twice a day, and was scheduled to be given at 08:30 am 8:00 pm, lidocaine cream 4% external apply topically to both knees and right ankle, every 12 hours for pain, scheduled for 9:00 am and 9:00 pm and Tylenol oral tablet 325, 2 tablets, every 12 hours for pain and was scheduled for 9:00 am and 9:00 pm. R7's medication audit report documentation showed R7 was administered docusate sodium scheduled 8:30 am dose was administered at 11:16 am. R7's documentation showed the 9:00 am dose for both lidocaine topical and Tylenol 650 mg were administered at 11:17 am. The next dose of Lidocaine topical was administered at 8:27 pm and the next dose of Tylenol 650 mg was given at 8:28 pm, both administered less than 12 hours apart as scheduled. 5.R8's medication audit report showed R8 was prescribed Procardia XL 60 mg. extended-release tablet, 1 tablet scheduled to be given every 12 hours scheduled for 9:00 am and 9:00 pm. The medication audit documentation showed that R8 was administered Procardia medication at 10:38 am and 8:39 pm on 6/26/2026. On 06/26/2026 at 10:34am, V5 (Assistant Director of Nursing) stated the expectation with medication administration is to administer the medication within one hour before and one hour after the schedule. V5 stated the importance of administering the medication within that timeframe is because these medications are vital for the residents' health; if it is a blood pressure medication, the facility did not want to administer it late to prevent blood pressure elevation and cause further damage to the resident. V5 stated the expectation is for the nurse to call the doctor that the medication was given late and to follow the order of the doctor if an order is given.On 06/27/2026 at 1:35pm, V2 (Director of Nursing/DON) stated the expectation if a resident missed a dose of medication is to notify the resident's provider, to ask if they need to give an alternative medication or to get an order to administer once delivered. V2 added it is important to notify the doctor to communicate what is going on to the resident.On 06/27/2026 at 1:38pm, V2 (DON) stated the rights of medication of administration include the right person, right dose, right time, medication, and route. Medication should be administered one hour before and after the schedule. If the medication was given late, the expectation is for the nurse to call the provider, to communicate that the medication was given late and to get an order to monitor the resident; it is also expected to document that the provider was notified. The Facility's policy title Medication Pass, dated 7/2/2025, showed it was the policy of the facility to follow all applicable laws and both stated and federal regulations regarding all medication pass procedures.

Based on observation, interview, and record review, the facility failed to ensure a resident who is dependent with staff assistance for ADL (Activities of Daily Living) was checked and changed every two hours and as needed in accordance with facility's incontinence policy. This failure affected 1 (R4) of 3 residents reviewed for incontinence care in the sample of 9.The Findings include:On 06/26/2026 at 10:48am with V5 (Assistant Director of Nursing) inside R4's room, there was a strong smell of urine in R4's room. V5 checked R4's incontinence brief. R4 stated the last time the staff came in to check her brief was before breakfast.On 06/26/2026 at 10:51am, R4's incontinence brief was fully soaked with urine. R4 stated she was last changed before breakfast. On 06/26/2026 at 10:55am, V5 checked the incontinence pad and flat sheet underneath R4. V5 turned R4 to her left side; the flat sheet was wet, and the incontinence pad had brownish stain formed at the border between the wet and dry areas of the incontinence pad. V5 stated the flat sheet, incontinence pad, and her (R4) gown are all wet and there's brownish staining on the incontinence pad. On 06/27/2026 at 10:32am, V6 (Certified Nursing Assistant/CNA) stated she has been at the facility for a year. She was assigned to (R4) on 06/26/2026. V6 stated she started at 6:30am and she checked R4 between 6:30am - 6:40am and informed R4 she will get a shower once she's done checking everyone and after she got the linens. V6 stated she tried to take R4 to the shower, but she could not because she was busy attending to other residents. V6 stated she was expected to check and change her assigned residents every two hours and as needed. V6 stated she was not able to check her assigned residents every 2 hours because she was still trying to get up her assigned residents who were mostly dependent residents. On 06/27/2026 at 1:51pm, V2 (Director of Nursing) stated the expectation is for the resident to be checked and changed every two hours and as needed to prevent skin alteration and skin breakdown. The importance of providing ADL (Activities of Daily Living) care timely is for skin integrity and patient dignity. Some residents cannot care for themselves, and they depend on staff to do it. On 06/27/2026 at 3:52pm, V1 (Administrator) stated the expectation is for staff to check and change residents every 2 hours and as needed. The brownish stain formed at the border between the wet and dry areas of the incontinence pad means the checked and changed likely extended beyond 2 hours. R4's admission Record documented that this resident's diagnoses include but are not limited to COPD (Chronic Obstructive Pulmonary Disease), morbid obesity, hypertension. R4's (05/19/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 11. Indicating the resident's mental status as moderately impaired. Section GG. GG0130. Self-Care. B. Oral hygiene. C. Toileting hygiene. E. Shower/Bathe self. F. Upper body dressing. G. Lower Body dressing. I. Personal hygiene. Coded: 1 - Dependent.R4's (01/29/2025) Nursing Admission/readmission documented, in part VII. Call Light Evaluation. 1. Is this resident cognitively able to use the call light. A: Yes. R4's (Target Date: 08/17/2026) care plan documented, in part has for alteration of bowel and bladder functioning related to incontinence. Will remain free from skin breakdown due to incontinence and brief use. Keep call light within reach. Remind, offer and assist with toileting as needed. R4's (target date: 08/17/2026) care plan documented, in part restorative nursing. Has an alteration in normal elimination rt (related to) decreased bladder tonicity. Display occasional bladder and bowel incontinence. Will be able maintain neat/clean/free from smell of body odor/urine. Incontinence: I would like the staff to check me for incontinence episode every shift and prn. I would also need assistance to wash, rinse and dry my perineum. I would also need assistance to change clothing PRN after incontinence episodes. The (undated) meal time documented that breakfast was from 7:15am to 8:30am. The (05/20/2022) Certified Nursing Assistant Job Description documented, in part Summary/Objective In keeping with our organization's goal of improving the lives of the Guests we serve, the Certified Nursing Assistant (C.N.A.) plays a critical role in providing superior customer service and nursing care to all Guests. The C.N.A. safeguards the health, safety and welfare of all Guests under their care by following applicable laws, regulations, and established nursing policies and procedures. Essential Functions: 1. Provides quality nursing care to Guests in an environment that promotes their rights, dignity and freedom of choice. 2. Provides individualized attention, which encourages each Guest's ability to maintain or attain the highest practical physical, mental and psychosocial well-being. 3. Carry out assignments required for the Guest's activities of daily living (ADL's) which include but not limited to bathing, dressing, grooming, toileting, and feeding. 4. Attends to individual needs of all Guests in regard to incontinent care, transferring, ambulation, range of motion, communication and other needs. 5. Provides care that maintains each Guest's skin integrity to prevent pressure ulcers, skin tears and other damage by changing incontinent Guests.The (6/30/25) Incontinence and Perineal Care documented, in part Policy Statement: It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition. Procedures: Do rounds at least every 2 hours to check for incontinence during shift. The (9/25) Residents' Rights for People in Long-Term Care Facilities Ombudsman Program documented, in part You have the right to Safety and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction.

Based on observation, interview, and record review, the facility failed to ensure a resident who is dependent on staff assistance with ADL (Activities of Daily Living) care had a functioning call device. This failure affected 1 (R4) of 1 resident reviewed for call device in the sample of 9 residents. The Findings Include: On 06/26/2026 at 10:39am, R4's call device cord was wrapped on the right-side rail. R4 stated she had been calling but nobody seemed to notice. When R4 to activated the call device; no light illuminated on the call device box attached to the wall or on the overhead indicator box outside of R4's room.On 06/26/2026 at 10:47am, V5 (Assistant Director of Nursing) pushed R4's call device. V5 stated there was no light that was lit on the call device box and on the overhead light indicator outside of R4's room. On 06/26/2026 at 11:00am, V20 (Maintenance Director) tested R4's call device, no light was lit on the call device box. V20 unwound the call device cord from the side rail and stated they should not have tied the cord on the side rail because when they raised the head of the bed up, it pulled the cord off the call device box. V20 stated they should have just clipped the call device to the resident's gown or sheet. V20 showed this surveyor the clip from the old called device. V20 stated all call devices have clips. V20 stated he checked her (R4) call device and it did not turn on. He replaced it with a new call device. V20 stated he told them all the time that they are not supposed to tie the cord of the call device on the siderail because it could break. V20 stated the facility should provide a working call device to the resident so they could tell the nursing staff they need help.On 06/27/2026 at 1:48pm, V2 (Director of Nursing) stated call device should be within reach and functioning. The purpose of giving a functioning call device so the resident can notify staff when they need assistance. If the call device is not functioning then the resident will not be able to get assistance in a timely manner. V2 stated the call device should not be wrapped on the siderail and it should clipped be within the resident's reach. If the cord is wrapped in the siderail, it could get frayed and malfunction.On 06/27/2026 at 3:50pm, V1 (Administrator) stated the call device should be functioning so the resident could call the staff for assistance outside of the regular rounding of every 2 hours and as needed.R4's admission Record documented that this resident's diagnoses include but are not limited to COPD (Chronic Obstructive Pulmonary Disease), morbid obesity, hypertension.R4's (05/19/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 11. Indicating the resident's mental status as moderately impaired. Section GG. GG0130. Self-Care. B. Oral hygiene. C. Toileting hygiene. E. Shower/Bathe self. F. Upper body dressing. G. Lower Body dressing. I. Personal hygiene. Coded: 1 - Dependent.R4's (01/29/2025) Nursing Admission/readmission documented, in part VII. Call Light Evaluation. 1. Is this resident cognitively able to use the call light. A: Yes.R4's (Target Date: 08/17/2026) care plan documented, in part has for alteration of bowel and bladder functioning related to incontinence. Will remain free from skin breakdown due to incontinence and brief use. Keep call light within reach. Remind, offer and assist with toileting as needed.R4's (target date: 08/17/2026) care plan documented, in part Restorative nursing. Has an alteration in normal elimination rt (related to) decreased bladder tonicity. Display occasional bladder and bowel incontinence. Will be able maintain neat/clean/free from smell of body odor/urine. Incontinence: I would like the staff to check me for incontinence episode every shift and prn. I would also need assistance to wash, rinse and dry my perineum. I would also need assistance to change clothing PRN after incontinence episodes.The (6/30/25) Call Light Policy documented, in part Policy Statement: It is the policy of this facility to ensure that there is prompt response to the resident's call for assistance. The facility also ensures that the call system is in proper working order.The (9/25) Residents' Rights for People in Long-Term Care Facilities Ombudsman Program documented, in part You have the right to Safety and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and failed to ensure fall precautions were implemented to prevent falls. These failures affected three residents (R12, R91, and R197) in a sample of 67 residents. This failure caused harm to R197, as evidenced by sustaining a right humorous fracture and traumatic hematoma on R197's forehead and contributed to R197's death 2 days after the fall.Findings include: R197's face sheet documents R197 was a [AGE] year-old resident with a prior medical history of chronic obstructive pulmonary disease, dementia without behavioral disturbance, restlessness and agitation, iron deficiency anemia, contusion of the head, and displaced supracondylar fracture of the right humerus. R197's minimum data set (2/4/2026) documents R197 had a brief interview of mental status summary score of 3, indicating R197 had severe cognitive impairment. R197 required substantial/maximal assistance with personal hygiene (including washing/drying face) and required partial/moderate assistance with transferring. Facility final incident report (3/12/2026) to the department documents R197 experienced an unwitnessed fall in her room. At approximately 6:00 AM, (V72- Certified Nursing Assistant) provided ADL and incontinence care and transferred R197 to the wheelchair. R197 wanted to remain in her room. (V72) left R197 in the room unsupervised and continued morning rounds. Staff heard R197's roommate yelling for help and observed R197 on her left side with a hematoma to the head. R197 told staff that R197 was trying to reach down and pick something up off the ground when R197 slid off the wheelchair. R197 was wearing non-skid socks and the environment was dry. R197 was treated at the hospital and diagnosed with a closed fracture of the right humerous. The facility was given instructions to follow up with an orthopedic physician and the plan of care was updated to address the needs of R197. R197's care plan documents R197 is at high risk for falls related to unsteady gait and dementia. R197 had goals of being free from fall related injury. Interventions to address the high fall risk in place included, I prefer to keep all needed items like water pitcher, tissue box, urinal, etc, within reach (2/27/2025), : I would like staff to provide me a safe environment: even floors, free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side rails as ordered, handrails on walls (2/27/2025), Remind me to ask for assistance. Reorient me on how to use the call light, if necessary (2/27/2025), Please make sure that my call light is within my reach and encourage me to use it for assistance as needed. I would like staff to address my needs with a prompt response to all requests for assistance. >Fall Mats/Early Riser. R197 also required assistance from staff for hygiene. R197's care plan was not updated to include any new interventions after the fall sustaining injury on 3/5/2026, as indicated in the facility report. There was no care plan developed or revised to address the fracture of the right humerus, splint use, monitoring of neurological decline/injury after R197 sustained head injury. This review directly contradicts the facility's report that The plan of care has been updated to address the needs of (R197). R197's hospital records (3/5/2026) document R197 presented to the emergency department from emergency medical services (EMS) from the nursing home after suffering a fall. Per EMS, R197 was sitting in the wheelchair and reached for an object on a table and subsequently fell and hit head against the ground. R197 was unable to recall what happened. Imaging was completed and R197 was diagnosed with 1) closed supracondylar fracture of right humorous 2) fall 3) traumatic hematoma of forehead. R197 was discharged to the facility and asked to follow up with primary care in 1-2 days. R197's progress notes document on 3/5/2025 at 6:36 AM, (R197) was sitting in wheelchair when she leaned too far forward reaching for something and fell out of wheelchair striking head. Pt noted with hematoma, soft BP, slightly hypoxic requiring o2 application, amd on Asa. Due to culmination of all of this will refer to ED for eval. At 7:56 AM, (Private Ambulance Company) here to transport resident to (hospital) for eval. Resident is leaving in stable condition. At 10:57 PM, Resident returned from (Emergency Department), after a fall. Dx: closed supracondylar fx rt humerus, and traumatic hematoma to her forehead. Right arm is placed in a splint., intact and elevated. Resident is alert and oriented to baseline. Resident placed in bed and made comfortable, call light within reach. Fall precautions in place, plan of care ongoing. There is no progress notes documented in the records until 3/7/2026 at 12:02 PM, LATE ENTRY Note Text : 9:10am While rounding resident observed resting in bed comfortably. 10:30am Resident offered medication and tolerated well writer took vitals BP 119/62, hr 88, r-18, O2-98%. 11:11am CNA was rounding on resident and noted in bed unresponsive to name. CNA alerted writer. Writer assessed resident and resident noted in bed unresponsive to verbal stimuli, painful and tactile stimuli. Writer verified code status, resident is a full code. Writer unable to palpate carotid or radial pulse. 11:12am Code blue initiated, CPR started and 911 called. AED applied with no shock advised. CPR continues with vitals unable to be obtained. CPR ongoing. 11:20am Evergreen Park paramedics and fire department arrive at the facility and took over compressions. 11:30am (Nurse Practitioner) notified of clinical status. 11:40am (V70 - Family Member) notified of change in condition and stated that (V70) was in route to the facility. 11:46am Paramedics CPR efforts cease and was pronounced deceased by (physician) 11:50am (EMS) left facility.12:00pm Postmortem care initiated. R197's death certificate (3/24/2026) documents R197's cause of death was organic cardiovascular disease and significant conditions contributing to death but not resulting in the underlying cause were multiple injuries due to fall(s), and chronic obstructive pulmonary disease. The death certificate indicates the injuries that contributed to R197's death occurred on 3/5/2026 at the nursing home and the injuries occurred from a fall and sustained injury. On 4/28/2026 at 1:01 PM, V71 (Physician, Forensic Pathologist) affirmed V71 is a medical physician and forensic pathologist for the coroner's office. V71 affirmed V71 completed the medical review of R197's death. V71 explained the coroner's office was notified by the police on 3/7/2026 of R197's death and the police believed R197's death was of natural causes. Later, the coroner's office was notified by the funeral home. The funeral home told the coroner's office R197 had hit her head in a fall recently before the fall. The coroner's office requested records from the facility to rule out if an autopsy was needed. V71 explained that a medical review was conducted in lieu of an autopsy. V71 stated, There is a small chance that a (brain) bleed could have developed after the CT was obtained by the hospital. But altered mental status or other neurological symptoms would start to develop. They (the facility) does not have good documentation from when (R197) got home on [DATE]) and then nothing (documented) until (R917) ended up passing. I can't speak to whether they were providing the care or not, but I would have expected if there was a change in condition they would have sent (R197) back to the hospital. V71 reviewed the findings of the medical record review and explained, Yes, we believe the falls did contribute to (R197's) death. We listed the cause of death to be organic cardiovascular disease, which is a blanket diagnosis for things related to hypertension, renal dysfunction, etc. that cause cardiac arrest. We think the falls contributed to the death for multiple reasons. Multiple traumatic injuries, especially with elderly individuals with a natural disease process, we might not normally think of an arm fracture to be super traumatizing, right? But it can put a lot of stress on a body because there will be internal bleeding, blood loss, especially when someone has anemia and being [AGE] years old. I think (R197) had a cardiac event that caused her death, but that the diagnosis of COPD (chronic obstructive pulmonary disease) and multiple falls with fractures contributed to that cardiac event. It's hard to say for sure if (R197) would be alive today if (R917) did not have the falls and fractures, however, it seemed like (R197) was fairly stable prior to the fall. Given the proximity of the fall to the death, we do believe they are related. I feel like with injuries related to falls, it only comes as the cause of death if it is a large fracture like a femur fracture, those put a very large amount of stress on the body that you can't ignore. As for a humorous fracture, I can't say the fracture is the reason for the death, but I do think it contributed. R197's neurochecks initiated after the fall on 3/5/2025 document V73 signed neurochecks as complete on 3/13/2026 and 3/15/2026, V69 signed neurocheck as complete on 3/14/2026, and V75 (Agency Registered Nurse) signed neurochecks as complete on 3/13/2026. R197's post-fall follow up Day 1 2/3 was signed by V69 on 3/14/2026 as complete. Day 2 (1/3, 2/3) were signed by V75 as complete on 3/13/2026. Day 2 (3/3) was signed as complete by V73 on 3/14/2026. There was no post fall charting completed for day 3 after the fall. On 4/28/2026 at 2:02 PM, V18 (House Supervisor/Licensed Practical Nurse/Falls Nurse) affirmed V18 oversees the fall prevention program for the facility and assists with fall investigations. V18 recalled R197 was confused at baseline, alert and oriented to self, and had a history of dementia. R197 had a history of impulsiveness but believed R197's behaviors were more at nighttime. R197 would frequently go to the dining room and self-propel the wheelchair with R197's feet. V18 reviewed R197's electronic health record and affirmed R197's last fall before the fall on 3/5/2026 was on 3/2/2025. The root cause was R197 trying to get up unassisted from bed so R197's care plan was updated to have R197 on an early riser program so R197 would be up and in the dining room in the early morning on 3rd shift. V18 also added fall mats to R197's floor to prevent injury. V18 recalled R197 was gotten up by the nurse aide (V72), put R197 in the wheelchair in R197's room and went to go assist another resident to dialysis. R197 was left unsupervised in the room. (V72) heard the roommate screaming, so (V72) went back to the room and observed R197 on the ground. R197 was laying on her left side on the floor and there was a large hematoma to R197's forehead. R197 said she was reaching for something on the ground. There wasn't anything on the ground in the reports. (V73, Licensed Practical Nurse) was the nurse that assessed R197 and sent her to the hospital. R197 came back in a sling. V18 believed R197 could safely be unsupervised as long as R197 was not in bed and in a wheelchair as all of R197's fall history was related to being in bed and not a wheelchair. V18 reviewed R197's electronic health record and the investigative reports related to the incident. V18 affirmed the floor mats were not in place at the time of the fall. V18 explained the purpose of the floor mats is to prevent injury from falls. V18 stated, I don't know if I would have the fall mats on the ground when (R197) was up in the wheelchair. You couldn't roll the wheelchair on them, so while she is in the wheelchair, I don't know if they would be on the ground. Yes, based on the care plan the fall mats should have been there. V18 affirmed that R197's care plan was not updated after the fall to address the new fracture or head injury. V18 explained the facility completed post-fall charting and neurological checks after the fall to check for level of consciousness, neurological decline. V18 affirmed the last neurocheck was due at 10 AM and was not completed by the nurse but all other neurochecks were completed. Observed the neurocheck charting and post fall charting with V18 and noted multiple neurocheck entries and post fall entries were charted on or after 3/13/2026 (6+ days after the resident had passed away). V18 explained the purpose of charting timely is to ensure accuracy of the records and make sure changes in condition were not missed. V18 recalled coming back from a leave and noticed they were completed but not signed out so V18 had to notify the non-compliant nurses and have them complete their charting. V18 confirmed that R197's death was not expected and believed the fall had been reported to the state survey agency by V2 (Director of Nursing). On 4/28/2026 at 3:47 PM, V35 (Licensed Practical Nurse) affirmed V35 was assigned to care for R197 in the past and was familiar with R197. V35 recalled R197 was confused, on a pureed diet, needed assistance feeding herself, and needed medications crushed. R197 was impulsive and frequently had behaviors, such as trying to get up from the wheelchair. V35 stated, We tried to keep her in the dining room as much as possible so we could have better supervision of her. I tried to keep her there as much as I could. I don't think it would be safe to leave her along in the room especially in the middle of the day. Maybe you could in the early morning, but sometimes (R197) was resistive to care on our shift. V35 denied any knowledge of the fall or seeing R197 after the fall before her death. On 4/28/2026 at 3:51 PM, V69 (Licensed Practical Nurse) affirmed V69 was assigned to care for R197 in the past and was familiar with R197. V69 described R197 a small, little woman who was confused, emotionally labile, and could be easily agitated. V69 expressed V69 would not feel comfortable leaving R197 in the room unsupervised unless maybe if R197 was sleeping in bed. R197 was impulsive and frequently tried to get up from her wheelchair unassisted. V69 affirmed V69 was assigned to care for R197 when she came back from the hospital and completed neurochecks. V69 didn't recall anything abnormal with R197's neurological status. V69 did not recall completing the neurochecks or the fall follow up at a later date, but affirmed V69 did them while caring for R197. On 4/28/2026 at 4:29 PM, V74 (CNA Supervisor) affirmed V74 was familiar with R197 and cared for R197 in the past. V74 recalled R197 was a night shift get up (Early Riser) program, was often restless, and confused. V74 denied V74 was present for R197's fall or death. V74 explained, I wouldn't feel comfortable leaving (R197) in a room alone, (R197) would think that (R197) could do things on her own, like stand up without assistance. On 4/29/2026 at 11:01 AM, V29 (Social Worker) affirmed V29 was assigned to R197's unit as the social worker. V29 affirmed R197 heard from staff reports that R197 would frequently try to get up unassisted. V29 denied V29 saw R197 after the fall or before she had passed. V29 affirmed based on R197's BIMS score, R197 has severe cognitive impairment. V29 stated, Yeah, based on (R197's) cognition, I don't know if I think it is safe that (R197) was left in a room unsupervised. On 4/29/2026 at 12:21 PM, V70 (Family Member) recalled R197's care at the facility. V70 explained, (R197) always thought she could walk. She thought she could get up. This isn't the first time this has happened, (R197) had multiple falls at other nursing homes too. (R197) had broken hips and elbows before from falling. A few days before (R197 passed), (R197) had a fall and (R197) broke her arm and hit her head. I saw (R197) after she passed, there was a lump on her head from when she fell the other day. I was told she hit her head from the fall. I told that to the funeral home when they were asking and they said they wanted to call the coroner to make sure they didn't want to do an autopsy. They said a lot of times when head injury is involved, they want to complete an investigation. I did talk to the coroner, and they said her cause of death was organic cardiovascular disease and multiple injury from falls, I have the death certificate here. (R197) was not on oxygen, we weren't really expecting it. At baseline (R197) was very confused. I don't think (R197) necessarily should have been left in the room because of her dementia. She can think she can walk. it's obvious now she can't. They (staff) treated (R197) good, but it was a Saturday. The regular people that took care of her probably weren't there. (R197) probably had newer caregivers that didn't know her that well. Maybe they didn't know she was at risk (for falling). On 4/29/2026 at 12:58 PM, V54 (Certified Nursing Assistant) recalled being assigned to R197 the day R197 had expired. V54 recalled, (R197) was pretty confused. I didn't really have a lot of behaviors with her on my shift, but I know she had behaviors on second shift. On the day (R197) passed, I was assigned to care for her in the morning. That morning, (R197) didn't eat much for breakfast. She was like holding food in her mouth. She didn't really want to eat. She was so tired, it was like she didn't sleep at all that night. I wouldn't say she had any unexpected weakness, she was probably weak from being that tired though. I reported it to the nurse. A little bit later, I went back on my next rounds and she was unresponsive. I yelled out for the nurse and they called for the code blue. We all did compressions, there were people everywhere. She was in bed that day and not in the dining room. I heard she tried to get up unassisted before. I don't recall if she had floor mats. On 4/29/2026 at 3:57 PM, V72 (Certified Nursing Assistant) affirmed that V72 was assigned to care for R197 the day R197 fell. V72 explained on the day of the incident V72 got R197 dressed and situated and gave R197 a warm washcloth to wash her face. V72 locked R197's wheelchair and left R197 in her wheelchair unsupervised next to her bed in her room. V72 went to another resident's room to get them ready for dialysis. About 5 minutes after, V72 heard screaming coming from R197's room and could saw R197 on the ground of her room by the wheelchair. V72 recalled R197 telling the nurse (V73) she had arm pain, and R197 had a large hematoma on the right side of her head that was approximately the size of a baseball. V72 recalled (V73) stayed with R197 until the resident was with EMS. V72 denied there were any floor mats in R197's room during the incident. V72 stated, I wasn't aware R197 was supposed to have floor mats. V72 affirmed R197 was a high fall risk and stated, Yes, that's why (R197) is a night shift get up. V72 stated, No, leaving (R197) alone in the room wasn't safe. V72 explained R197 was left unsupervised because another resident needed to go to dialysis. On 4/29/2026 at 4:15 PM, V2 (Director of Nursing) affirmed V2 was familiar with R197 and completed the investigation into the fall. V2 explained R197 needed assistance with ADLs, was alert and oriented to self, forgetful and was impulsive. R197 would try to get things without assistance. V2 affirmed R197 needed increased supervision because of the behaviors. V2 affirmed that V2 completed the investigation and recalled V72 observed R197 on the floor of her room. Was sent to the hospital, subsequently diagnosed with a humorous fracture, contusion to the head, and sent back to the facility. V2 affirmed the facility staff completed neurochecks and V2 had talked to the staff that had cared for R197 prior to her death and they did not report any signs of a change in condition. V2 affirmed R197's death was not expected and that the death was not reported to the state survey agency. V2 stated, If I felt like the fall was related to (R197's) death was related to the fall, I would have reported that. I don't think the fall is related, no personally, she fell and then passed, nothing really stuck out to me. Fractures are a reportable incident, the death is not reportable. V2 accessed R197's electronic health record. V2 affirmed that facility staff should be following the care plan and the care plan was not revised to include the humorous fracture diagnosis or head trauma. V2 affirmed that a plan of care should have been developed. V2 stated, Yes, (R197) should not have been left alone. We have educated V72. V2 reviewed the post-fall charting/neurochecks and affirmed multiple entries were signed as complete on 3/13/2026. V2 stated the facility standard is to be charting as you go, so you don't miss anything. If charting isn't completed timely, it may not be as accurate. Record review of the facility nursing schedule indicates V69 (Licensed Practical Nurse), V73 (Licensed Practical Nurse), V75 (Agency Registered Nurse), and V76 (Agency Licensed Practical Nurse) were assigned to care for R197 after the fall occurred and before R197 expired. On 4/30/2026 at 10:35 AM, V75 (Agency Registered Nurse) affirmed V75 was assigned to work AM and PM shift on 3/6/2026. V75 could not remember any details about the shifts or R197. V75 could not remember if V75 completed neurochecks on any resident while at the facility. V75 denied any knowledge of charting neurochecks or fall follow up documentation after the shifts on 3/13/2026. V75 stated, Yeah, I worked my day there with my agency and haven't been back. I haven't been back to chart anything late, I don't remember doing that. On 4/30/2026 at 12:45 PM, V73 (Licensed Practical Nurse) affirmed V73 was assigned to care for R197 on 3/5/2026 when R197 fell and 3/6/2026 the following night before R196 expired. V73 recalled R197 was confused and impulsive at baseline and incontinent. On night shift, R197 was typically sleeping through the night but was an early riser get up. V73 recalled on 3/5/2026, V73 gave R197 medication between 4-5 AM and R197 was in bed. Around 6:30 AM, V73 was sitting in the nurses station and V72 came to V73 and stated R197 fell. V73 initiated fall protocols and assessed R197 for injury. One arm was moving better than the other and R197 had a large hematoma to her forehead that was about the size of a golf ball. V73 applied an ice pack to R197's head, started neurochecks and notified EMS. V73 denied any abnormal findings during neurological assessment. V73 denied observing floormats on the floor of R197's room. V73 stated, R197 was on the floor on the ground of the room, there was no mat. V73 stated, Hmm . should (R197) be left alone in the room? Well, I don't think any resident should be in a wheelchair while in the room unsupervised. I remember (V72) told me (V72) was getting another resident up when (R197) fell. V73's late charting of the post fall/neurochecks was reviewed with V73. V73 stated, I don't recall doing my charting late, I thought all of it was in there. I did double check my work. All of the neurochecks should be documented prior to the end of shift, that is the standard. I don't recall why it says I completed them after. On 4/30/2026 at 1:27 PM, V76 (Agency Licensed Practical Nurse) affirmed V76 was assigned to care for R197 when R197 passed. V76 explained V76 was working an agency shift at the time. Someone had called in so they had an urgent agency need and V76 picked up the shift, arriving at approximately 9:00 AM and began passing medications. V76 did not get report from the off going nurse V76 recalled seeing R197 during med pass at around 9:45, but did not complete a neurological check. R197 stated, Nothing really seemed off. R76 was in bed, watching the news and we had a typical conversation. I didn't notice any disorientation or confusion or tiredness. Nothing seemed out of the ordinary. I didn't get report from the offgoing nurse so I don't know why (R197) wasn't up in the dining room. I didn't do a neurocheck. When residents need a neurocheck, I usually, come in and ask them questions. I don't want to have them feel like they are being examined. I talk to them about things like what is on television, regular conversations to see if they are alert in general. I did not assess (R197's) orientation but (R197's) speech seemed ok. R197 was able to move her limbs and I didn't recall anything abnormal. I didn't ever use a pen light to assess for pupil reactivity. Around 11, the CNA told me R197 was unresponsive. So, I went and assisted with CPR along with the other staff until EMS took over. There were no floormats that I could remember in her room. The general care policy (revised 6/30/25) states it is the facility's policy to provide care for every resident to meet their needs. Upon admission or readmission, the facility will evaluate the resident for physical and psychosocial needs. Physical needs would include but are not limited to ADL (Activities of Daily Living). The facility will assist the resident to meet these needs. Record review of CMS' Resident Assessment Instrument (RAI) Manual (October 2025) documents in part, Falls result in serious injury, especially hip fractures . DEFINITIONS INJURY RELATED TO A FALL Any documented injury that occurred as a result of, or was recognized within a short period of time (e.g., hours to a few days) after the fall and attributed to the fall. INJURY (EXCEPT MAJOR) Includes, but is not limited to, skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall-related injury that causes the resident to complain of pain. MAJOR INJURY Includes, but is not limited to, traumatic bone fractures, joint dislocations/ subluxations, internal organ injuries, amputations, spinal cord injuries, head injuries, and crush injuries. A fall refers to unintentionally coming to rest on the ground, floor, or other lower level or as a result of an overwhelming external force (e.g., being pushed by another resident). A fall without injury is still a fall. Falls are a leading cause of morbidity and mortality among the elderly, including nursing home residents. Falls may indicate functional decline and/or the development of other serious conditions, such as delirium, adverse medication reactions, dehydration, and infections. A potential fall is an episode in which a resident lost their balance and would have fallen without staff intervention .The information gleaned from the assessment should be used to identify and address the underlying cause(s) of the resident's fall(s), as well as to identify any related possible causes and contributing and/or risk factors. The next step is to develop an individualized care plan based directly on these conclusions. The focus of the care plan should be to address the underlying cause(s) of the resident's fall(s), as well as the factors that place them at risk for falling . R91 is [AGE] years old and has a history of hemiplegia/hemiparesis following cerebral infarction affecting the left non-dominant side, a history of falling, anemia diabetes, atrial fibrillation, osteoporosis and dizziness. On 3/9/2026 R91's Brief Interview of Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Minimum Data Set (MDS) dated [DATE] Section GG indicated that R91 had impairment of both upper and lower extremities and required substantial/maximal assistance, in which the helper does more than half of the effort, with toileting hygiene which includes the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. On 04/27/2026 10:28 AM R91 stated R91 called for help on 2/10/2026 because R91 had to have a bowel movement and did not want to have an accident. R91 got to the bathroom, slid off the toilet, tried to catch the wheelchair to prevent a fall, but because the wheelchair was not locked, R91 slid to the floor. On 4/28/2026 at 11:02 V18 (House Supervisor/Licensed Practical Nurse/Fall Prevention Coordinator) stated R91 needs assistance going to the bathroom. On 2/10/2026 R91 was in the dining room and needed to go to the bathroom. Activity staff brought R91 from the dining room to R91's room and left R91 unattended. R91 went to the bathroom, slid off the toilet, and fell. V18 stated activities staff should have stayed with R91. V18's expectation is that the activities staff should have assisted R91 back to the room and handed R91 off to the nurse or CNA, not leave R91 in the room alone knowing that R91 had to go to the bathroom. On 4/29/2026 at 1:58 AM V32 (Certified Nursing Assistant) stated V32 was working when R91 fell. R91 had to go to the bathroom. An activity aide brought R91 back to the room and left R91 unattended. R91 tried to go to the bathroom without assistance and fell. On 4/29/2026 at 2:43 PM V2 (Director of Nursing/DON) stated R91 was at risk of falling based on the 12/2025 Minimum Data Set (MDS) Section GG. V2 stated that V45 (Restorative Nurse/Licensed Practical Nurse) completed the MDS. If V45 felt that R91 needed assistance, V45 should have communicated the concern about R91's fall risk. V2 stated, This fall could have been prevented. Better communication could have prevented this fall. R91's Minimum Data Set (MDS) Section GG dated completed 12/18/2025 at 10:59 AM by V45 (Restorative Nurse/LPN) documented that for Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment, R91 needed substantial/maximal assistance. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear, R91 required substantial/maximal assistance. Toilet transfer: The ability to get on and off a toilet or commode., R91 required partial/moderate assistance. R91's care plan originally dated 10/23/2025 and revised 12/18/2025 stated: R91 is at high risk for falls. Goal is that R91 will be free of falls through next period. Interventions included: a working and reachable call light and encourage R91 to use it for assistance as needed, staff to address needs with a prompt response to all requests for assistance, and prompt toileting. R91's Resident Interview Notes dated 2/10/2026 and provided by the V18 (Fall Prevention Coordinator) documented: Is resident able to transfer independently? Answer: no. Transfer device used by resident regularly? Answer: gait belt. R12 is [AGE] years old and has a history of atrial fibrillation, hypertensive urgency, myocardial infarction, history of fall with facial bone fractures 12/22/2025, difficulty walking, anemia, diabetes, dementia and abnormalities of gait and movement. On 4/9/2026 R12's BIMS score was 11 indicating moderate cognitive impairment. Minimum Data Set (MDS) dated [DATE] Section GG indicated that R12 required partial/moderate assistance, in which the helper does less than half of the effort, with toileting hygiene which includes the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. On 4/28/2026 at 10:47 AM V18 (House Supervisor/LPN/Fall Prevention Coordinator) stated R12 had a fall in December 2025. R12 had a heart attack which was thought to cause the fall. On 2/7/2026 R12 slipped trying to get on the toilet and fell after the wheelchair moved. Prompt toileting, closer observation of R12 and making sure R12 locks the wheelchair may have prevented the fall. R12's Resident interview note dated 2/7/2026 documented: Is the resident able to transfer independently? Answer: no. What was the resident doing that resulted in the fall? Answer: Trying to put self on toilet. Transfer device used by resident (regularly). Answer: Gait belt. Fall occurrence policy dated 6/30/2025: It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary.

Based on observation, interview, and record review the facility failed to provide evening snacks to residents. This failure affected four (R91, R101, R102, 125) out of four residents reviewed for evening snacks. This failure has the potential to affect all residents residing in the facility. Findings:Facility census (4/27/2026) documents 164 residents reside in the facility.On 04/27/2026 at 10:28 AM R91 stated I've been losing weight, but I don't eat a lot. I eat snacks in between meals. We don't always get snacks at night for a variety of reasons. Mainly, the staff says we didn't get them (snacks) tonight. Other residents say that the staff eat the snacks. R91's electronic health record (EHR) documentation of R91's weight on 10/1/2025 was 147.4 pounds. On 04/06/2026, R91 weighed 136.2 pounds. R91 experienced a 7.6% weight loss in six months.On 04/27/2026 at 10:38 AM R102 stated the facility quite often does not have snacks in the evening. Staff say they don't have snacks at night, so you just have to go to sleep and wait until breakfast the next day. On 4/28/2026 at 8:43 AM R101 stated staff say they don't have any snacks sometimes. It happened two nights ago. R101 wanted a snack, but staff said they did not have any snacks to give R101.On 4/7/2026 at 1:30 PM Resident Council members stated that residents do not get enough snacks. The facility provides snacks on a tray in the evening, but there are not enough for every resident who wants a snack. R125 asked for a snack every day for three months and got a snack only once in those three months. Resident Council stated diabetic residents are supposed to get snacks, but they don't always get a snack in the evening. Some residents are fortunate enough to have a family or friends who bring snacks. For the residents who do not have family or friends to bring snacks, they go without. The Certified Nursing Assistants (CNAs) sometimes eat the snacks.On 04/28/2026 at 3:15 PM V7 (Dietary Manager) stated snacks are sent to the units between 6 PM and 7 PM. On each cart is a snack for residents who are on a list to receive snacks. The resident's name is on the snack. V7 stated when Illinois Department of Public Health was at the facility about three weeks ago, V7 started to put extra snacks on the cart because V7 heard that residents who wanted a snack weren't getting one. V7 heard yesterday at the stand-up meeting, the facility's daily morning meeting, that residents were saying they are not getting snacks, but they were not on the list to get a snack. Nurses distribute snacks. V7 was not sure if staff are eating the snacks instead of providing them to residents. V7 stated It is possible.On 4/29/2026 at 11:01 AM V7 (Dietary Manager) stated breakfast leaves the kitchen at 7:30 AM and service begins at 7:45 AM. The last breakfast tray is served around 8:35 AM daily. Dinner is served at 4:25 PM (over 14 hours between dinner and breakfast). If a resident is on the snack list, they should get a snack. If a resident is not on the snack list, V7 sends snack crackers, You know, whatever we've got as extra snacks.On 4/29/2026 at 11:36 AM V55 (Regional Clinical Nutrition Manager) stated snacks are delivered in the evening to each unit. Snacks are delivered to the nurses station and passed by nursing. It is a resident's right to get a snack.Review of facility task for the last 30 days, to the question Did Resident Take a Snack , the electronic health records reflects that R91 had no response on 4/11/2026, 4/14/2026, 4/25/2026, 4/26/2026 or 4/28/2026. R101 had no response on 4/25/2026 or 4/28/2026. R102 had no documentation on 4/14/2026, 4/19/2026, 4/25/2026 or 4/28/2026. R135 had no documentation on 4/2/2026, 4/4/2026, 4/5/2026, 4/7/2026 through 4/15/2026, 4/17/2026, or 4/22/2026 through 4/26/2026. None of the residents were documented as being on hospital leave on the dates that no snacks were documented as received or declined by the resident.Review Minimum Data Set (MDS) Section F to the question How important is it to you to have snacks available between meals?, R91 answered very important on 9/24/2025. R101 answered very important on 10/20/2025. R102 answered somewhat important on 11/12/2025. R125 answered very important on 2/26/2026.Facility policy titled Bedtime Snacks reviewed 6/26/2026 stated the facility must offer snacks at bedtime daily.

Based on observation, interview, and record review, facility failed to dispose of garbage and refuse appropriately, failed to ensure dumpster lids were covered, failed to ensure garbage, including food/drink waste and medical waste were properly contained. This failure affected all 164 residents that reside within the facility.Findings include:Facility census (4/27/2026) documents 164 residents reside in the facility.On 4/27/2026 at 11:17 AM, observed facility dumpsters with scattered garbage on the ground including, but not limited to, PPE (gloves), cans, food wrappers, and soiled boxes. One dumpster lid was fully open and another could not fully close due to large boxes filling the dumpster and trash bags. Directly adjacent to the garbage area, observed piles of refuse including dead leaves, cigarette butts, food wrappers, drink containers, that covered approximately 15% of the smoking area. Approximately 60% of the area had cigarette butts on the ground. V7 (Dietary Manager) observed the areas and confirmed these findings. V7 was unsure the reason why the dumpster lids were supposed to be closed. V7 reported that the garbage/refuse disposal responsibility lies with housekeeping/maintenance.On at 7/27/2026 at 11:45 AM, observed the dumpster area and the vicinity with V8 (Maintenance Director). The garbage/refuse was still observed on the ground around the dumpsters and in the direct vicinity, and the dumpster lids were still open and contained the same refuse. V8 confirmed these observations. V8 affirmed there was garbage, cigarette butts, and other refuse on the ground and that the dumpster lids were open. V8 stated, Yes, the dumpster lids should be closed and garbage should be in the dumpster. The lids need to be closed because otherwise the wind will pick up the trash inside and it will go everywhere. It also attracts pests like raccoons and can cause a pest control problem. On 4/28/2026 at 6:59 PM, V1 (Administrator) stated via email communication that the facility does not have a garbage/refuse/dumpster policy.The manual Residents' Rights for People in Long-Term Care Facilities (Revised 11/18) documents in part .Your facility must be clean, safe, comfortable, and homelike.

Based on observation, interview, and record review, the facility failed to follow policy and procedure; failed to ensure staff appropriately doff appropriate personal protective equipment (PPE) after performing high contact care on one resident; failed to ensure staff don appropriate PPE when performing high contact resident care for one resident; failed to ensure the EBP (enhanced barrier precaution) sign was posted on one resident's door; and failed to implement appropriate measures for the transport and containment of clean linen throughout the facility. These failures affected three residents (R17, R65, and R165) residents reviewed for infection control and have the potential to affect all 164 residents residing at the facility. Findings include: On 4/27/26 at 9:32AM, V1 (Administrator) stated the facility census is 164 residents residing at the facility. On 04/27/2026 at 10:36am in R65's room, R65 was lying on bed. There was a dressing on his left forearm. Inquiring about the dressing on his left forearm, R65 stated he is on dialysis and staff applied dressing after dialysis. Surveyor checked R65's door, there was no EBP sign posted. On 04/27/2026 at 10:43am, V23 (Clinical Care Coordinator) stated he (R65) should be placed on EBP and there should be an EBP sign posted if he really is on dialysis so staff know they should wear gown and gloves prior to rendering ADL care to resident. On 04/27/2026 at 11:12am, V3 (Assistant Director of Nursing) checked R65's dressing on his left forearm and stated residents getting dialysis via an AV (Arteriovenous) fistula access do not need to be placed on EBP but since he still has the dressing, he should be on EBP and should have an EBP sign posted to let the staff, family, and visitor know he is at risk of getting infection; to prevent bringing infection to the resident. On 04/28/2026 at 10:47am, there was a clean linen cart outside of R165's room and an EBP (Enhanced Barrier Precautions) sign posted by his door. V42 (Certified Nursing Assistant) stated she was doing Patient Care to R165. Inside R165's room, there was a basin on the sink with water and towels; V42 was touching R165's sheets and gown; V42 was wearing gloves, with no isolation gown on. On 04/28/2026 at 10:52am, outside of R165's room with V43 (Licensed Practical Nurse). Inquiring about the use of gloves and gown when providing care to a resident on EBP, V43 stated staff should wear gown and gloves when providing adl (activities of daily) care to residents to prevent cross contamination, to prevent infection. This surveyor requested V43 to do an observation of V42. V43 knocked on R165's door, opened the door, and saw V42 rendering care to R165. V43 entered the room and told V42 you should wear a gown. V43 stated she is not wearing a gown, and she should have when performing high contact care to a resident for infection control. On 04/28/2026 at 2:07pm, V2 (Director Of Nursing) stated if residents have dressing, it should be classified as EBP because they don't know what is in the dressing. The purpose of placing a resident on EBP is to prevent any type of infection and there should be an EBP sign posted. If a resident has any opening, that is an entry point for infection. On 04/28/2026 at 2:14pm, V2 (Director Of Nursing) stated staff are expected to don isolation gown and gloves when rendering high contact care to residents, if the staff anticipate touching a resident then the staff should don appropriate PPE like gown and gloves. The purpose is for infection control. R65's (Active Order As Of: 04/27/2026) Order Summary Report documented, in part Diagnoses: (include but are not limited to) dependence on renal dialysis, heart failure, and fluid overload. Order Summary: AV Fistula, location: Left Arm. Hemodialysis 3 times per week every day shift every Mon, Wed, Fri. Active. Order Date: 04/19/2026. R65's (04/27/2026) care plan documented, in part Focus: is on Enhanced Barrier Precaution is at risk for infection. Dialysis – AV Fistula. Goal: Potential spread of infection will not occur. Ensure that gown and gloves are used during high-contact resident care activities (like dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, Device care or use for those with central line, urinary catheter, feeding tube, tracheostomy/ventilator, and Wound care for any skin opening requiring a dressing) that provide opportunities for transfer of MDROs to staff hands and clothing. R165's admission Record documented that R165's diagnoses include but are not limited to hemiplegia (paralysis) and hemiparesis (muscle weakness), muscle wasting and atrophy of right and left shoulder, and multi focal osteomyelitis, hypertension. R165's (04/18/2026) Minimum Data Set documented, in part Section C. – Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 10. Indicating the resident's mental status as moderately impaired. R165's (Active Order As Of: 04/28/2026) Order Summary Report documented, in part Order Summary. Left foot cleanse with normal saline solution, apply betadine soaked gauze every day shift Tuesday, Thursday, and Saturday and as needed for wound care. Active. 04/27/2026. Right great toe: cleanse with normal saline solution, pat dry, paint betadine, lota (leave open to air) everyday shift Tuesday, Thursday, and Saturday and as needed. On 4/27/26 at 10:25 AM, V49 (contract phlebotomy staff) was observed doffing personal protective equipment (PPE) in the hallway, outside of R17's room. V49 stated she knows the procedure to doff PPE is inside the room but did not see the garbage can in the R17's room. R17's garbage can was observed inside the room under the alcohol hand rub. V49 then stated she just saw it the garbage can. R17's face sheet documents diagnoses that include but are not limited to osteomyelitis of vertebra, sacral and sacrococcygeal region, local infection of the skin and subcutaneous tissue, and diabetes mellitus due to underlying condition with diabetic neuropathy. R17's Nursing Care Plan dated 4/7/26 documents, in part, is on Enhanced Barrier Precaution and at risk for infection. R17 has wounds, and foley with a history of Candida auris of the urine & PICC/Midline. and interventions that documents, in part, Ensure that gown and gloves are used during high-contact resident care activities(like dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, Device care or use for those with central line, urinary catheter, feeding tube, tracheostomy/ventilator, and Wound care for any skin opening requiring a dressing) that provide opportunities for transfer of MDROs to staff hands and clothing. On 4/27/26 at 11:48am, accompanied by V52 (Laundry Manager/Accounting Manager), a tour of the facility's laundry room was conducted. Four clean linen carts were observed. V52 said that the four clean linen carts are used for transporting the clean linen throughout the facility to replenish the stock. V52 stated that the clean linen carts are covered during transport but was not sure if the bottom shelves of the clean linen cart were required to be solid (barrier-type shelf) for infection control purposes. V52 said, This is what we (facility) always have used. On 4/28/26 at 1:45pm, upon observation of the clean linen carts near the laundry area, with V3 (ADON/Assistant Director of Nursing) and V4 (Infection Preventionist/IP), six clean linen carts, prepared in the laundry area for transport and distribution throughout the facility to replenish point-of-use supplies, were observed to be covered; however, they lacked protective measures (solid bottom shelves) to prevent potential contamination and the spread of infection. The six metal carts were equipped with open, grated bottom shelves, which did not ensure cleanliness or adequately protect the linens from potential contamination by microbes, dust, dirt, debris, spills, or moisture during transport from the facility's clean laundry area to points of use throughout the facility. V3 (ADON) and V4 (IP) confirmed that the open, grated bottom shelves on the linen carts do not prevent environmental contamination of clean linens. V4 (IP) said, The bottom open shelving exposes the linen to dirt and debris that can pop up from the floor. Facility census dated 4/27/26, documents 30 residents residing on Unit 400 at the facility. On 4/27/26 at 10:15 a.m. one clean linen cart at point of use on unit 400 (between rooms 413-416) was not covered and contained. Two corners of the mesh cover on the left side and right sides of the cart cover were ripped and hanging off the corners of the clean linen cart, exposing the clean linen. On 4/29/26 at 11:00 a.m. One clean linen cart (same cart observed on 4/27/26 at 10:15 a.m.) at point of use on unit 400 (between rooms 408-412) was not covered and contained. Two corners of the mesh cover on the left side and right sides of the cart cover were ripped and hanging off the corners of the clean linen cart, exposing the clean linen. On 4/29/26 11:00 AM V50 (Certified Nursing Assistant/CNA) affirmed the clean linen cart next to room [ROOM NUMBER] had tears on two sides and the cart was not covered and contained. On 4/29/26 11:10 AM V54 (Certified Nursing Assistant/CNA) affirmed the clean linen cart next to room [ROOM NUMBER] had rips on two corners and the cart was not covered and contained. Record review of facility's policy titled, Linen Handling by Laundry Staff, dated 6/30/25, documents, in part, It is the policy of this facility to wash linens and clothes to produce hygienically clean laundry. Procedures: All laundry staff will be trained upon hire how to handle regular soiled linens and isolation linens and clothing properly, to avoid cross-contamination. Clean linens will be brought to the floor in a cart that prevents contamination from the environment. Clean linens may be placed in a clean linen room or left in the cart that is protected from the environment. The (9/16/25) Enhanced Barrier Precaution documented, in part POLICY: The facility will use Enhanced Barrier Precautions (EBP) to reduce transmission of multi-drug-resistant organisms in the nursing homes. EBP involves the use of gowns and gloves to reduce transmission of resistant organisms during high-contact resident care activities for residents known to be colonized or infected with MDROs as well as residents with wounds and/or indwelling medical devices. PROCEDURE: EBP will be used for any resident in the facility: With Open wound/s (pressure ulcer, diabetic ulcer, venous ulcer, arterial ulcer, unhealed surgical wounds, etc) whose drainage can be contained by dressing. This generally includes residents with chronic wounds, and not those with only shorter-lasting wounds, such as skin breaks or skin tears covered with a Band-aid or similar dressing. 3. The EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of XDROs to staff hands and clothing. Use of eye protection may be necessary when splash or spray may occur. Examples of high-contact resident care activities requiring gown and glove use among residents that trigger EBP use include: b) Bathing/showering. 7. An EBP sign should be posted on the doors of each resident on EBP. The (6/30/25) Infection Prevention and Control documented, in part Policy Statement: The facility has established a policy to Identify, Record, Investigate, Control, Test, and Prevent infections in the facility. The facility will also maintain a record of incidents and corrective actions implemented for the identified infection. 8. A sign will be provided outside the room for residents on transmission-based precaution indicating the type of the precaution (Contact, Droplet, or EBP). Record review of Pamphlet titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike.

Based on observation, interview and record review, the facility failed to ensure dryer lint traps were clean and without damage to provide a safe environment for the residents. These failures affect all 164 residents residing at the facility.Findings include:On 4/27/26 at 9:32AM, V1 (Administrator) stated the facility census is 164 residents residing at the facility.On 4/27/26 at 11:48am, accompanied by V52 (Laundry Manager/Accounting Manager), a tour of the facility's laundry room was conducted. V52 opened the lint compartment for dryer #4 and the lint compartment floor had loose lint on the floor, and the lint screen was fully covered with lint. V52 said, There shouldn't be that much lint. V52 said that the dryer lint compartments are cleaned every hour and the staff document when the lint screens are cleaned. V52 opened the lint compartment for dryer #2 and the lint screen was observed damaged with a large amount of lint. V52 said, Yeah, it (lint screen) needs to be replaced. It's (lint screen) not capturing the lint like it (lint screen) should be. V52 opened the lint compartment for dryer #1 and the lint compartment floor had loose lint on the floor, and the lint screen was fully covered with lint. V52 said, We (facility staff) clean the lint compartments to prevent a fire.V1's (Administrator) e-mail, dated 4/28/26 at 11:57am, documents, in part, No Dryer Maintenance policy.Record review of facility job description titled, Maintenance Director, dated 12/01/19, documents, in part, In keeping with our organization's goal of improving the lives of the Guests we serve, the Director of Maintenance plays a critical role in maintaining all physical plant assets on the property. The Director of Maintenance manages the day-to-day operations of the maintenance department. Operates the maintenance department in a safe manner by ensuring compliance with Federal, State, and local regulations and following established policies and procedures. Ensures the physical building meets all safety and building codes. Ensure that regular equipment and systems maintenance schedules are monitored and followed at all times. Works with department heads to ensure routine maintenance in Guest care areas does not interfere with the care or safety of Guests. Follow established safety precautions when performing tasks and using equipment and supplies. Reports all hazardous conditions, damaged equipment, accidents/incidents and supply issues to the supervisor. Maintains the comfort, privacy and dignity of Guests and interacts with them in a manner that displays warmth, respect and promotes a caring environment. Ensure each Guest receives person centered care.Record review of facility job description titled, Housekeeper, dated 12/01/19, documents, in part, In keeping with our organization's goal of improving the lives of the Guests we serve, the Housekeeper plays a critical role in providing superior customer service and housekeeping services to all Guests in the facility. The Housekeeper is responsible maintaining environmental and infection control standards by performing a variety of general cleaning tasks. Cleans and sanitizes Guest rooms, offices, hallways and other areas inside the facility as well as outside and the entire property. Reports all hazardous conditions, damaged equipment, accidents/incidents and supply issues to the supervisor. Maintains the comfort, privacy and dignity of Guests/guests and interacts with them in a manner that displays warmth, respect and promotes a caring environment. Ensure each Guest receives person centered care.Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, Your facility must be safe, clean, comfortable, and homelike. You should receive the services and/or items included in the plan of care.

Based up observation, interview, and record review the facility failed to follow policy procedures, failed to provide (R85) required feeding assistance and failed to ensure that call lights were within reach for five of 43 residents (R1, R26, R85, R99, R177) in the sample reviewed for accommodation of needs.Findings include: R85's (4/7/26) BIMS (Brief Interview Mental Status) determined a score of 8 (moderate impairment). R85's (4/7/26) functional assessment affirms resident requires substantial/maximal assistance for rolling left/right and is dependent on staff for sit to stand and transfers. R85's (7/16/25) care plan states resident requires assistance with ADL's (Activities of Daily Living), interventions: keep call light within reach when in bedroom. On 4/27/26 at 9:51am, R85 was lying in bed, however the call light was on the floor - out of reach. R85's call light cord was tied to the side rail, and the clip was near the floor - not the push button. Surveyor inquired if R85 could reach the call light R85 nodded her head no. On 4/27/26 at 9:52am, surveyor inquired if R85's call light was within reach V9 (CNA/Certified Nursing Assistant) subsequently entered the room and stated No, it's on the floor. Surveyor inquired where the call light should be placed, V9 responded Across her (R85). V9 then exited the room without providing R85 the call light. On 4/27/26 at 9:53am, surveyor inquired about the location of R85's call light V10 (CNA) subsequently entered the room and stated Oh, my goodness. Probably when they (staff) let her (R85) head up it probably fell off. V10 placed the call light on R85's chest however failed to secure it with the clip. Surveyor inquired if there was a clip on R85's call light V10 inspected the cord and stated, It's a clip on there; it was just too far back to clip it. R177's BIMS determined a score of 3 (severely impaired). R177's (2/9/26) functional assessment affirms resident is dependent on staff for rolling left/right. R177's (1/30/26) care plan states resident requires assistance with ADL's, interventions: keep call light within reach when in bedroom. On 4/27/26 at 9:57am, R177 was lying in bed however the call light was between the side rail and the mattress- out of reach. Surveyor inquired if R177 could reach the call light R177 responded No. On 4/27/26 at 10:01am, surveyor inquired about the location of R177's call light V11 (LPN/Licensed Practical Nurse) entered the room and stated, It's on the side of the bed, it should be on top of him (R177). R1's (2/5/26) BIMS determined a score of 4 (severe impairment). R1's (2/5/26) functional assessment affirms resident is dependent on staff for rolling left/right. R1's (7/27/26) care plan states resident requires assistance with ADL's, interventions: keep call light within reach when in bedroom. On 4/27/26 at 10:20am, R1 was lying in bed, however the call light was dangling below the mattress - out of reach. R1's right upper extremity was noted to be severely contracted, and the call light cord was tied to the bed rail (on R1's impaired side). Surveyor inquired if R1 could reach the call light R1 nodded her head no. On 4/27/26 at 10:22am, surveyor inquired about the location of R1's call light V11 (LPN) stated It was on the side of the rail, side of the bed and affirmed it was out of reach. On 4/27/26 at 12:24pm, R85 was (alone) in the room and feeding herself, however R85's dietary card states 1:1 feeding assistance required. R85's (4/7/26) functional assessment affirms the resident requires supervision or touching assistance with eating. On 4/27/26 at 12:38pm, R85 remained in the room alone - without feeding assistance. R85 was able to feed herself a cheeseburger however all the other food items (requiring utensils) remained untouched. The general care policy (revised 6/30/25) states it is the facility's policy to provide care for every resident to meet their needs. Upon admission or readmission, the facility will evaluate the resident for physical and psychosocial needs. Physical needs would include but are not limited to ADL (Activities of Daily Living). The facility will assist the resident to meet these needs. R99's face sheet documents in part the following diagnoses: cerebral infarction, muscle wasting and atrophy, type 2 diabetes mellitus, right sided hemiplegia and hemiparesis, hyperlipidemia, and history of falling. R99's minimum data set (2/21/2026) documents R99 has a brief interview of mental status (BIMS) summary score of 10, indicating R99 is cognitively impaired. Additionally, R99 requires assistance from staff with activities of daily living, including wheeling a wheelchair, transferring, and toileting. R99's care plan (2/18/2026) identifies R99 is at risk for falls related to a history of falling, reports of dizziness, right sided hemiplegia and hemiparesis and impaired balance. R99's goal related to the risk of falls is (R99) will request assistance prior to mobility attempts). Interventions to address this risk include, Remind me to ask for assistance. Reorient me on how to use the call light, if necessary (02/18/2026), and Please make sure that my call light is within my reach and encourage me to use it for assistance as needed. I would like staff to address my needs with a prompt response to all requests for assistance. (2/18/2026) On 4/27/2026 at 10:40 AM, observed R99 in a wheelchair next to the window right of R99's bed. R99's call light was observed on the left side of the bed near the left side of the mattress. R99 could not reach the call light from R99's position in the room. Observation was confirmed with V77 (Licensed Practical Nurse). V77 stated R99 is able to use the call light and the call light should be within reach of R99 to allow R99 to call for assistance. R99 pulled the call light from the side of the bed and clipped it to the side of R99's wheelchair. The cord of the call light was taut from the wall to the wheelchair with no slack in the call light. V77 was unable to place the call light near R99's lap or any closer to V77 as the cord was not long enough. This was confirmed with V77. R26's face sheet documents diagnoses that include but are not limited to secondary chronic gout, multiple sites, without tophus, muscle wasting and atrophy, not elsewhere classified, right and left shoulders, morbid (severe) obesity due to excess calories, type 2 diabetes mellitus with diabetic chronic kidney disease, difficulty in walking, and recurrent depressive disorders. R26's BIMS (brief interview for mental status) score, dated 2/2/26 is 14 which indicates R26 is cognitively intact. R26's nursing care plan, dated 4/27/26, documents, in part, Focus: R26 is at risk for falls r/t recent history of falls, incontinence, requires ADL assistance, Gout, DM. with interventions that documents, in part, Please make sure that my call light is within my reach and encourage me to use it for assistance as needed. I would like staff to address my needs with a prompt response to all requests for assistance. On 04/28/2026 11:15 AM, observed R26 sitting in wheelchair at the end of the bed. R26 stated she needs to have a bowel movement. R26 said that she cannot push herself in her wheelchair because she has pain in both her shoulders. R26 pointed to the call light and stated that she could not call for the CNA as the call light was attached to left upper bed rail. On 4/28/26 at 11:17 AM, V22 (Registered Nurse/RN) affirmed R26's call light was out of R26's reach and moved R26 close to the bed to access the call light. On 4/29/26 at 2:48pm, V3 (Assistant Director of Nursing/ADON) said, Call lights should be placed within reach, either clipped to the shirt, blanket, depending on resident's preference; But should be within reach so they (residents) can call for help, assistance to restroom, ice water, make needs known, and thing like that. The call light policy (revised 6/30/25) states be sure call lights are placed within reach of residents who are able to use it at all times.

Based on observation, interview and record review, the facility failed to ensure that staff provide grooming (nail care and shaving) for residents who were dependent on staff for Activities of Daily Living (ADL). This failure affected five (R16, R59, R69, 165 and R176) of six residents reviewed for ADL care.Findings include:R16 is [AGE] years old and have resided at the facility since 2025, face sheet listed the following past medical history in part: nontraumatic intracerebral hemorrhage, iron deficiency anemia, gastrostomy status, adult failure to thrive, hear failure, diabetes mellitus, etc.Minimum Data Set (MDS) assessment dated [DATE], section c (cognitive patterns) scored R16 with a brief interview for mental status (BIMS) score of 6, section gg (functional) of the same assessment indicated that R16 is dependent on staff for all activities of daily living (ADL) care needs.On 04/27/2026 11:00AM, R16 was observed in bed, awake but could not respond to questions, noted with long dirty fingernails on both hands. 04/28/2026 11:10AM, R16 was observed again still with long dirty fingernails on both hands, with crusty dry skin all over, him. ADL care plan initiated 4/3/2026 documented the following: Resident requires assistance with ADL's (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting). R59 is 72 years and has resided at the facility since 2022, face sheet listed the following past medical history in part: hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, unspecified protein calorie malnutrition, depression, acute ischemic heart disease, other seizures, hyperlipidemia, essential primary hypertension, dysphasia, etc.MDS assessment dated [DATE], section c (cognitive patterns) scored R59 with a BIMS score of 3, section gg (functional) of the same assessment indicated that R59 is dependent on staff for all activities of daily living (ADL) care needs.ADL care plan initiated 10/12/2024 documented that R59 has an ADL Self Care Performance Deficit and Impaired Mobility.On 04/27/2026 at 11:00AM, R59 was observed sleeping in bed, contracture noted to the left side, fingernails noted to be long and dirty with the left fingernails digging into resident's hands. On 04/28/2026 at11:10AM, R59 was observed again in bed, awake and alert and stated that he needed to be turned. Resident still noted with long dirty fingernailsOn 4/28/2026 at 11:50AM V44 (C.N.A) was presented with resident's long dirty fingernails and she acknowledged that they are long and need to be trimmed. V44 said that fingernails are supposed to be clipped during activities of daily living (ADL) care. R69 is 71 years, admitted to the facility on [DATE], past medical history includes, but not limited to hemiplegia and hemiparesis following non traumatic intracerebral hemorrhage affecting left non-dominant side, dysphagia oral phase, hyperlipidemia, other lack of coordination, anemia, etc.On 04/27/2026 10:37AM, R69 was observed up in chair, awake and alert, stated he is doing okay. R69 was observed with long fingernails with brownish substances on both hands, Resident said he would like them trimmed. 04/28/2026 10:31AM, R69 was observed in bed again, still noted with long dirty nails.MDS assessment dated [DATE], section c (cognitive patterns) scored R69 with a BIMS score of 14 section gg (functional) of the same assessment indicated that R69 is dependent on staff for all activities of daily living (ADL) care needs.Care plan initiated 3/20/2026 documented that (Interim) R69 requires assistance with ADL's (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting).R165 is 87 years admitted to the facility on [DATE], past medical history includes, but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia oral phase, difficulty walking, hyperlipidemia, essential primary hypertension, unspecified osteoarthritis, etc.On 04/27/2026 at 10:07AM, R165 was observed sleeping in bed and noted with lots of facial hair and long fingernails with brownish substances on both hands. On 04/28/2026 at 12:00 PM, R165 was again observed in bed, still with long dirty nails and lots of facial hair. R165 said that he will like a shave, does not remember the last time his nails were trimmed.MDS assessment dated 4/182026, section c (cognitive patterns) scored R165 with a BIMS score of 10 section gg (functional) of the same assessment indicated that R165 I requires partial to moderate assistance with eating, and dependent on staff for all other activities of daily living (ADL) care needs.Care plan initiated 4/22/2026 documented that resident has an ADL Self Care Performance and Impaired Mobility Deficit related to limited mobility to right hand.R176 is 95 years admitted to the facility on [DATE], past medical history includes, but not limited to other abnormalities of gait and mobility, muscle wasting and atrophy left shoulder, hyperlipidemia, generalized anxiety disorder, hypotension, etc.On 04/27/2026 at 10:45AM, R176 was observed in bed awake and alert and stated that he would like to have a shave, does not recall the last time he was shaved. R176 also has long fingernails on both hands with brownish substances underneath. 04/28/2026 11:00AM, observed R176 again in bed, still with lots of facial hair and long dirty fingernails.MDS assessment dated [DATE], section c (cognitive patterns) scored R176 with a BIMS score of 13 section gg (functional) of the same assessment indicated that R176 requires substantial/maximal assistance to partial/ moderate for all other activities of daily living (ADL) care needs.Care plan initiated 4/22/2026 stated that residents have an ADL Self Care Performance and Impaired Mobility Deficit related to limited mobility to right hand. On 4/29/2026 at 2:52PM, V3 (ADON) said that residents' nails are supposed to be free of debris, clean and at acceptable length. Nail care should be provided by CNAs during Activities of daily Living (ADL) care. Some residents do like their nails long so staff will ask them if they want them to be clipped. V3 said that residents' shaving should also be done during ADL care by the CNAs, residents will be asked if they need their face shaved.General care policy revised 6/20/2025 documented in part: Policy Statement - It is the facility's policy to provide care for every resident to meet their needs.Procedures:1. Upon admission or readmission, the facility will evaluate the resident for physicaland psychosocial needs. Physical needs would include, but are not limited to ADL,wound care, medical needs, etc. Psychosocial needs would include but are notlimited to areas of mental and psychosocial well-being.Nail care policy revised 7/2/2025 stated in part: policy statement: The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections.General guidelines: 1. Nursing staff shall check the residents for nail care which includes cleaning and regular trimming.2. proper nail care can aid in the prevention of skin problems around the nail bed.

Based on observation, interview, and record review, the facility failed to follow the medication pass policy and failed to administer medications within regulatory requirements (within 1 hour before and 1 hour after the scheduled time) therefore failed to maintain a medication error rate below 5%. There were 6 medication errors out of 27 opportunities resulting in a 22.22% medication error rate. Two of four residents (R89, R144) in the medication administration sample were affected.Findings include:R89's Physician Orders include Sevelamer Carbonate 800mg (milligrams) with meals, Amlodipine Besylate 10mg daily, Aspirin chewable 81mg daily, Renal Capsule 1mg daily, and Hydralazine HCL 50mg three times daily.On 4/28/26 at 9:30am, V34 (Licensed Practical Nurse) dispensed R89's Selevamir Carbonate (scheduled for 8am administration per EMAR-Electronic Medication Administration Record), Amlodipine Besylate (scheduled for 7:30am administration per EMAR), Aspirin (scheduled for 7:30am administration per EMAR), Renal Capsule (scheduled for 7:30am administration per EMAR), and Hydralazine (scheduled for 7:30am administration per EMAR) in a medication cup then affirmed she (V34) was prepared to administer the medication. Surveyor inquired about the regulatory requirement for medication administration V34 stated One hour before and 1 hour after. Surveyor inquired why R89's medications were not administered within regulatory requirements V34 responded This is the end of my (V34) med pass, I (V34) had other things I had to prioritize. R144's Physician Orders include Magnesium Oxide 400mg daily and Metoprolol Succinate ER (Extended Release) 25mg (2 tablets) daily.On 4/28/26 at 9:51am, V22 (Registered Nurse) dispensed R144's Metoprolol Succinate ER (scheduled for 7:30am administration per EMAR), and Magnesium Oxide (scheduled for 7:30am administration per EMAR) in a medication cup then affirmed she (V22) was prepared to administer the medication. Surveyor inquired about the regulatory requirement for medication administration V22 stated A hour before or a hour after. Surveyor inquired why R144's medications were not administered within regulatory requirements V22 responded We (staff) try to wrap it up, but it does get busy because we got people going to dialysis and everything. R144 subsequently refused the Metoprolol - which was therefore excluded from the medication error rate. The Medication pass policy (revised 7/25/25) states it is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures.

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that (R1, R17, R49, R74, R105, R136) medications were labeled appropriately, failed to ensure multidose medication were dated when opened, failed to ensure medication carts were lock, failed to ensure medications were stored in locked storage areas, failed to ensure narcotic medications were double locked, and failed to ensure (R25, R133) refrigerated medications and six (6) emergency box insulins were stored within the required temperature range. These failures have the potential to affect 164 residents.Findings include:The 4/26/26 census includes 164 residents.On 4/28/26 at 9:02am, surveyor inspected the (100 - front) medication cart with V35 (LPN/Licensed Practical Nurse). R105's Humalog pen was not in a bag and did not have a pharmacy sticker attached. R105's name was handwritten (in smeared marker) on the Humalog pen and barely legible. Surveyor inquired if medications are supposed to be labeled V35 stated Absolutely and it should be bagged because the bag also has a label on it. On 4/28/26 at 9:04am, V36 (LPN) left the (100 - back) medication cart unlocked and unattended in the hallway. At 9:08am, (5 minutes later) V36 returned to the medication cart. Surveyor inquired if the medication cart was locked (while unattended) V36 proceeded to press the medication cart handle downward and opened the drawer (without touching the electronic lock keypad). Surveyor inquired why the cart wasn't locked V36 stated It was something with the battery, but I (V36) already reported it I wanna say a couple days ago. Narcotic medication was single locked. On 4/28/25 at approximately 9:20am, V34 (LPN) approached the (200 - front) medication cart and opened the drawer (without touching the electronic lock keypad). Surveyor inquired if the medication cart was locked, V34 stated The keypad is not locking. Surveyor inquired if the issue was reported V34 responded It's been reported. Surveyor inquired how long ago the issue was reported V34 replied Maybe a week. Narcotic medication was single locked.On 4/28/26 at 9:53am, the (400 - back) medication cart was inspected with V22 (Registered Nurse) R17's Lispro was opened and undated. V22 inspected R17's Lispro and stated, This one don't have a expiration date. On 4/28/26 at 10:03am, surveyor inspected the (200- back) medication cart with V37 (LPN). V37 affirmed that the Geri-Tussin container was opened and undated. Surveyor inquired about the requirement for multidose medications V37 stated We (staff) put the date that you open it. R1's Lantus pen, R74's Novolog pen, R49's Novolog pen, R136's Lispro pen were opened, unbagged, did not have a pharmacy sticker attached and handwritten names were on each pen. Surveyor inquired about concerns with the opened/unlabeled insulin pens V37 responded If they don't have the bag they supposed to be labeled.On 4/29/26 at 12:13pm, the medication room was inspected with V43 (LPN). The medication refrigerator thermometer was noted to 48F (Fahrenheit) therefore not within the required range. Surveyor inquired about the temperature in the medication refrigerator V43 stated its 48. Surveyor inquired what the medication refrigerator temperature range should be V43 responded 38 and 41. The following contents were in the medication refrigerator at this time: an emergency box containing six (6) insulin pens, R133's Prevnar 20 vaccine, R133's Abrysvo vaccine, and R25's Trulicity insulin. The (April 2026) refrigerator temperature log states temperature range for all refrigerators are to be between 38-41 degrees at all times. The medication storage, labeling and disposal policy (revised 7/2/25) states it is the facility's policy to comply with federal regulations in storage, labeling, and disposal of medications. Medications from the pharmacy will be labelled by the pharmacy to include the name of the resident, route of administration, instruction, medication name, strength, and expiration date when applicable. Medications will be stored safely under appropriate environmental controls. Medications will be secured in locked storage areas. Schedule 2 medications will be double locked (placed in a locked medication cart inside a locked controlled medication box).

Based on observation, interview and record review, the facility failed to ensure resident's refrigerators maintained temperature parameters for food safety; failed to properly log residents' refrigerator temperatures; failed to date outside open food items; and failed to ensure residents refrigerators were clean. These failures affect four residents (R17, R50, R78, and R89) reviewed for safety of personal food items, in a total sample of 67 residents.Findings include: On 4/27/26 at 10:25am, observation of R17's personal refrigerator revealed the absence of a temperature monitoring log. Additionally, a large amount of a brown, sticky substance was noted on the bottom shelf. On 4/27/26 at 10:25am, R17 said, Yes, that's my fridge. Just my food in there. The facility got it for me. Housekeeping usually comes and cleans it. No, I'm not sure when the last time they (housekeeping) came and cleaned it. There used to be a paper on top of the fridge that they (staff) were checking and putting down what the temp was. R17's face sheet documents diagnoses that include but are not limited to osteomyelitis of vertebra, diabetes mellitus, and paraplegia. R17's BIMS (brief interview for mental status) score, dated 3/3126, is 15 which indicates R17 is cognitively intact. On 4/27/26 at 10:33am, V27 (Staffing Coordinator/Scheduler) affirmed that R17's refrigerator lacked a temperature monitoring log and acknowledged that the refrigerator was not clean. V27 said, I think housekeeping is responsible for cleaning the fridge. I am not sure who is responsible for checking the temperatures of the fridge. I think the CNAs, but I am not positive. On 4/27/26 at 10:33am, observation of R50's and R78's personal refrigerator revealed an undated Tupperware container with garlic bread and lasagna and undated clear plastic sandwich bag with cheese puffs inside. On 4/27/26 at 10:33am, R50 said, That container (lasagna and garlic bread) is R78's. Yeah, the cheese puffs too. We (R50 and R78) both use it. R78 just uses it more than me I guess. I've seen housekeeping going through the fridge before. Maybe last week was the last time. R50's face sheet documents diagnoses that include but are not limited to Type 2 diabetes and chronic kidney disease. R50's BIMS (brief interview for mental status) score, dated 2/05/26, is 14 which indicates R50 is cognitively intact. R78's face sheet documents diagnoses that include but are not limited to polyneuropathy, need for assistance with personal care, hypertension, and mixed receptive-expressive language disorder. R78's BIMS (brief interview for mental status) score, dated 4/16/26, is 8 which indicates R78's cognition is moderately impaired. R78 unable to be interviewed due to altered mental status. On 4/27/26 at 10:54am, V51 (Housekeeper) said, We (housekeeping) check the resident's refrigerators. Yeah, clean them and make sure the temperature is good. The CNAs check the food. I won't throw a resident's food out unless I ask them while I'm cleaning. I swear R17 had a temperature log this morning. I'll go check now and clean it (R17's refrigerator). On 4/29/26 at 2:48pm, V3 (Assistant Director of Nursing/ADON) said, Housekeeping makes sure the temperatures are checked, and the refrigerators are clean. Some of refrigerators, I expect open food to be dated and ask resident before discarding. V1's (Administrator) e-mail, dated 4/28/26 at 11:57am, documents, in part, No personal refrigerator policy. On 04/27/2026 at 10:46 AM R89's personal refrigerator had a daily temperature log with no temperature check documentation from 4/23/2026 through 4/27/2026. The thermometer in the refrigerator was observed to be 50 degrees. On 04/27/2026 at 10:49 AM V18 (Nursing Supervisor/Licensed Practical Nurse/LPN) stated the refrigerator should be set at between 38 and 40 degrees. If it is too high, maintenance needs to check it. Refrigerators in residents' rooms are checked and cleaned daily by housekeeping. On 4/27/2026 at 10:51 AM V17 (Housekeeper) stated personal refrigerators in residents' rooms should be between 38 and 41 degrees. If it is below 38 or above 41 degrees, we take the refrigerator downstairs to defrost and clean it. V18 (Nursing Supervisor/LPN) stated R89's refrigerator has not been checked since 4/22/2026. V18 opened the refrigerator and stated to V17 It is 50 degrees inside this refrigerator. It needs to be checked and it should be cleaned. V18 stated We should be concerned. We don't know how long it has been like that since it has not been checked since 4/22/2026. V18 stated the concern is that the food is not properly stored. It could make R89 sick. On 04/27/2026 at 12:33 PM R89 stated staff told R89 they took the refrigerator away because it wasn't working right. Facility policy titled Kitchen revised 6/30/2025 stated if the resident rooms have refrigerators, the facility will ensure that the daily temperature is checked to ensure proper temperature. Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, Your facility must provide equal access to quality care regardless of diagnosis. Your facility must be safe, clean, comfortable, and homelike. Record review of facility job description titled, Housekeeper, dated 12/01/19, documents, in part, In keeping with our organization's goal of improving the lives of the Guests we serve, the Housekeeper plays a critical role in providing superior customer service and housekeeping services to all Guests in the facility. The Housekeeper is responsible maintaining environmental and infection control standards by performing a variety of general cleaning tasks. Cleans and sanitizes Guest rooms, offices, hallways and other areas inside the facility as well as outside and the entire property. Reports all hazardous conditions, damaged equipment, accidents/incidents and supply issues to the supervisor. Maintains the comfort, privacy and dignity of Guests/guests and interacts with them in a manner that displays warmth, respect and promotes a caring environment. Ensure each Guest receives person centered care.

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to follow physician orders, failed to ensure that designated times were specified for applying/removing restorative devices, failed to include all required device(s) in Nursing Rehab tasks, and failed to ensure that staff provide and/or document restorative care/devices for two of 43 residents (R1, R59) in the sample reviewed for range of motion/mobility. Findings include: The general care policy (revised 6/30/25) states that upon admission or readmission, the facility will evaluate the resident for physical and psychosocial needs. The facility will assist the residents to meet these needs. R1's diagnoses include hemiplegia and hemiparesis following cerebral infarction- affecting the right side. R1's Physician Orders include (12/22/25) Right knee brace for contracture management 4 hours daily to progress to as tolerated. (1/20/26) Nursing Rehab: right hand resting splint. R1's (4/14/26) care plan affirms the resident is on a splint and/or brace assistance program. Interventions: please provide assistive and supportive device as needed (right) hand resting splint 2-4 hours daily and right knee brace 4 hours daily. R1's (April 2026) documentation survey report (which specifies Nursing Rehab tasks) includes the right-hand resting splint; however specified times to place on and/or remove the device were excluded. R1's prescribed right knee brace was also excluded. On 4/27/26 at 10:17am, R1's right arm was extremely contracted (at the elbow) and appeared to be in a fixed position - roughly 45-degree angle. R1's right hand was also contracted however the hand/arm splint was observed on the dresser - not in use. V12 (Restorative Aide) entered R1's room and inspected the refrigerators (as requested), however then left the room without applying R1's splint. On 4/27/26 at 10:22am, surveyor inquired why R1's splint was not in use V11 (LPN/Licensed Practical Nurse) stated, Restorative will come through and put it on her (R1). Surveyor inquired when R1's splint should be applied. V11 responded, I (V11) don't know it's different times. R49 (Roommate) replied, They (staff) usually put it on in the morning. On 4/27/26 at 10:24am, V11 (LPN) and V13 (CNA/Certified Nursing Assistant) provided R1's incontinence care then left the room however R1's splint was not applied. On 4/27/26 at 10:42am, surveyor inquired why R1's splint was not in use. V13 (CNA) stated, That's restorative, they (restorative) come around and put em on for her (R1) right hand. This is my (V13) first time working with her, I (V13) think it's their (restorative) department. On 4/27/26 at approximately 10:45am, V16 (Family) stated, We (V15/Family, V16) come here (facility) almost every day. She's (R1) supposed to have a splint on her (R1) right arm, it's not on and she's supposed to have on a leg brace, but they (staff) don't put it on. V16 subsequently opened R1's closet and presented R1's knee brace. On 4/29/26 at 11:57am, surveyor inquired who's responsible for applying and/or removing resident splints. V12 (Restorative Aide) stated, Restorative puts splints on, and on the weekends the CNAS will. I (V12) don't work the weekends. Surveyor inquired where splint application and removal are documented. V12 responded, You (staff) go in the charting (referring to the Electronic Medical Record - Nursing Rehab) where it says you put it on and took it off. Surveyor inquired if the staff name and/or initials are documented when splints are applied and removed. V12 replied, Yes, cause its under my (V12) charting information. Surveyor inquired when R1's splint(s) are supposed to be applied and removed. V12 stated, Anywhere between 2 to 4 hours, it's no designated time when it goes on and when it comes off. Surveyor inquired if it was appropriate to exclude actual times to place and remove resident splints. V12 responded, Yes and no, not necessarily. Surveyor inquired about R1's splints. V12 replied, I put her (R1) splints on today. Surveyor inquired about R1's wound (on the right forearm/antecubital area - identified 2 days prior). V12 stated, I'm (V12) not aware of a wound. On 4/29/26 at 12:05pm, (7 minutes later) R1's right hand splint was on, and a large dressing was observed on the (right) arm with the wound partially exposed. Surveyor inquired when R1's right hand splint was applied. V15 (Family) stated, I (V15) think they (staff) put it on yesterday. [R1's right hand splint is supposed to be on for 2-4 hours daily]. R1's (April 2026) documentation survey report includes Nursing Rehab: assistance with right hand resting splint (off) and assistance with right hand resting splint (on). The response for placing the splint on is Y for Yes or N for No. The response for taking the splint off is 2 for Yes or 1 for No however from 4/1-4/28 the entries are marked X which affirms nothing was documented. On 4/29/26 at 2:55pm, surveyor inquired about R1's (April 2026) right hand splint documentation. V3 (Assistant Director of Nursing) reviewed R1's documentation survey report and stated, It says 6:30am in the morning to 2:30pm but I don't see anything documented it's just X's. If it was applied, a number 1 for No or number 2 for Yes (for off) would be documented. For the (on), it says was the brace/splint applied? a Y for yes and an N for no. All I (V3) see are X's. Surveyor inquired if R1's Nursing Rehab tasks includes a right knee brace. V3 responded, No. The restorative nursing policy (revised 7/3/25) states it is the policy of this facility to assess for comprehensive nursing and restorative needs upon admission. Appropriate nursing and restorative services consistent to the resident's functional needs must be provided. Restorative programs shall be reflected and indicated in the resident's electronic restorative log in order to document the provision of services and the frequency by the Nurses, CNA's and/or restorative aides. R59 is 72 years and has resided at the facility since 2022, face sheet listed the following past medical history in part: hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, unspecified protein calorie malnutrition, depression, acute ischemic heart disease, other seizures, hyperlipidemia, essential primary hypertension, dysphasia, etc. Minimum Data Set (MDS) assessment dated [DATE], section c (cognitive patterns) scored R59 with a brief interview for mental status (BIMS) score of 3, section gg (functional) of the same assessment indicated that r59 is dependent on staff for all activities of daily living (ADL) care needs. On 04/27/2026 at 11:00AM, resident was observed in bed sleeping, contracture noted to the left side, resident did not have any brace or splint to his left side, Fingernails noted to be long and dirty with the left fingernails digging into resident's hands. On 04/28/2026 at11:10AM, R59 was observed again in bed, awake and alert and stated that he needed to be turned. R59 was asked if he had any splint, brace or arm rest that goes to his left side, and he said no. Physician order dated 05/01/2024 documented the following: Nursing Rehab: Assistance with splint or brace (specify) resting hand splint to left upper extremity (LUE) at bedtime. Order for right arm rest comfort ACTA_BACK, order date 8/15/2024. On 4/28/2026 at 11:50AM V44 (CNA) said that she is not assigned to R59 today but has worked with him before and does not recall resident having any splint or brace or arm rest for his left side. V44 asked resident if he had any splint or brace and he said no. On 4/28/2026 at 2:02PM V45 (LPN/ restorative nurse) was presented with this observation, and he could not state whether R59 has any type of splint, brace or arm rest. On 4/28/2026 at 2:13PM, V46 (Restorative aide) said that resident does not have any brace or splint or arm rest, V46 have not seen resident with any since she starred working here. Documentation survey report for April 2026 presented by V3 (ADON) under nursing rehab: assistance with left hand resting splint application and removal was marked with an X for the whole month, except on 4/29/2026, after surveyor brought it to the attention of the restorative nurse and aide.

Based on observation, interview and record of review, the facility failed to develop a baseline care plan and failed to provide the resident with a copy/summary of the baseline care plan. This failure affected one resident (R202) in a sample of three residents reviewed for baseline care planning. Findings include: R202's face sheet documents R202 is a [AGE] year-old resident that admitted to the facility on [DATE]. R202's diagnoses include, but is not limited to: surgical aftercare following surgery on the skin, muscle wasting and atrophy, anemia, type 2 diabetes mellitus with hyperglycemia, hypertension, acute kidney failure, Fournier Gangrene. R202's progress notes document R202 admitted to the facility on [DATE] and is alert and oriented x 4 (person, place, time, situation). R202 was admitted to the facility following hospitalization for a fall and an infected groin wound. There is no indication in the progress notes that R202's baseline care plan was developed, or a copy of the baseline care plan was given to R202. On 4/27/2026 at 10:44 AM, R202 explained that R202 was a new resident of the facility and had admitted about 5 days ago. R202 denied ever receiving a copy of R202's baseline care plan. R202 stated, No, I don't know anything about a care plan. They told me I have a care plan meeting on the 29th, but I was never provided a copy of any baseline care plan or a summary. Yes, I would have wanted a copy of that. R202 affirmed R202 is at the facility to receive therapy services and wound care after being diagnosed with a groin wound and sepsis. R202's baseline care plan does not indicate R202 is receiving therapy services. There is no documentation on the baseline care plan that the baseline care plan or the summary was provided to R202. On 4/27/2026 at 1:10 PM, V21 (MDS Coordinator, Registered Nurse) affirmed V21 was the RN assessment coordinator for the facility, and oversees the development of the care plans with the interdisciplinary team. V21 explained residents are supposed to get a copy of the baseline care plan within 48-72 hours of admission and that it should be documented in the clinical record. V21 was unsure which staff member provides the baseline care plan or summary between the admission nurse, guest services, and the social services staff. V21 reviewed R202's clinical record and affirmed there was no documentation the baseline care plan or summary was distributed to R202. V21 stated, (R202) should have recieved a copy by (4/25/2026) or (4/26/2026), it should be documented in the chart. There is no documentation. V21 reviewed the baseline care plan in the chart and affirmed the base line care plan did not address R202's therapy goals. V21 accessed the medical record and affirmed V21 was actively being treated by therapy and had orders by R202's physician to treat. V21 affirmed therapy services should have been included on the baseline care plan. V21 explained the purpose of the baseline care plan is to inform/identify the resident/staff of diagnoses, problems, and treatment goals to ensure the residents needs are being met. Facility care plan policy (6/30/2025) documents It is the policy of the facility to ensure that all care plans including base line care plans are in conjunction with the federal regulations . Based on F655 regulation a baseline care plan will be completed within 48 hours of admission. 1.During admission, the facility may put in place baseline care plans within 48 hours to address resident's care. 2. The baseline care plan at a minimum should include initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and PASARR recommendations if applicable. 3. The facility will provide the resident/representative a written summary of the baseline care plan by the completion of the comprehensive care plan. This policy does not meet regulatory requirements for baseline care planning, as the facility must provide a copy of the baseline care plan or summary to the resident. By providing a summary of the baseline care plan to the resident upon completion of the comprehensive care plan, a resident would not be allowed to participate in the care planning process until the development of the comprehensive care plan.

Based on interview and record review, the facility failed to ensure that staff revise and update resident's (R197) care plan after a fall to address a newly acquired fracture and head injury and failed to update a resident's (R16) care plan to reflect the correct advance directives. These failures affect two (R16 and R197) of two residents reviewed for care plan revision in a sample of 67 residents.Findings include: R16 is [AGE] years old and have resided at the facility since 2025, face sheet listed the following past medical history in part: nontraumatic intracerebral hemorrhage, iron deficiency anemia, gastrostomy status, adult failure to thrive, hear failure, diabetes mellitus, etc. Per record review, R16 was listed as a do not resuscitate (DNR) and do not hospitalize (DNH) on his face sheet. IDPH uniform Practitioner order for life sustaining treatment (POLST) form dated [DATE] documented that R16 is a DNR and DNH. Care plan initiated [DATE] documented the following: ADVANCE DIRECTIVE STATUS (CODESTATUS: Full Code) Pursuant to resident rights, personal choices, and the individual's desire to retain control and autonomy over his health care decisions, the individual (or representative) has been educated on Advance Health Care (including end of life care) options. The resident's existing Advance Directive will be honored. The EMR chart should identify FULL CODE status On [DATE] at 12:26PM V5 (Social Service Director) was presented with this observation and she said that social service department is responsible for the resident's advance directive, if a resident's code status changes, the care plan should be updated, social service staff are supposed to check weekly for any changes in resident's code status and update accordingly. Surveyor asked V5 what could be the implication of not having the righr code status in resident's care plan and she said that staff will not follow the rifght advance dirctive and resident's wishes in an emergency situation. R197's face sheet documents R197 was a [AGE] year-old resident with a prior medical history of chronic obstructive pulmonary disease, dementia without behavioral disturbance, restlessness and agitation, iron deficiency anemia, contusion of the head, and displaced supracondylar fracture of the right humerus. R197's minimum data set ([DATE]) documents R197 had a brief interview of mental status summary score of 3, indicating R197 had severe cognitive impairment. R197 required substantial/maximal assistance with personal hygiene (including washing/drying face) and required partial/moderate assistance with transferring. R197's hospital records ([DATE]) document R197 presented to the emergency department from emergency medical services (EMS) from the nursing home after suffering a fall. Per EMS, R197 was sitting in the wheelchair and reached for an object on a table and subsequently fell and hit head against the ground. R197 was unable to recall what happened. Imaging was completed and R197 was diagnosed with 1) closed supracondylar fracture of right humorous 2) fall 3) traumatic hematoma of forehead. R197 was discharged to the facility and asked to follow up with primary care in 1-2 days. R197's progress notes document on [DATE] at 6:36 AM, (R197) was sitting in wheelchair when she leaned too far forward reaching for something and fell out of wheelchair striking head. Pt noted with hematoma, soft BP, slightly hypoxic requiring o2 application, amd on Asa. Due to culmination of all of this will refer to ED for eval. At 7:56 AM, (Private Ambulance Company) here to transport resident to (hospital) for eval. Resident is leaving in stable condition. At 10:57 PM, Resident returned from (Emergency Department), after a fall. Dx: closed supracondylar fx rt humerus, and traumatic hematoma to her forehead. Right arm is placed in a splint., intact and elevated. Resident is alert and oriented to baseline. Resident placed in bed and made comfortable, call light within reach. Fall precautions in place, plan of care ongoing. There is no progress notes documented in the records until [DATE] at 12:02 PM, LATE ENTRY Note Text: 9:10am While rounding resident observed resting in bed comfortably. 10:30am Resident offered medication and tolerated well writer took vitals BP 119/62, hr 88, r-18, O2-98%. 11:11am CNA was rounding on resident and noted in bed unresponsive to name. CNA alerted writer. Writer assessed resident and residentnoted in bed unresponsive to verbal stimuli, painful and tactile stimuli. Writer verified code status, resident is a full code. Writer unable topalpate carotid or radial pulse. 11:12am Code blue initiated, CPR started and 911 called. AED applied with no shock advised. CPR continues with vitals unable to be obtained. CPR ongoing. 11:20am Evergreen Park paramedics and fire department arrive at the facility and took over compressions. 11:30am (Nurse Practitioner) notified of clinical status. 11:40am (V70 - Family Member) notified of change in condition and stated that (V70) was in route to the facility. 11:46am Paramedics CPR efforts cease and was pronounced deceased by (physician) 11:50am (EMS) left facility.12:00pm Postmortem care initiated. Facility final incident report ([DATE]) to the department documents R197 experienced an unwitnessed fall in her room. At approximately 6:00 AM, (V72- Certified Nursing Assistant) provided ADL and incontinence care and transferred R197 to the wheelchair. R197 wanted to remain in her room. (V72) left R197 in the room unsupervised and continued morning rounds. Staff heard R197's roommate yelling for help and observed R197 on her left side with a hematoma to the head. R197 told staff that R197 was trying to reach down and pick something up off the ground when R197 slid off the wheelchair. R197 was wearing non-skid socks and the environment was dry. R197 was treated at the hospital and diagnosed with a closed fracture of the right humerous. The facility was given instructions to follow up with an orthopedic physician and the plan of care was updated to address the needs of R197. R197's care plan documents R197 is at high risk for falls related to unsteady gait and dementia. R197 had goals of being free from fall related injury. Interventions to address the high fall risk in place included, I prefer to keep all needed items like water pitcher, tissue box, urinal, etc, within reach ([DATE]), : I would like staff to provide me a safe environment: even floors, free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side rails as ordered, handrails on walls ([DATE]), Remind me to ask for assistance. Reorient me on how to use the call light, if necessary ([DATE]), Please make sure that my call light is within my reach and encourage me to use it for assistance as needed. I would like staff to address my needs with a prompt response to all requests for assistance. >Fall Mats/Early Riser. R197 also required assistance from staff for hygiene. R197's care plan was not updated to include any new interventions after the fall sustaining injury on [DATE], as indicated in the facility report. There was no care plan developed or revised to address the fracture of the right humerus, splint use, monitoring of neurological decline/injury after R197 sustained head injury. This review directly contradicts the facility's report that The plan of care has been updated to address the needs of (R197). On [DATE] at 2:02 PM, V18 (House Supervisor/Licensed Practical Nurse/Falls Nurse) affirmed V18 oversees the fall prevention program for the facility and assists with fall investigations. V18 reviewed R197's electronic health record and the investigative reports related to the incident. V18 affirmed that R197's care plan was not updated after the fall to address the new fracture or head injury. V18 explained the facility completed post-fall charting and neurological checks after the fall to check for level of consciousness, neurological decline. On [DATE] at 4:15 PM, V2 (Director of Nursing) affirmed V2 was familiar with R197 and completed the investigation into the fall. V2 accessed R197's electronic health record. V2 affirmed that facility staff should be following the care plan and the care plan was not revised to include the humorous fracture diagnosis or head trauma. V2 affirmed that a plan of care should have been developed. Record review of CMS' Resident Assessment Instrument (RAI) Manual ([DATE]) documents in part, Falls result in serious injury, especially hip fractures . DEFINITIONS INJURY RELATED TO A FALL Any documented injury that occurred as a result of, or was recognized within a short period of time (e.g., hours to a few days) after the fall and attributed to the fall. INJURY (EXCEPT MAJOR) Includes, but is not limited to, skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall-related injury that causes the resident to complain of pain. MAJOR INJURY Includes, but is not limited to, traumatic bone fractures, joint dislocations/ subluxations, internal organ injuries, amputations, spinal cord injuries, head injuries, and crush injuries. A fall refers to unintentionally coming to rest on the ground, floor, or other lower level or as a result of an overwhelming external force (e.g., being pushed by another resident). A fall without injury is still a fall. Falls are a leading cause of morbidity and mortality among the elderly, including nursing home residents. Falls may indicate functional decline and/or the development of other serious conditions, such as delirium, adverse medication reactions, dehydration, and infections. A potential fall is an episode in which a resident lost their balance and would have fallen without staff intervention .The information gleaned from the assessment should be used to identify and address the underlying cause(s) of the resident's fall(s), as well as to identify any related possible causes and contributing and/or risk factors. The next step is to develop an individualized care plan based directly on these conclusions. The focus of the care plan should be to address the underlying cause(s) of the resident's fall(s), as well as the factors that place them at risk for falling .Facility policy titled Care Plan (revised [DATE]) documents in part, It is the policy of the facility to ensure that all care plans including base line care plans are in conjunction with the federal regulations . 5. These will be periodically reviewed and revised by a team of qualified person after each assessment .

Based on observation, interview, and record review, the facility failed to follow policy procedures, failed to ensure that multiple linen layers were not on the LALM (Low Air Loss Mattress) while in use, failed to implement preventive interventions, and/or failed to identify skin integrity impairment for one of 43 residents (R174) in the sample reviewed for pressure ulcers. Findings include: R174's progress note, dated 3/10/26, per V48 (Wound Care Nurse Practitioner), documents, in part, Patient (R174) was examined, found to have no active wounds. Continue current preventative measures. Nursing staff to contact wound care with any new open wounds. R174's progress note, dated 4/09/26, per V57 (Wound Care Nurse Practitioner), documents, in part, Patient (R174) being seen today for new skin alteration. New site noted to right bunion, treatment recommendation provided. Wound Assessment: Location: Right bunion; Primary Etiology: Pressure Ulcer/Injury; Stage/Severity: DTI (Deep Tissue Injury); Wound Status: New; Size: 1 cm x 1.1 cm x 0 cm. Calculated area is 1.1 sq cm.; Treatment Recommendations: 1. Cleanse with normal saline. 2. apply Skin Prep to base of the wound. 3. secure with Leave open to air. 4. change 3 times per week, and PRN. R174's progress note, dated 4/16/26, per V48 (Wound Care Nurse Practitioner), documents, in part, Patient (R174) being seen today for new skin alteration. New site noted to right bunion, treatment recommendation provided. 4/16/26: Wound is stable and measuring larger in size since previous assessment, reviewed results of doppler with ABI (ankle brachial index) exam performed 4/16/26 for suspected arterial insufficiencies: Results: No hemodynamically significant arterial stenosis seen bilaterally. Wound Assessment: Location: Right bunion; Primary Etiology: Pressure Ulcer/Injury; Stage/Severity: DTI (deep tissue injury); Wound Status: Present on Admission; Size: 1 cm x 2 cm x 0 cm. Calculated area is 2 sq cm; Continue with current recommendations at this time. Continue to recommend pt (R174) float heels while in bed with use of heel boots. Patient (R174) is at moderate risk for pressure ulcer formation related to incontinence of urine and stool, decreased mobility, and comorbidities. Treatment Recommendations: 1. Cleanse with normal saline. 2. apply Skin Prep to base of the wound. 3. secure with Leave open to air. 4. change 3 times per week, and PRN. (Wound is larger) R174's progress note, dated 4/23/26, per V48 (Wound Care Nurse Practitioner), documents, in part, 4/16/26: Wound is stable and measuring larger in size since previous assessment, reviewed results of doppler with ABI exam performed 4/16/26 for suspected arterial insufficiencies: Results: No hemodynamically significant arterial stenosis seen bilaterally. Wound Assessment: Location: Right bunion; Primary Etiology: Pressure Ulcer/Injury; Stage/Severity: DTI; Wound Status: Stable; Size: 1 cm x 2 cm x 0 cm. Calculated area is 2 sq cm.; Continue with current recommendations at this time. Patient has limited mobility. Please ensure that patient is turned and/or repositioned when in or out of bed as per facility protocol. Continue to recommend pt (R174) float heels while in bed with use of heel boots. Patient is at moderate risk for pressure ulcer formation related to incontinence of urine and stool, decreased mobility, and comorbidities. 4/23/26: DTI to right bunion remains stable, no changes to measurements or tissue quality. On 4/28/26 at 10:25am, R174 was observed lying in bed on a low air loss (LAL) mattress, with both feet/heels resting directly on the mattress (heels not offloaded) and without the use of heel protection devices (heel boots). On 4/16/26, V48 (Wound Care Nurse Practitioner) recommended R174 to float heels while in bed with use of heel boots. R174's face sheet documents diagnose that include but are not limited to hypertension, history of falling, syncope and collapse, low back pain, and chronic diastolic heart failure. R174's BIMS (brief interview for mental status) score, dated 4/10/26, is 8 which indicates R174's cognition is moderately impaired. R174 unable to be interviewed due to altered mental status. R174's Braden Scale, dated 3/27/26, documents a score of 7 which indicates R174 is at high risk for developing pressure ulcers. R174's Braden Scale and Clinical Evaluation, dated 3/27/26, documents, in part, Does the resident have a history of and/or existing pressure ulcer? Yes; Left heel and sacrum resolved. R174's Order Summary Report, dated 4/29/26, documents, in part, Low Air Loss Mattress. R174's Order Summary Report, dated 4/29/26, documents, in part, right bunion - cleanse with ns (normal saline) and pat dry. apply skin prep and LOTA (leave open to air) every day shift every Tue, Thu, Sat for wound care. R174's care plan, dated 7/18/23, documents, in part, (R174) with difficulty in turning and repositioning every day due to weakness on lower legs and feet limited range of motion due to the contributing medical condition and factors affecting function. R174's care plan, dated 7/18/23, documents, in part, admitted with self-care deficit in ADL (activities of daily living) Dressing Bathing Grooming, with interventions that documents, in part, 'Provide assistance with dressing, bathing, personal hygiene, toileting, transferring, and eating as needed. R174's care plan, dated 7/21/25, documents, in part, Resident (R174) has an actual impairment to skin integrity. Pt is noncompliant with wound care recommendation, with interventions that documents, in part, HIGH RISK -Skin check every shift. Report abnormalities to the nurse; Off load heels; Turn and reposition at least every 2 hours and as needed. R174's progress note, dated 4/16/26, documents, in part, Resident (R174) has been experiencing a decline in ADL (activities of daily living) performance and mobility. Referred to therapy. On 4/29/26 at 9:29am, V48 (Wound Care Nurse Practitioner) said, R174 had bilaterial arterial and venous doppler done of her (R174) legs and it showed no stenosis, was negative. Yes, she (R174) has a pressure ulcer on her (R174) right medial foot that was acquired here (facility). I did the original skin assessment (3/10/26) and there were no skin issues. I was on vacation when the new pressure ulcer developed, this new deep tissue injury (DTI). My colleague was the one that did the first assessment of R174's new ulcer. I am not sure if R174's DTI was avoidable. The arterial and venous doppler were negative, but I still cannot say if the DTI (R174) was avoidable. I am not sure how she (R174) could have gotten it (DTI). DTIs are caused by anything that would subject the area to constant pressure. Record review of R174's POC (PointClickCare)Task: MONITOR - Turn and Reposition: Was resident turned and repositioned? documents, in part, the following: 3/31/26: 3 entries at 3:08am showing R174 was repositioned; 1 entry at 8:00am; 1 entry at 10:00am; 1 entry at 12:00pm; 1 entry at 2:00pm; 1 entry at 8:36pm; 2 entries at 8:37pm; 1 entry at 10:15pm. 4/01/26: 1 entry at 11:50am; 1 entry at 11:51am; 2 entries at 8:42pm; 1 entry at 8:43pm; 1 entry at 9:06pm 4/02/26: 4 entries at 6:06am; 1 entry at 8:00am; 1 entry at 10:00am; 1 entry at 12:00pm; 1 entry at 2:00pm; 1 entry at 3:20pm; 1 entry at 6:00pm; 1 entry at 8:00pm; and 1 entry at 10:00pm. 4/03/26: 1 entry at 5:42am; 3 entries at 5:43am; 1 entry at 8:00am; 1 entry at 10:00am; 1 entry at 12:00pm; and 1 entry at 2:00pm. 4/04/26: 1 entry at 10:12pm; and 3 entries at 10:13pm. 4/05/26: 4 entries at 5:56am; 1 entry at 8:59am; 1 entry at 12:05pm; 1 entry at 12:06pm; and 1 entry at 1:02pm. 4/06/26: 1 entry at 8:00am; 1 entry at 10:00am; 1 entry at 12:00pm; 1 entry at 2:00pm; 1 entry at 5:00pm; 1 entry at 5:02pm; 1 entry at 7:26pm; and 10:19pm. 4/07/26: 2 entries at 5:32am; 2 entries at 5:33am; 1 entry at 8:00am; 1 entry at 10:00am; 1 entry at 12:00pm; 1 entry at 2:00pm; 1 entry at 9:58pm. 4/08/26: 4 entries at 2:13pm; 1 entry at 4:10pm; 1 entry at 5:37pm; 1 entry at 8:23pm; and 10:17pm. 4/09/26: 1 entry at 4:17pm; 1 entry at 6:43pm; 1 entry at 8:28pm; and 10:02pm. 4/10/26: 1 entry at 8:00am; 1 entry at 10:00am; 1 entry at 12:00pm; 1 entry at 2:00pm; 1 entry at 3:45pm; and 3 entries at 10:25pm. 4/11/26: There was no documentation that R174 was repositioned for this day. 4/12/26: 3 entries at 5:09am; 1 entry at 5:10am; and 1 entry at 4:22pm. 4/13/26: 4 entries at 5:02am; 1 entry at 7:55am; 1 entry at 9:16am; 1 entry at 12:39pm; and 1 entry at 2:01pm. 4/15/26: 1 entry at 1:33pm; 3 entries at 1:34pm; 1 entry at 9:39pm; and 3 entries at 9:41pm. 4/16/26: 1 entry at 8:00am; 1 entry at 10:00am; 1 entry at 12:00pm; 1 entry at 2:00pm; 1 entry at 5:17pm; 1 entry at 7:27pm; 1 entry at 7:14pm; and 1 entry at 9:54pm. 4/18/26: 2 entries at 7:35pm and 2 entries at 9:55pm. 4/19/26: 2 entries at 2:42am; 1 entry at 8:00am; 1 entry at 10:00am; 1 entry at 12:00pm; 1 entry at 2:00pm; and 1 entry at 11:59pm. 4/20/26: 3 entries at 6:27am; 1 entry at 8:00am; 1 entry at 10:00am; 1 entry at 12:00pm; 1 entry at 2:00pm; 1 entry at 4:00pm; 1 entry at 6:00pm; 1 entry at 8:00pm; and 1 entry at 10:00pm. 4/21/26: 1 entry at 10:00am; 1 entry at 12:00pm; 1 entry at 2:00pm; 1 entry at 4:20pm; 2 entries at 10:28pm; and 1 entry at 10:29pm. 4/25/26: 3 entries at 3:54am and 1 entry at 5:55am. 4/27/26: 1 entry at 12:00am; 1 entry at 2:00am; 1 entry at 4:00am; 1 entry at 6:00am; 1 entry at 11:48am; 2 entries at 11:51am; and 1 entry at 2:00pm. On 4/29/26 at 12:44pm, with V40 (Wound Care Nurse/LPN) and another surveyor, R174 was lying in bed, with both feet/heels resting directly on the mattress (heels not offloaded) and without the use of heel protection devices (heel boots). V40 said, They (R174's feet) are probably not off loaded because she (R174) is eating. The LAL mattress helps with offloading. I'm not sure about the heel boots, I'll check. Surveyor inquired the reason that R174's heels cannot be off loaded while eating, V40 replied, Well, I guess they (R174's feet) can. V40 stated, R174 has a deep tissue injury, but it may not be an actual deep tissue injury. It may be a diabetic ulcer or vascular ulcer. Surveyor stated that R174 recently had an arterial and venous ultrasound done which showed R174 doesn't have vascular insufficiency issues. V40 replied, Oh, that's right. You see that (arterial/venous doppler)? Let me check her (R174) diagnoses. On 4/29/26 at 12:57pm, V40 (Wound Care Nurse/LPN) said, R174 does not have diabetes. She (R174) does have a pressure ulcer classified as a deep tissue injury. Yes, it (pressure ulcer) was acquired here (facility). No, not necessarily prolonged pressure, deep tissue injuries are caused by pressure, but not necessarily prolonged pressure. There's damage to the tissue caused by pressure. R174's pressure ulcer is unavoidable. Surveyor asked what makes R174's pressure ulcer unavoidable? V40 replied, Well.ummm. cause it's not really a pressure point. Surveyor said, You don't think R174's deep tissue injury location is on a pressure a point? V40 replied, No, no. It is on a pressure point. Surveyor asked again, what makes R174's pressure ulcer unavoidable and V40 replied, Cause that is what I believe, it (R174's pressure ulcer) was unavoidable. Surveyor asked if V40's statement, Cause that is what I believe, is V40's response to the question What makes R174's pressure ulcer unavoidable, V40 replied, Yes. There may be more evidence in my boss's office, but she is on vacation and not here. On 4/29/26 at 2:28pm, V3 (Assistant Director of Nursing/ADON) said, I'm not sure if staff charts in PCC every time, they (staff) turn a resident or just once a shift. I'll have to check. I'll look into getting you more information on R174's pressure ulcer regarding the determination of unavoidability. On 4/30/26 at 12:42pm, On 4/30/26 at 12:42pm, V66 (Registered Dietician) said, According to records, R174's appetite varies from poor to good. Multiple supplements are offered to her (R174). She (R174) is considered underweight but has been stable between 131 to 137 pounds for over 3 months now. Albumin is not a great indicator for nutritional status. It can vary due to what is going on in the residents' system. I am not sure if her (R174) current nutritional status is a cause or affects the pressure ulcer. What I can say is, she (R174) is a stable patient (R174) and she's (R174) receiving her nutritional means and her (R174) needs are being met. On 4/30/26 at 2:00pm, V48 (Wound Care Nurse Practitioner) said, R174's pressure ulcer is considered unavoidable. (R174) had a low air loss mattress in place, and there were no facility-related factors identified that would have caused pressure to the bunion area. (R174) has a medical history of heart failure and hypertension, as well as advanced age and limited mobility, all of which are risk factors for pressure injury development. Yes, for limited mobility staff should be turning and repositioning R174 every 2 hours. The staff should be following my recommendations to have R174's heels offloaded, and heel protection boots. I talked with the staff to put these in place. When used, heel boots are intended to offload and protect the entire foot, with built-in padding to reduce pressure. I can't really give you an exact cause for the ulcer. Given the location, arterial and venous studies were considered negative but R174 does have heart failure, which can contribute to circulatory issues, although no specific arterial or venous abnormalities were identified. These conditions may increase the resident's overall risk for developing additional wounds. The offloading and heel boots I recommended April 16th (4/16/26). The heel boots are to be on at all times while the resident (R174) is in bed. I did see R174 today and cannot confirm whether they (heel boots) were in place at that time. The nurse had prepared the resident (R174) prior to the assessment. I cannot really say if the heel boots, offloading of heels, and repositioning the resident (R174) are not being done is not helping or delaying healing the ulcer (R174's pressure ulcer) but the staff need to be doing these things. V48 affirmed the interventions for R174 in regard to the heel boots, offloading of heels, and repositioning R174 every 2 hours are in place to help improve and prevent worsening of R174's facility acquired pressure ulcer. Facility presented document titled, Wound Specialist's Assessment of Wound/Pressure Injury Avoidability/Unavoidability, dated 4/29/26 at 4:44pm, per V48 (Wound Care Nurse Practitioner) documents that R174's DTI was unavoidable due to comorbidities and interventions in place such as offloading of heels with pillows or other devices and turning and repositioning every 2 hours. Surveyor observed on 2 separate days (4/28/26 and 4/29/26) that R174's heels were not off loaded with pillows or other devices. Record review shows that out 28 days, R174 was repositioned per V48 (Wound Care Nurse Practitioner) recommendations of every 2 hours, only 7 out of 28 days. Surveyor did not receive facility's expectations on charting when repositioning residents. E-mail from V3 (Assistant Director of Nursing/ADON), dated 4/30/26 at 9:34am, documents, in part, we (facility) do not have a policy for turning/repositioning.

Based on observation, interview, and record review, the facility failed to follow provider order for continuous oxygen, failed to ensure the nebulizer mask was labeled with the date it was changed, and failed to ensure the respiratory equipment was contained when not in use. These failures affected two (R101 and R129) residents reviewed for respiratory care in the total sample of 67 residents.Findings include: On 04/27/2026 at 10:53am, there was a red and white sign posted on R129's door frame No smoking, No open Flame, Oxygen in use. Inside R129's room, there was a nebulizer mask and tubing by R129's nightstand. On 04/27/2026 11:03am, V22 (Registered Nurse) checked R129's nebulizer mask on R129 nightstand and stated the nebulizer mask and tubing were not labeled with date and were not contained. V22 stated these should be dated and contained in clear plastic bag. V22 took R129 mask and tubing and stated she would provide her (R129) with a new nebulizer mask and tubing. On 04/28/2026 at 2:02pm, V2 (Director of Nursing) stated the nebulizer mask should be contained in clear plastic bag when not in used to prevent cross contamination and to prevent infection. Changing of nebulizer mask is weekly on Sunday night and as needed. The staff who changed the mask should label it with the date it was changed for the same reason; to prevent cross contamination and to prevent infection. R129's (Active Order As Of: 04/27/2026) Order Summary Report documented, in part Diagnoses: (include but are not limited to) chronic obstructive pulmonary disease, hypertension, respiratory failure with hypoxia, and sepsis. Order Summary: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-. Albuterol) 1 vial inhale orally every 6 hours as needed for SOB (shortness of breath)/Congestion. Active 04/09/2026. R129's (04/12/2026) Minimum Data Set documented, in part Section C. – Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating the resident's mental status as cognitively intact. Section I. Active Diagnoses. I8000. Acute respiratory failure, muscle wasting, and sepsis. R129's (04/10/2026) careplan documented, in part Focus: is at risk for alteration in respiratory functioning related to: COPD, acute respiratory failure with hypoxia. Goal: Resident will not have respiratory distress and that their respiratory functioning will improve or maintain. Interventions: Administer oxygen and other medications and respiratory treatments as ordered. The (04/28/2026) email correspondence with V2 (Director of Nursing) documented, in part It is the expectation of this facility that respiratory equipment (when not in use) be bagged. The (7/3/25) Respiratory Therapy Equipment Use documented, in part Policy Statement: It is the facility's policy to ensure that oxygen and nebulizer equipment use is compliant with the acceptable standards of practice. Procedures: 1. All oxygen equipment including nasal cannula, humidifier, and nebulizer mask will not be reused. 2. Once opened, this equipment will be dated and discarded after 7 days of use, whether used continuously or on a prn (as needed) basis. R101's face sheet documents in part the following diagnoses: end stage renal disease, hypertension, peripheral vascular disease, acute pulmonary edema, acute respiratory failure with hypoxia, acquired absence of bilateral legs below the knee, anemia in chronic kidney disease, and major depressive disorder. R101's minimum data set (1/12/2026) documents in part a brief interview of mental status (BIMS) summary score of 15, indicating R101 is cognitively intact. R101 had a medical order in the electronic health record dated 4/14/2026 for oxygen continuous three liters per minute via nasal cannula by V14 (Nurse Practitioner). End date indefinite. On 4/28/2026 at 8:43 AM, observed R101 not wearing oxygen. Oxygen tubing and nasal cannula were laid over the machine and not in bag. R101 stated they (staff) took the oxygen off earlier this morning and did not put it back on me. On 4/28/2026 at 8:48 AM V32 (Certified Nursing Assistant) stated oxygen tubing and cannula should be in in a bag so it does not get dirty. Pointing to R101's oxygen tubing, V32 stated that oxygen tubing and cannula should be in a bag. It's not right. The risk is that R101 could get an infection. If R101 breathes in air that has dirt in it or if the tubing and cannula hit the floor, whatever is in the air or on the floor it could make R101 sick. On 4/28/2026 at 8:50 AM V18 (House Supervisor/Licensed Practical Nurse/LPN) stated R101 should be on oxygen. R101's order is for continuous oxygen. V18 pointed to R101's oxygen tubing and cannula and stated, That tubing should be in a bag. Policy titled Physician Orders revised 7/3/2025 stated it is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS (plan of service). Policy titled Oxygen Therapy and Administration reviewed 7/2/2025 documented the procedure to include confirm order from physician which should include liter flow, FiO2 and delivery device).

Based on interview and record review, the facility failed to document post-fall charting and neurological checks (neurocheck) charting in a timely manner, in accordance with professional standards. This failure caused R197's medical records not to be readily accessible or accurate for up to 9 days after R197's fall. This failure affected one (R197) of 67 residents reviewed for resident records. R197's face sheet documents R197 was a [AGE] year-old resident with a prior medical history of chronic obstructive pulmonary disease, dementia without behavioral disturbance, restlessness and agitation, iron deficiency anemia, contusion of the head, and displaced supracondylar fracture of the right humerus. R197's minimum data set ([DATE]) documents R197 had a brief interview of mental status summary score of 3, indicating R197 had severe cognitive impairment. R197 required substantial/maximal assistance with personal hygiene (including washing/drying face) and required partial/moderate assistance with transferring. R197's progress notes document on [DATE] at 6:36 AM, (R197) was sitting in wheelchair when she leaned too far forward reaching for something and fell out of wheelchair striking head. Pt noted with hematoma, soft BP, slightly hypoxic requiring o2 application, amd on Asa. Due to culmination of all of this will refer to ED for eval. At 7:56 AM, (Private Ambulance Company) here to transport resident to (hospital) for eval. Resident is leaving in stable condition. At 10:57 PM, Resident returned from (Emergency Department), after a fall. Dx: closed supracondylar fx rt humerus, and traumatic hematoma to her forehead. Right arm is placed in a splint., intact and elevated. Resident is alert and oriented to baseline. Resident placed in bed and made comfortable, call light within reach. Fall precautions in place, plan of care ongoing. There is no progress notes documented in the records until [DATE] at 12:02 PM, LATE ENTRY Note Text : 9:10am While rounding resident observed resting in bed comfortably. 10:30am Resident offered medication and tolerated well writer took vitals BP 119/62, hr 88, r-18, O2-98%. 11:11am CNA was rounding on resident and noted in bed unresponsive to name. CNA alerted writer. Writer assessed resident and resident noted in bed unresponsive to verbal stimuli, painful and tactile stimuli. Writer verified code status, resident is a full code. Writer unable to palpate carotid or radial pulse. 11:12am Code blue initiated, CPR started and 911 called. AED applied with no shock advised. CPR continues with vitals unable to be obtained. CPR ongoing. 11:20am Evergreen Park paramedics and fire department arrive at the facility and took over compressions. 11:30am (Nurse Practitioner) notified of clinical status. 11:40am (V70 - Family Member) notified of change in condition and stated that (V70) was in route to the facility. 11:46am Paramedics CPR efforts cease and was pronounced deceased by (physician) 11:50am (EMS) left facility.12:00pm Postmortem care initiated.R197's neurochecks initiated after the fall on [DATE] document V73 signed neurochecks as complete on [DATE] and [DATE], V69 signed neurocheck as complete on [DATE], and V75 (Agency Registered Nurse) signed neurochecks as complete on [DATE].R197's post-fall follow up Day 1 2/3 was signed by V69 on [DATE] as complete. Day 2 (1/3, 2/3) were signed by V75 as complete on [DATE]. Day 2 (3/3) was signed as complete by V73 on [DATE]. There was no post fall charting completed for day 3 after the fall. On [DATE] at 2:02 PM, V18 (House Supervisor/Licensed Practical Nurse/Falls Nurse) affirmed V18 oversees the fall prevention program for the facility and assists with fall investigations. V18 explained the facility completed post-fall charting and neurological checks after the fall to check for level of consciousness, neurological decline. V18 affirmed the last neurocheck was due at 10 AM and was not completed by the nurse but all other neurochecks were completed. Observed the neurocheck charting and post fall charting with V18 and noted multiple neurocheck entries and post fall entries were charted on or after [DATE] (6+ days after the resident had passed away). V18 explained the purpose of charting timely is to ensure accuracy of the records and make sure changes in condition were not missed. V18 recalled coming back from a leave and noticed they were completed but not signed out so V18 had to notify the non-compliant nurses and have them complete their charting. On [DATE] at 3:51 PM, V69 (Licensed Practical Nurse) affirmed V69 was assigned to care for R197 in the past and was familiar with R197. V69 affirmed V69 was assigned to care for R197 when she came back from the hospital and completed neurochecks. V69 didn't recall anything abnormal with R197's neurological status. V69 did not recall completing the neurochecks or the fall follow up at a later date but affirmed V69 did them while caring for R197. On [DATE] at 4:15 PM, V2 (Director of Nursing) affirmed V2 was familiar with R197 and completed the investigation into the fall. V2 reviewed the post-fall charting/neurochecks and affirmed multiple entries were signed as complete on [DATE]. V2 stated the facility standard is to be charting as you go, so you don't miss anything. If charting isn't completed timely, it may not be as accurate. Facility policy for timely documentation was requested from V2. This policy was not recieved prior to the exit of the survey. Record review of the facility nursing schedule indicates V69 (Licensed Practical Nurse), V73 (Licensed Practical Nurse), V75 (Agency Registered Nurse), and V76 (Agency Licensed Practical Nurse) were assigned to care for R197 after the fall occurred and before R197 expired. On [DATE] at 10:35 AM, V75 (Agency Registered Nurse) affirmed V75 was assigned to work AM and PM shift on [DATE]. V75 could not remember any details about the shifts or R197. V75 could not remember if V75 completed neurochecks on any resident while at the facility. V75 denied any knowledge of charting neurochecks or fall follow up documentation after the shifts on [DATE]. V75 stated, Yeah, I worked my day there with my agency and haven't been back. I haven't been back to chart anything late, I don't remember doing that. On [DATE] at 12:45 PM, V73 (Licensed Practical Nurse) affirmed V73 was assigned to care for R197 on [DATE] when R197 fell and [DATE] the following night before R196 expired. V73 recalled R197 was confused and impulsive at baseline and incontinent. On night shift, R197 was typically sleeping through the night but was an early riser get up. V73 recalled on [DATE], V73 gave R197 medication between 4-5 AM and R197 was in bed. Around 6:30 AM, V73 was sitting in the nurses' station and V72 came to V73 and stated R197 fell. V73 initiated fall protocols and assessed R197 for injury. One arm was moving better than the other and R197 had a large hematoma to her forehead that was about the size of a golf ball. V73 applied an ice pack to R197's head, started neurochecks and notified EMS. V73 denied any abnormal findings during neurological assessment. V73 denied observing floormats on the floor of R197's room. V73 stated, R197 was on the floor on the ground of the room, there was no mat. V73 stated, Hmm . should (R197) be left alone in the room? Well, I don't think any resident should be in a wheelchair while in the room unsupervised. I remember (V72) told me (V72) was getting another resident up when (R197) fell. V73's late charting of the post fall/neurochecks was reviewed with V73. V73 stated, I don't recall doing my charting late, I thought all of it was in there. I did double check my work. All of the neurochecks should be documented prior to the end of shift, that is the standard. I don't recall why it says I completed them after.

Based on observation, interview, and record review, the facility failed to ensure the required daily nurse staffing information was accurately completed. These failures have the potential to affect all 164 residents residing in the facility.Findings include:On 4/27/26 at 9:32AM, V1 (Administrator) stated the facility census is 164 residents residing at the facility.On 4/27/26 at 10:08am, surveyor observed the Daily Nurse Staffing information posted near the receptionist area. The posting was dated 4/27/26, with a census of 177.V1's (Administrator) e-mail, dated 4/28/26 at 10:49am, documents the facility's census is 163 residents residing in the facility on 4/28/26.On 4/28/26 at 10:32am, surveyor observed the Daily Nurse Staffing information posted near the receptionist area. The posting was dated 4/28/26, with a census of 177.On 4/28/26 at 11:01am, V27 (Staffing Coordinator/Scheduler) said, I am responsible for the daily staffing posting. It is supposed to be accurate. Oh, I have to change that (census number). That's not right. I probably didn't look at it right. I was moving fast.V1's (Administrator) e-mail, dated 4/28/26 at 11:57am, documents, in part, Daily Staffing we follow regulation.Record review of the facility's Daily Nursing Staffing form posted on 4/27/26, documents in part, (Name of facility) Daily Nursing Staffing Hours; Date: 4/27/26, failed to document the correct census of the residents residing in the facility.Record review of the facility's Daily Nursing Staffing form posted on 4/28/26, documents in part, (Name of facility) Daily Nursing Staffing Hours; Date: 4/27/26, failed to document the correct census of the residents residing in the facility.Record review of facility policy titled, Postings, dated 7/03/25, documents, in part, It is the policy of the facility to comply with federal regulations in regard to posting of information for the resident. Other federally required postings such as names and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, Medicare and Medicaid contact numbers, Grievance procedures, and the Medicaid Fraud Control Unit will be posted in a form and manner accessible and understandable to residents and resident representatives.Record review of Pamphlet titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike.

Based on interview and record review, the facility failed to follow their guidelines of promptly transferring a resident who exhibited signs and symptoms of sepsis for six hours prior to transfer. This failure affected one (R1) of three residents reviewed for quality of care. This failure resulted in R1 requiring hospitalization and diagnosed with septic shock and pneumonia. Findings include:R1 is a [AGE] year old resident with diagnoses including but not limited to Benign Neoplasm of Cerebral Meninges, Other Seizures, Spastic Hemiplegia Affecting Right Dominant Side, Encephalopathy, Unspecified, Neoplasm of Unspecified Behavior of Brain, Type 2 Diabetes Mellitus Without Complications, Hyperlipidemia, Unspecified, Depression, Unspecified, Cerebral Edema, Cerebral Infarction, Unspecified, Gastro-Esophageal Reflux Disease Without Esophagitis, Shortness of Breath, Aphasia, Anemia, Thrombocytopenia, Unspecified, Acute Embolism and Thrombosis of Unspecified Deep Vein of Left Lower Extremity, Localized Swelling, Mass, and Lump, UnspecifiedR1's hospital records ([DATE]) documents (in part), R1 presented to the ER (emergency room) due to abnormal labs and leukocytosis. Per the ER physician, EMS (emergency medical staff) reported that R1 was on 2 L(liters) nasal cannula but was hypoxic on the 2 L, and R1 was placed on a non-rebreather mask. On arrival to the ER, R1 had a 103-degree Fahrenheit fever, 22 respirations per minute, and tachycardia between 120-140 beats/min (minute). R1 was subsequently diagnosed with pneumonia and septic shock.R1's Speech Therapy Treatment Encounter Note ([DATE] at 11:10 AM) completed by V7 documents in part that during R1 was warm to the touch and grimaced at time (non-verbal indication of pain). V7 notified the nurse on duty, vital signs were assessed and R1 had increased heart rate and low BP (potential signs of sepsis).On [DATE] at 10:14 AM, V4 (Registered Nurse) documented, Was notified by ST (Speech Therapist) that resident's skin is hot to touch. Vitals checked as follows: BP (blood pressure) 97/58 PR (pulse rate) 135 RR (respiration rate) 30 rapid shallow Temp 98.8 non-contact O2 RA (oxygen room air) 85-90% no verbal complaints of pain but resident is observed to be grimacing with movement. Checked g tube site as well - site is dry, no redness/ swelling. Abdomen is soft to touch. (V6 Nurse Practitioner) made aware - orders for STAT KUB (kidneys ureters and bladder x-ray), CXR (chest xray), EKG (electrocardiogram), CBC (complete blood count) and BMP (basic metabolic panel), hold feeding for now, put on o2 (oxygen), 0.9 nacl (sodium chloride, Intravenous solution) x 83ml/hr (milliliters/hour) x 1 liter and respiratory panel and covid testing. All orders in place, carried out and called in. Resident placed on o2 via nasal cannula at 1LPM (liter per minute)- sat 96%.On [DATE] at 12:47 PM (Late Entry, created on [DATE] at 1:51 PM), V6 (Nurse Practitioner) documented, (R1) was seen on [DATE]. His blood sugars have been elevated. He was placed on 1 liter n/c (nasal cannula). He has coarse breath sounds. He did have an episode of n/v (nausea/vomiting) yesterday per the nurse. No fever or chills noted. Vitals are stable. PMH: T2DM (Type 2 Diabetes Mellitus), CVA (cardiovascular accident), hyperlipidemia, PE (pulmonary embolism), depression, DVT (deep vein thrombosis. Upon examination, pt was seen lying in bed. NAD (no acute distress). Normocephalic. Conjuctivae clear. Oral mucosa is moist. Neck supple, no JVD (jugular vein distention) or carotid bruit. Heart rate is regular, normal S1 and S2, no murmurs. Lungs are coarse throughout, no wheezes, on 1 liter n/c. Abdomen is soft, non-tender, non-distended, bowel sounds present, PEG tube in place. No LE edema. Right side is flaccid. Right ankle swelling noted. A/P (assessment/plan): #1 Acute hypoxic respiratory failure, on 1 liter n/c (this indicates organ failure, signs of severe sepsis) #2 T2DM w/hyperglycemia #3 Acute/subacute left ACA (Anterior Cerebral Artery) stroke #4 Benign neoplasm of cerebral meninges s/p (status post) bilateral frontal craniotomy with mass resection #5 h/o (history of) CVA w/right-sided weakness #6 Dysphagia s/p PEG #7 Depression #8 h/o DVT/PE on Eliquis #9 Hyperlipidemia #10 Fall risk #11 Right ankle pain/swelling #12 Seizures on Keppra #13 At risk for malnutrition Plan: Stat chest xray, KUB and labs ordered. Titrate O2 to keep sats >92%. I will add a sliding scale for better bs (blood sugar) control. Continue PT/OT/ST (physical therapy, occupational therapy, speech therapy). Dietician following, continue tube feeding recommendations. Maintain fall precautions per facility protocol. Plan discussed with pt.'s nurse. (Per this documentation, there was no assessment of R1's vital signs or addressing the abnormal vital signs and symptoms that V4 reported/obtained.)On [DATE] at 10:54 AM, V4 (Registered Nurse) documented, Follow up made with (Hospital) spoke with RN (REDACTED)- (R1) to be admitted . Dx: Pneumonia and septic shock.On [DATE] at 9:34 PM, V5 (Registered Nurse) documented a late-entry SBAR note for [DATE] that documents (in part) R1's change in condition and identifies that R1 had abnormal labs and labored breathing. V6 (Nurse Practitioner) was notified at 6:30 PM and R1 was transferred to the hospital for evaluation.On [DATE] at 9:50 AM, V9 (R1's Family Member) recalled on [DATE], a nurse had called in the morning saying R1 had elevated blood sugar levels and R1's blood pressure was 80/64. V9 told the nurse to send R1 to the hospital because R1 was clearly septic, this is always what (R1) does when (R1) develops sepsis. They didn't send him when I requested for (R1) to be sent out. (R1) got sent out later that night and developed shock. (R1) could have died. I told them (the facility) he was septic.On [DATE] at 11:27 AM, V4 (Registered Nurse) stated that sepsis is a whole-body response that is caused by infection. V4 explained that signs of sepsis include elevated temperature, elevated pulse rate, elevated respiratory rate, and low blood pressure. V4 reviewed R1's electronic health record with surveyor and recalled caring for R1 on [DATE]. V4 explained, V4 was doing rounds and asked R1 if he was in pain and R1 didn't respond. R1 was usually able to respond with a smile or shaking R1's head, but that day R1 didn't. V4 stated, He wasn't at his baseline, I thought there was something wrong. V4 recalled assessing R1's vital signs and noted that R1 had increased heart rate and rapid shallow breathing. V4 affirmed that V4 was concerned that R1 was potentially developing sepsis so V4 contacted V6 (Nurse Practitioner) and recalled telling V6 about the change in status. V4 stated, I didn't say anything to (V6) about sepsis, (V6) was aware of the signs and symptoms (R1) was experiencing. (V6) gave orders and I carried them out. V4 affirmed that sepsis is potentially life-threatening and would normally immediately send a resident to the hospital if a resident was experiencing a life-threatening change in condition. V4 could not recall speaking to V9 about R1's change in condition.On [DATE] at 11:38 AM, V2 (Director of Nursing) was familiar with R1 but did not recall the events that led to R1 being sent to the hospital on [DATE]. V2 explained that sepsis is potentially life-threatening whole-body response to an infection and signs of sepsis include fever, low or high blood pressure, increased pulse, and increased respirations. V2 affirmed that the facility is not able to treat sepsis within the facility and sepsis requires a higher level of care. V2 stated that if a nurse suspects or has signs of sepsis that they call the physician immediately and expect to send the resident out to the hospital. V2 explained that if sepsis is not treated, it can lead to septic shock and death.On [DATE] at 12:47 PM, V6 (Nurse Practitioner) affirmed that V6 is supervised by V8 (Medical Director). V6 explained any infection can cause sepsis and sepsis can present with changes in condition including low blood pressure, tachycardia, tachypnea, fever, changes in mental status, and abnormal laboratory values. V6 stated, if sepsis is not treated patients can crash, deteriorate and can develop septic shock but not always. V6 recalled being told about a change in condition for R1 from V4 on [DATE]. V6 stated, I do not recall them (abnormal vital signs). I do recall visiting (R1) a few hours after I talked to (V4) but (R1) seemed fine to me. I did not assess (R1's) vital signs during my visit. Tachypnea and tachycardia, I thought maybe aspiration pneumonia because (R1) had vomited the day before which is why I ordered for a chest x-ray and CBC, CMP. (R1) did have crackles in (R1's) lungs. V6 denied knowledge that R1's family members requested R1 to be sent to the hospital. V6 affirmed that V6 was not notified of any other changes in condition after V6's visit and did not give the order to send R1 to the hospital. V6 stated, I think they (facility staff) sent (R1) out because of an increase white count. R1's vital signs from [DATE] were reviewed with V6 and V6 stated, yeah in the hospital they would have called a code sepsis. But if I were to send people out every time, they had an increased pulse and respirations, we would be sending people out all the time. On [DATE] at 1:47 PM, V7 (Speech Therapist) affirmed that V7 was familiar with R1 and recalled treating R1 on [DATE]. V7 explained that V7 went to treat R1 and R1 wasn't acting per R1's baseline. V7 stated, (R1) usually wasn't too happy to see me as (R1) had a lot of difficulties speaking and would struggle with speech therapy. That day, (R1) grabbed my hand and it was really warm, there was something off. I (V7) recall asking (R1) if (R1) wanted to go to the hospital. (R1) couldn't speak well, so I told (R7) to squeeze my hand if (R1) wanted to go the hospital and (R1) squeezed my hand. I told him I would go get the nurse and (R1) didn't want me to leave. This wasn't (R1's) baseline at all. I left and got the nurse. I heard afterward, (R1) was hospitalized .On [DATE] at 2:43 PM, V2 (Director of Nursing) and V3 (Infection Preventionist, Registered Nurse) reviewed R1's electronic health record and confirmed that no screening for sepsis was completed for R1, per the facility policy. V2 affirmed that R1 was not comfort care, and there was no indication that R1 requested not to go to the hospital. V2 affirmed there is no records that blood cultures, a CMP, coagulation tests or a lactate were ordered or drawn, per facility policy. V3 recalled seeing R1 on [DATE] and recalled that R1 was experiencing malaise and the facility obtained respiratory panel lab work to rule out infection. V2 was unsure if the facility had a sepsis screening UDA (user defined assessment) within the electronic health record that could be used to screen for sepsis. V3 affirmed that R1 was not sent out by the time V3 left for the day around 5:00 PM. On [DATE] at 3:44 PM, V5 (Registered Nurse) affirmed that V5 was the nurse that sent R1 to the hospital on [DATE]. V5 recalled seeing that R1's white count was elevated during V5's medication pass. V5 could not recall if R1 had any changes in condition, labored breathing or assessing R1 for a change in condition. V5 stated that V5 received a call from R1's family and they were concerned about R1 going into sepsis as R1 had a history of sepsis. V5 sent R1 to the hospital because the family requested it, so I called an ambulance and sent him out. V5 recalled leaving V6 a voicemail to notify V6 of R1 being sent out. V5 affirmed that paramedics did place R1 on a non-rebreather mask prior to leaving the facility. V5 could not recall if V5 completed an assessment of R1's health status and could not recall vital signs. V5 could not recall if V5 listened to R1's breath sounds.On [DATE] at 4:30 PM, V8 (Medical Director) stated, V8 is the medical director for the facility, and is the supervising physician for V6. R1's vital signs were reviewed with V8 and V8 stated the vital signs could indicate sepsis, it's a possibility, there's a lot of things that could cause that. R1's progress notes were reviewed with V8 and V8 stated, You know, facilities can treat sepsis in house now. V6 did everything right, the hospital wouldn't have done anything different than V6 did. The facility's Sepsis Nursing Care Guidelines were reviewed with V8, and surveyor asked if staff should have followed the facility-approved guidelines. V8 became aggressive and stated, Let me ask you something. Did the patient die? No? Then (V6) did everything (V6) needed to. In my professional opinion, (V6) sent (R1) out due to change in condition, that's my answer.Facility policy titled, Sepsis Nursing Care Guidelines (undated) documents in part Purpose: The facility will use a standardized, physician approved, nursing assessment and care guidelines to help identify sepsis as early as possible in its course in order to provide early treatment and prevent progression leading to hospitalization or adverse event. II. Criteria/ Definitions: 1. Sepsis: Sepsis in an infection, regardless of the primary site of the source that manifests with select systemic symptoms, signs and/or functional capacity changes and may be associated with one or more organ dysfunction and/or failure. 2. Systemic Inflammatory response Syndrome (SIRS) Criteria a. Fever greater than or equal to 100.4 Fahrenheit or less than or equal to 96.8 Fahrenheit. b. Heart rate greater than 90 beats per minute c. Respiratory rate greater than 20 breaths per minute d. Systolic blood pressure less than 90 mmHg. 3. SIRS screening results a. Sepsis: Suspicion or documentation of infection AND two or more SIRS criteria b. Severe Sepsis: Sepsis and one or more organ dysfunctions 4. Organ Dysfunction a. Assessed through observation and clinical assessment (clinical correlation and comparison to patient's baseline vital signs are important consideration): i. Respiratory SQ02 less than 90 percent or increasing 02 requirements ii. Cardiovascular: Systolic blood pressure less than 90 mmHg or 40 mmHg less than baseline iii. Renal: Urine output less than 0.5 ml/kg over the last 8 hours iv. Central nervous system: New mental status changes b. Assessed through laboratory results with clinical correlation and comparison to baseline levels (use results during last 24 hours) 1. Platelets less than 100,000 ii. INR greater than 1.5 (if not on anticoagulant therapy with Coumadin/Warfarin) iii. Bilirubin greater than or equal to 4.0 ml/dl iv. Serum lactic acid greater than or equal to 2mEq/l. III> Process: 1. All residents/patients with a confirmed or suspected infection will be screened for sepsis using SIRS criteria by the IP/IC nurse or designee. Confirmed or suspected infection includes but is not limited to . d) myalgia . f) vomiting . h) localized, redness, heat pain swelling purulent discharge . 2. If a resident/patient with a confirmed of suspected infection meets two or more SIRS criteria, the Sepsis Nursing Care Guidelines will be implemented by the IP/IC nurse or designee . IV. Procedures: 1. The nurse will review assess the SIRS screening results and assess for organ dysfunction. 2. If the resident screens positive for sepsis or severe sepsis, the IP/IC nurse or designee contacts the physician and initiates the physician approved sepsis care guidelines by starting IV fluids stat. 3. The Interact Care Path recommends that all patients/residents with suspected or confirmed infection and possible sepsis be considered for transfer to an acute care hospital unless; a) the patient is on comfort or palliative care plan or is on hospice with an order for no hospitalization from the attending physician. b) the patient or decision maker wants the condition to be treated but not in the acute care hospital and understands the risks; and the facility has the capability of managing sepsis according to recommended interventions . 4. Family or resident representative is contacted about change in condition. 5. If sepsis is being considered and patient/resident is not being immediately transferred to the acute care hospital by the physician (See item #3), blood will be drawn for cultures, CMP, coagulation tests and lactate level stat before starting antibiotics as indicated. 6. Nurse will assess the residents response to IV fluids as soon as possible. Additional fluid administration should be guided by frequent reassessment of hemodynamic status. 7. If the decision is to transfer to acute care hospital, nurse will contact ER to give nurse to nurse report/handoff. 8. Ensure that all recent lab results and completed SBAR are communicated to the ER and included in the transfer documents

Based on interview and record review, the facility failed to ensure that one resident who was on pain medication had an effective bowel regime program to prevent constipation. This affected one of one resident (R18) reviewed for quality of nursing care and prevention of constipation. This failure led to R18 being sent to the hospital with a diagnosis of severe fecal impaction with stool ball measuring over 8 centimeters (CM). Findings include: R18 was admitted to the facility on [DATE] with a diagnosis of dependence on supplemental oxygen, heart failure , spinal stenosis, type II diabetes and atrial fibrillation. R18's brief interview for mental status dated 3/4/25 documents a score of 9 which indicates moderate cognitively impairment. R18 physician orders document: tramadol 50 mg (milligrams), take one tablet by mouth twice a day for moderate to sever pain. Start date 12/11/24. Fentanyl patch 12mcg/hr (micrograms/hour). Apply one patch every 72 hours for pain. Start date 1/17/25. On 5/23/25 at 12:00PM, V27( Nurse Practitioner) said fecal impaction is caused by constipation which is preventable but can be attributed to lack of movement, nutrition, hydration and pain medications. R18 did not mention being constipated and were unaware that R18 was having concerns. V27 said she would expect staff to notify them of any changes in bowel movement or lack of bowel movements for three days. On 5/22/25 at 11:46, V17(ADON) said R18's hospital stay related to fecal impaction was preventable. R18 was taking a pain medication and had a medication related to constipation but was not effective. R18's medical doctor assisted with putting in an effective bowel management for R18. Point of care charting for March 2025 bowel movements documents 3/1/25 and 3/2/25 a small bowel movement; 3/3/25 - 3/7/25 documents none. R18's hospital record dated 3/9/25 documents under CT abdomen impression severe fecal impaction at the rectum with stool ball measuring over 8 centimeters. Mild perirectal inflammatory changes may reflect stercoral proctocolitis. Under history documents Patient is found to have sever fecal impaction with findings consistent with stercoral proctocolitis. Patient disimpacted with large amount of stool collected, no blood noted or black, and she is feeling better afterwards, also received enema. Bowel management revised 7/26/24 documents: it is the facility policy to record resident's bowel movement in the medical record. The certified nurse aide each shift will record the resident's bowel movement. The facility will assess the resident when the resident shows sign and symptoms of abdominal stress, if there is a change in the resident's pattern of bowel movements, the facility will notify the physician.

Based on observations, interviews, and record reviews, this facility failed to consistently and accurately assess, monitor, and implement interventions to prevent skin breakdown, and failed to ensure the intervention of the low air loss mattress was implemented per manufacture guidelines. This affected two of three residents (R62, R176) reviewed for pressure sore and pressure sore prevention. This failure resulted in R62 being admitted to the facility on [DATE] with skin in tact and developing a facility acquired pressure sore ( unstageable) wound to the sacrum area by 4/25/25. Findings include: 1. R62's braden scale evaluation, dated 4/2/25, notes R62 is at high risk for developing skin breakdown. R62's admission skin/wound evaluation, dated 4/2/25, notes R62 does not have a current skin alteration and/or newly healed wound. V13 (wound care nurse practitioner) initial assessment of R62's sacral wound, dated 4/30/25, notes R62 with an unstageable pressure injury to sacrum, measuring 9cm x 8cm x 0.1cm. 60% epithelial, 30% granulation tissue, 10% slough. There is no order for LAL mattress or documentation of when it was placed on R62's bed; R62 had a LAL mattress at start of survey on 5/20/25. R62's POS (physician order sheet), dated 5/6/25 notes an order for juven supplement twice daily and prostat supplement twice daily. There also is an order for pureed diet, thin liquids. On 5/23/25 11:30 AM, wound care observation with V12 (wound care director). R62 was observed to have an unstageable sacral pressure injury, measuring 6cm (centimeters) x 7.5cm x 0.1cm, 30% epithelial tissue, 10% granulation, 60% eschar. Wound cleaned with normal saline, medihoney applied, calcium alginate applied and covered with bordered gauze. On 5/22/25 at 3:00 PM, V12 stated that R62 developed a facility acquired pressure ulcer. V12 stated that R62 has scarring on sacrum due to pressure ulcer from previous stay in this facility (2023) and it re-opened. V12 stated that R62 was placed on a low air loss mattress and heel protectors were applied bilaterally. V12 stated that R62 receives nutritional supplements to promote wound healing. 2. R176 was diagnosis with scalp surgical dehiscence and left lateral ankle full thickness wound. R176's vital report dated 5/6/25 documents: 124.6 (one hundred and twenty-four point six) pounds. Skin and wound note dated 5/15/25 documents: The patient (R176) continues on an alternation air mattress for pressure redistribution. Ensure settings are maintained at an appropriate level bases on the patient's needs and body habitus. On 5/20/25 at 11:28am, R176 was observed laying on an alternation air mattress for pressure redistribution control panel/weight setting at one hundred and fifteen (115) pound. R176's mattress was observed deflated in the upper middle portion of the mattress. R176's shoulder was sunk in between the partially inflated sections of the middle top portion of the mattress. V17 (adon) said, R176's mattress was set at 115 pound. V17 said, R176 mattress was deflated middle top portion of the mattress. R176 who was alert and orient to person place and time, said his mattress had been deflated since yesterday. R176 said, his hurting his back. R176 complained of pain a 10/10. Pain management provided. On 5/20/25 at 11:32am, V12 (wound care director) said, the middle top portion of R176's mattress looks flat/deflated. V12 said, someone must have move R176's bed, the cord has been pulled out of the socket. R176's power cord to his alternating air mattress was observed hanging out of the electric socket. The electric cord was not secure to the power source so that R176's mattress would remain inflated. On 5/20/25 at 11:37am, V16 (cna) said, R176's alternative mattress was deflated in the top middle upper portion. V16 said, R176 mattress was full at the bottom and flat at the top. V16 said, she informed staff an hour ago that R176 mattress was deflated. On 5/21/25 at 12:35pm, R176 was observed on his specialized mattress which was set at one hundred and fifty (150) pounds. R176 said, his specialized mattress feels much better today. On 5/22/25 at 11:09am, V12 said, R176's weighs one hundred and twenty four (124) pounds. R176 requested for his specialized mattress to remain set at one hundred and fifty (150) pounds because it was comfort. On 5/23/25 at 8:23am, V12 (wound director) said, R176 has a full thickness wound on his ankle that could be classified as a stage three or four. V12 said, R176 is on the alternating pressure redistribution mattress. If the mattress is not fully inflated it's cannot providing redistribution. Alternating pressure redistribution mattress guidelines 3/2020 documents: Enter resident's weight accordingly if the alternating pressure redistribution mattress has a weight specification button.

Based on observation, interview, and record review the facility failed to ensure fall prevention intervention to include supervision/monitoring were implemented to reduce the risk of falling, failed to ensure residents were assessed and able to use assistive device safely to prevent falls and injuries. This affected six of six residents (R1, R2, R4, R5, R6, R8) reviewed for falls and safety. This resulted in R1, R2, R6, and R8 having fall resulting lacerations to the scalp, R4 being in a fall incident attempting to use an assistive device and sustained a left fibula fracture, and R5 bumping into open door using a motorized wheelchair and sustain a right and left tibia fracture. Findings include: 1. R4 face sheet shows diagnosis of hemiplegia, hemiparesis following cerebral infraction affecting right dominate side, other lack of coordination, and history of falling. R4 MDS assessment dated [DATE] denotes in-part section C for cognition shows a score of 3 (cognitive impairment). R4 incident report dated 9/11/24 denotes in-part writer summons to room by CNA, upon entering I (writer) observed resident sitting on floor in front of her closet. Prior to sitting in wheelchair near closet. Predisposing physiological factors- confused, gait imbalance. Predisposing situational factors- trying to stand without assist. R4 fall risk evaluation dated 9/11/24 denotes in-part a score of 13 (high risk), R4 fall risk evaluation dated 9/29/24 denotes in-part a core of 18 (high risk). R4 incident report dated 9/29/24 completed by V1 denotes in-part fall without injury, incident location, resident room. right at her residence bed alarm sounding upon entering residence room writer observed resident sitting on the edge of the bed holding her walker writer asked resident what she was trying to do, and resident stated she needed to use the restroom. While writer was assisting residents to the restroom, resident appeared to lose her balance, while assisting resident to the floor both the writer and resident fell resulting in resident falling on writer. Resident noted with non-skid socks on, room free of clutter. Call light in reach but not activated. Head to toe assessment completed no bleeding bruising or deformities noted at this time. Vitals assessed BP 110 / 60, heart rate 57, temp 97.6, blood sugar 100, respirations 18, O2sat 97% room air. Resident transfer back to bed via Hoyer lift, two staff assist, resident complaints of pain 0 of 10. Fall coordinator notified. Physician notified and orders received to send resident to (hospital name) hospital for further evaluation. Sister notified. Predisposing environmental factors none of the above. Predisposing physiological factor; use of blood thinners, diabetes, balance poor/balance disorders. Predisposing situation factors: ambulating with assist, recent room change, using walker. Agencies/people notified; DON/designee and family. R4 post fall investigation/ RCA (root cause analysis) dated 9/30/24 denotes in-part observed fall with injury, location- resident room, did incident result in injury-yes, type of injury- left closed fibula fracture. Activity at time- ambulating with staff, mental status- alert and orient 2-3, poor safety awareness, is resident at risk for falls- yes, does resident have history of falls- yes. Root cause analysis- R4 is a [AGE] year old female with diagnosis of bipolar disorder major depressive disorder hemiplegia and hemiparesis following cerebral infarction affecting right dominant side alert and oriented times 2 to 3 BIM score of three and a stand and pivot in transferring. R4 was changed in bed by CNA at 4:00 PM. The nurse responded to R4's bed it alarm sounding when the nurse entered the room R4 was observed sitting on the edge of the bed. When the nurse asked R4 what she was trying to do R4 stated she had to use the bathroom. The nurse was assisting a resident to the bathroom using a gate belt when R4 lost her balance the nurse eased the resident to the floor both resident and a nurse fell resulting in falling on top of the nurse resident was transferred out for evaluation per MD orders facility anticoagulation protocol. Therapy to evaluate and treat. On 10/4/24 R4 said the nurse was helping her to bathroom and she fell . R4 said she broke her ankle. On 10/8/24 at 11:48am V2 (CNA) said he has worked with R4, V2 said he has ambulated R4 using her walker. V2 said when he uses the walker, he put the wheelchair behind R4 just in case she gets weak and fall. V2 was asked how is R4 safe to use a walker if she might get weak and fall. V2 said that's why I use the wheelchair too, it just depends on what she needs. V2 said he was R4's aide when R4 had a fall on 9/11/24. V2 said he observed R4 on the floor in her room sitting on her buttocks, R4 told him her legs got weak and she fell , when she was at the closet. On 10/8/24 at 10:21am V1 (Nurse) said she heard R4 bed alarm sound, she went in the room and observed R4 sitting at the bedside with a walker. V1 said R4 stated she wanted to go to the restroom, V1 said she offered to help R4. V1 said she put a gait belt around R4 waist, she stood R4 up, R4 had the walker in front of her, as R4 was ambulating R4 lost her balance a fell backwards toward her, which caused her to fall with R4. V1 said R4 landed on top of her. V1 said R4 used a walker for ambulating. On 10/8/24 at 1:14pm V9 (Fall coordinator) said she conducted the fall investigation for R4 fall, date of fall was 9/29/24. V9 said R4 had a fall while ambulating to the restroom. V9 said the root cause of R4 fall was that R4 was ambulating and fell . V9 said R4 was not assessed to use a walker, V9 said R4 ambulation status was not assess or evaluated. V9 said she had never observed R4 ambulating. V9 said R4 had a room change and she believes that walker was left in the room. V9 said she called R4's family and the said they did not give R4 that walker. V9 said R4 should not have a walker, that's why she removed the walker when she found out staff was using that walker for R4. V9 said she was not aware that staff was ambulating R4, she was not aware that staff was ambulating R4 with a walker. V9 said R4 family did not want R4 to have any functional decline. V9 said she did not refer R4 to therapy for functional decline until R4 had the fall on 9/29/24. On 10/8/24 at 2:01pm V11 (Restorative Director) said staff should not ambulate a resident without having an assessment completed. V11 said staff should not be ambulating R4 with a walker if R4 was not assessed to use a walker by therapy. During a follow up interview V11 said R4 did not receive an evaluation or an assessment from restorative after the fall for 9/11/24. R4 was referred to physical therapy after the 9/29/24 fall with injury. On 10/11/24 at 1:59pm V22 (care plan coordinator) said she initiated R4 plan of care and the assistive device for ambulating should be a gait belt, V22 said she don't know why she did not document what assistive device that R4 uses. V1 (Nurse) witness statement denotes in-part, resident was being assisted by staff to restroom when resident lost her balance and was shaky and fell down with staff member. R4 current plan of care presented by V8 (Director of Nursing) denotes safety: fall admitted in unit was observed she is high risk for falls related to current medications use, poor safety awareness, unsteady gait, disease process: sarcoidosis, CHF, alcohol use with withdrawals cognitive impairment, gait problems, such as unsteady gait, even with mobility aid or personal assistance, slow gait, takes small steps, takes rapid steps or lurching gait, hemiplegia/hemiparesis, history of falls. Contributing factors: physical/function status, ambulation; needs physical and verbal assist, poor standing balance, unsteady gait, needs assist in transfers, on and off pain/ discomfort, incontinence, needs reminders: safety awareness, prev (prevention) of fall reminders to use call light. R4 will participate during safe transfer technique with 1-2 staff assistance from bed to chair w/o (without) resistance, w/o undetected, unrepeated incident of fall. R4 need to wear nonskid socks/shoes, proper footwear, bed locks/WC (wheelchair), locks engage for transfer, use assistive devices during ambulation to prevent falls, skilled rehab therapy eval and treatment as indicates, ensure call light, phone and supplies within reach, keep mostly needed items within reach, ensure room is clutter free and dry. SPOST (status post) fall initial intervention5/3/24 sent to hospital for eval, signage (precaution) floor mat (1), bed alarm, restorative to evaluate/referral, therapy eval. R4 hospital records dated 9/30/24 denotes in part clinical impression closed fibula fracture. Facility falls occurrence policy with last revised date of 7/26/24 denotes in-part it is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. The fall assessment form will be completed by the nurse or the falls coordinator upon admission, quarterly, significant change and annually. Those identified as high risk for falls will be provided fall interventions. An incident report will be completed by the nurse by the nurse each time a resident fall. The falls coordinator will review the incident report and may conduit his/her own fall investigation to determine the reasonable cause of fall. The nurse may immediately start interventions to address falls in the unit even prior to the Fall Coordinator investigation. Ultimately, the falls coordinator may change the interventions provided by the nurse if the falls investigation identifies a more appropriate intervention for the individual. Facility care plan policy with last revised date of 7/26/24 it is the policy of the facility to ensure that all care plans including baseline care plans are in conjunction with the federal regulations. Comprehensive care plan must be developed after the comprehensive assessment of the resident. 2. R6 face sheet shows diagnose of history of falling, unspecified dementia. R6 MDS dated [DATE] denotes in part, BIMS score of 7 (cognitive deficits). Section GG for functional abilities and goals denotes toileting hygiene: 03 (partial to moderate assist). R6's final incident report to the department dated 9/17/24 denotes in-part, diagnosis COVID, hypertension, anemia, hyperlipidemia, atherosclerotic heart disease, atherosclerotic coronary artery bypass graft, GERD, prostate hyperplasia, non-infective gastroenteritis colitis, type 2 diabetes mellitus, COPD, dementia. R6 was observed lying on the floor near his bedside. Body assessment was completed, resident noted with small cut to the left side of his head. Area was cleansed with normal saline and dry dressing applied. Pain medication administration per physician order. Range was limited as patient did not want to move. BP (blood pressure) 148/76, P (pulse) 77, R(respiration) 19, T(temp) 97.6, 02 sat 95%. Physician was notified. Resident transported to hospital for further evaluation. R6 readmitted back to the facility with three staples to the left side of his head. No additional injuries noted. The plan of care has been reviewed and updated to address the resident's needs. Injury: yes, 3 staples to left side of head. When interviewed R6 stated I got up to go to the bathroom by myself I didn't push the call light for help because I thought I could make it by myself. I took a couple steps and lost my balance landing on floor. Based upon further investigation, staff interviews, and medical records review. Prior to the incident at 11:30 PM the assigned CNA did rounds and noted the residence in the dry and resting comfortably. At 1:50 AM upon rounds the nurse heard R6 calling out for assistance, when she entered the room, she noted R6 laying on the floor his incontinence brief was open and urine on the floor. Body assessment was completed. Resident sustained a small cut to left side of his head. Area was cleaned with normal saline and dry dressing applied. Pain medication administered. V9 was asked if R6 had the mental capacity to remember to pull call light before going to the bathroom. V9 said R6 knew how to use the call light. V9 was asked does R6 have the mental capacity to understand safety concerns and that he could injury himself if he did not press the call light and wait for staff to coma and take him to the bathroom. V9 did not respond. Facility incident report dated 9/11/24 denotes in-part upon doing rounds resident noted on the floor near his bedside with his brief off and urine on the floor. Prior to the incident resident was noted resting in bed comfortably with no distress noted. Injury type: top of scalp. Pain:8. Oriented to person. Wet floor, incontinent, weakness/fainted, altered mental status, dementia related behaviors, fragile skin. Physician, ombudsmen, and family notified. Facility post fall investigation/ RCA (root cause analysis) R6 is an [AGE] year-old male with diagnosis of unspecified dementia, history of falls, COPD, type 2 diabetes, alert, and oriented x2-3 with periods of confusion. R6 was observed by CNA in the bed at 11:30pm, resting comfortably and dry. R6 stated he had to go to the bathroom and did not pull his call light for assistance, he got out the bed independently, took a couple of steps and that's when he fell on to the floor. R6 couldn't remember if he had any socks or shoes on and 45 minutes prior to the incident, R6 was seen in bed asleep by the nurse. R6 admission/ readmission assessment shows call light evaluation- is the resident cognitively able to use the call light, no is checked. R6 fall risk assessment dated [DATE] shows a score of 17 (high risk). On 10/10/24 at 10:02am V9 (Fall coordinator) said R6 was admitted on [DATE], R6 fell on [DATE]. V9 said R6 was admitted for rehab and due to a respiratory infection. V9 said R6 was alert times 2 (person, place) with episodes of confusion. V9 said R6 root cause of his fall was due to R6 had a fall because he got up to go to the bathroom. V9 said the incident happened around 1:50am. V9 said R6 had a sitter that was provided by the family during the day. V9 said the unit Nurse's informed her that R6's family request that R6 have a chair alarm and that R6 had previous falls at home. V9 said she provided R6 with the chair alarm. V9 said she did not follow up with the family to inquire about R6 fall history at home and why the family was requesting a chair alarm. V9 said the nurse did not give her any information regarding R6 fall history. V9 said she don't know if the nurse asked the family about R6 fall history. V9 did not respond when asked if she asked R6 about his fall history at home. V9 said she don't know if R6 was getting up at night at home when his falls occurred. V9 said she should have inquired further about R6 fall history at home and that would have helped her to implement fall interventions for R6. V9 was asked why did R6 have a sitter, V9 did not respond. V9 said the aides do rounds every two hours. V9 said R6 daughter did not want R6 getting out of bed. V9 said she did not ask R6 daughter why she did not want R6 getting in out of bed. V9 said she don't know if it was related to R6 having falls. On 10/10/24 at 3:13pm V30 (LPN) said she initiated R6 plan of care for falls, V30 said R6 informed her that he had previously fell at home. V30 said she did not ask R6 about his fall history, she did not gather further information to determine what R6 was doing when he fell at home. V30 said next time she will ask more questions. V30 said Resident rounds are done every two hours or as needed. V30 said incontinent care is completed during resident rounds. V30 said R6 has dementia. V30 did not respond when will R6 remember to use the call light to call for assistance. V31 statement presented by the facility denotes in part I started my rounds at 1130pm, Resident was in bed resting comfortably, bed in lowest position call light within reach. Around 150am while doing rounds again, I heard the nurse call for assistance. When I entered the room, I observed the resident laying on the floor diaper was opened and urine on the floor and nurse assessing the resident. V31 statement included in facility investigation does not show that she anticipated R6 needs for using the restroom. V31 (CNA) was called and texted on 10/10/24 at 1:45pm, 10/16/24 at 10:34, for an interview, V31 did not respond to call or text message. R6 care plan with initiated date of 9/10/24 denotes in-part safety/fall, admitted in the unit on 9/9/24 and was observe that R6 is at risk for fall/ safety injury due to multiple medical functional, mental, and physiological conditions resulting to be at risk for falls. Contributing factor's physical function status, ambulation; need assistance in walking, poor sitting balance, poor standing balance, unsteady gait, needs assistance in transfer, pain, and discomfort. Forgetful needs reminders cues, poor safety awareness regarding prevention to use call light. Call for assistance, periods of restlessness and agitation. Newly admitted to the facility, new environment, admitted with recent decline in function, multiple aches and pains, discomfort. Provide privacy to the resident, staff to make sure bed in a lowest possible position, staff to give friendly approach to resident and anticipate needs, provide safe therapeutic environment (free from clutter), manage pain for comfort and facilitate free movement. Remind me to ask for assistance. Reorient me to how to use the call light if necessary. Please make sure that my call light is within my reach and encourage me to use it for assistance as needed. I would like staff to address my needs with prompt response to all request for assistance. Chair alarm, bed alarm, fall mat, vision/sound monitor. R6 hospital records dated 9/11/24 denotes in [AGE] year-old male with history of CAD, COPD, dementia presents for evaluation for unwitnessed fall. Physical exam 2 cm left posterior partial scalp laceration. Laceration repair, two staples. 3. R5 diagnosis hemiplegia, hemiparesis following a cerebral infraction, cerebral ischemia, difficulty in walking, optic neuritis, repeated falls, retinal ischemia, glaucoma of right eye, primary open angle glaucoma of left eye severe stage, corneal edema, diabetes mellitus type 2, pseudophakia of both eyes, branch retinal artery occlusions of right eye, ocular ischemic syndrome. R5 MDS dated [DATE] denoted visual impairment. R5 MDS section for functional abilities dated 8/21/24 denotes for mobility devices is documented for no for wheelchair use (manual or motorized). Does the resident use a motorized wheelchair or scooter, no is documented. R5 MDS dated [DATE] section GG for mobility devices denotes in-part check all that were normally used in the last 7 days, none of the above were used (cane/crutch, walker, wheelchair, limb prosthesis). R5 facility final incident report to the State department dated 9/13/24 with date of incident 9/9/24 denotes in-part osteoporosis osteoarthritis, chronic pain, hyperlipidemia, polyneuropathies, anal fistulas. Other type of incident not listed here: wheelchair incident. Location of incident 500-unit hall. R5 was transporting himself in his electric wheelchair down the hall as he turned his wheelchair around to go in the opposite direction R5's wheelchair rolled over his right foot before R5 was able to stop his wheelchair. Body assessment was completed resident noted with a small abrasion to the right inner ankle. This area was cleansed with normal saline and dry dressing applied. Pain medication administered per physician order. Range of motion within normal limits. B/P (blood pressure) 127/74, P90, R18, T97.6. Physician was notified new orders received for state X-ray of right ankle right foot. Responsible party was notified. Resident transported to hospital for further evaluation and subsequently admitted . The plan of care would be addressed upon readmission. Injury: yes. Acute nondisplaced fracture at the visualized distal tibia and fibula. Final investigation/conclusion- R5 was transporting himself in his electric wheelchair down the hall as he turned his wheelchair around to go in the opposite direction he bumped into the wall, R5 accidently rolled over his right foot with his wheelchair. When interviewed, R5 stated I was rolling down the hallway when I bumped into the wall. I didn't feel my wheelchair rolling over my foot. I didn't even know I rolled over my foot until the staff came to assist me. Resident transported to hospital where he was subsequently admitted with right distal tibia and fibular shaft fractures. The plan of care will be addresses upon readmission. V18 statement included with facility investigation denotes in part, I (V18) while rounding on the 500 unit heard a boom. I observed the resident R5 right foot under his motorized wheelchair. I instantly called for help from my nurse. I told R5 to stop so we could help him because his foot was under his wheelchair. R5 told me he didn't need any help and proceeded to move his wheelchair backward rolling over his right foot again. After that my nurse arrived along with additional help. When I asked R5 where he was going because this is not his unit, he proceeded to tell me that he was just riding down the hall trying to turn around. V29 statement denotes in part, R5 stated he was riding in his wheelchair and his leg dropped and he ran over his foot. R5 physical therapy discharge summary, with discharge date of [DATE] denotes in-part current reason for referral patient referred to skill PT (physical therapy) intervention for motorized wc (wheelchair) mobility training. LTG (long term goal) 2 IND (independent) with manual wc (wheelchair) but is SUP (supervision) with motorized (wc) wheelchair management and operations for safety. Education and instruct on safety precautions and how to maneuver his motorized wc. Performed really well but will need SUP with his wheelchair to better carry over of safety instructions regarding motorized wheelchair. Treatment results communicated with interdisciplinary team. Discharge recommendations- recommend to continue with restorative nursing therapy for wc (wheelchair) management. R5 incident report dated 2/6/24 denotes in part writer was notified by resident that he hit his leg on the wheelchair ramp with his wheelchair after his appointment at u of c medicine. R5 stated he was moving his wheelchair into the medicar and ran his wheelchair into the ramp and hit both his legs when getting in the van. On 10/9/24 at 10:58am V18 (CNA) said she was in a resident's room, when she heard a boom sound and she came out the room, and observed R5 in his motorized wheelchair, the wheelchair against the door. V18 said R5 hit the one of the double doors that was open. V18 said R5 right foot was observed behind the wheel of his motorized wheelchair. V18 said she said told R5 wait let me help you R5 said he did not need help and R5 rolled over his right foot again, trying to turn around. V18 said she summons the nurse and the nurse arrived to assess R5. V18 said R5 complained of pain after rolling over his foot the second time. V18 said R5 leg rest was up and R5 right foot was behind the leg rest, and behind the wheels of the chair. V18 said she had never seen R5 leg in that position. V18 said she is familiar with R5, R5 would complain of visual problems during activities. V18 said she used to be an activity aide. V18 said she believed R5 had trouble seeing. V18 said she don't recall if R5 wore glasses. V18 said she don't recall if R5 had on glasses on the day of the incident. V18 said she summons the nurse. On 10/9/24 at 2:38pm V23 (Physical therapist) said R5 was referred to physical therapy for wheelchair training. V23 said he don't know why R5 needed wheelchair training. V23 said R5 did mention to him that he could see shadows and could not see details V23 said he did not report to anyone in the facility that R5 complain of not being able to see details and saw shadows. V23 said he dropped the ball. V23 said R5 could not see the power on and off button on the wheelchair, R5 was able to steer the wheelchair. V23 said he worked on steering, turning, and going around tables with R5. V23 said the recommendations upon discharge was independence with manual wheelchair and supervision for motorized wheelchair. V23 said supervision for R5 was that staff should walk along side R5 while he steers the wheelchair. V23 said it's for safety so that R5 does not bump into things. V23 said when the staff walk alongside R5 it's considered contact guard and not one on one. V23 said R5 could not see the power on/ off button on the wheelchair. V23 was asked how is R5 safe to use a motorized wheelchair if he saw shadows/ visual impairment and needed someone to walk along side of him. V23 did not respond. On 10/10/24 V23 followed up with surveyor and said R5 was safe to use a motorized wheelchair. On 10/9/24 at 1:52pm V11 (Restorative Nurse) said R5 was referred to physical therapy for wheelchair management and safety in May 2024. V11 said R5 was not in any restorative programs for motorized wheelchair safety after discharging from physical therapy in June 2024. During a follow up interview V11 said R5 sustained an injury in his motorized wheelchair, that's why he was referred to physical in May 2024. On 10/11/24 at 2:30pm V8 (Director of nursing) said eye contact was the intervention implemented to reduce the risk of injury for R5, when R5 used his motorized wheelchair. V8 said there was staff present when R5 ran into the door with his motorized wheelchair. V8 said the eye contact was an effective intervention for R5. V8 was asked how was eye contact an effective intervention for R5, and R5 ran into an open door and broke his right leg. V8 said the staff could not get to R5 fast enough. R5 previous incident reviewed with V8, V8 discussed R5 bumped into the ramp of the vehicle and injured his left leg. R5 history of visual impairment was discussed with V8, V8 said R5 could see. V8 was asked how did R5 run into an open door if he did not have any issues with his vision. V8 said it was an accident, accidents happen. V8 said R5 did not go to his appointment to check his visual field. V8 omitted reason why R5 did not go to his appointment to check his visual field. V8 was asked why did R8 need an exam to check his visual field if he did not have visual impairment. V8 said residents have rights, and R5 wanted to use his motorized wheelchair. R5 physical therapy recommendation reviewed with V8 denoting that R5 was independent with manual wheelchair and supervision with motorized wheelchair. V8 continue to say R5 was a proud man and he begged her to use his motorized wheelchair, after the motorized wheelchair was removed from R5 use after R5 incident of running into a vehicle ramp in February. V8 said R5 did not have a care plan in place for the motorized wheelchair, and R5 did not have a care plan in place for the supervision while using a motorized wheelchair. V8 said she does not know why R5 did not have a care plan in place for the motorized wheelchair and supervision. V8 omitted discussing risk and benefits with use of motorized wheelchair for R5. V8 suggest surveyor request the consultation for R5 optometrists visit. R5 after visit summary from the eye clinic shows R4 had an appointment on 8/14/24 for visual field and return appointment for the eye doctor. V8 said R4 did not go to the follow up appointment with the eye doctor and the visual field. R5 hospital records dated 9/9/24 denotes in part comminuted right tibia shaft fracture, comminuted right distal tibia fibula fracture, comminuted left tibial plateau fracture. Facility care plan policy with last revised date of 7/26/24 it is the policy of the facility to ensure that all care plans including baseline care plans are in conjunction with the federal regulations. Comprehensive care plan must be developed after the comprehensive assessment of the resident. 40066 4. R1 diagnosis include but not limited to Alzheimer's Disease, History of Falling, Unsteadiness On Feet, Repeated Falls, Scoliosis, Age Related Osteoporosis, Dementia, Mood Disorder, Generalized Anxiety Disorder. Fall with Injury report dated 9/17/24 stated R1 observed laying on floor. Facility Final Incident Report stated 9/25/24 states R1 transported to hospital for evaluation. R1 return to the facility with 8 sutures to forehead and a closed nondisplaced fracture of second metacarpal bone of right hand. R1 fall without injury dated 7/16/2024 notes R1 on the floor. R1 stated she was trying to transfer herself from wheelchair to bed. Root cause analysis states R1 was trying to get back in bed. On 10/5/24 at 10:41AM R1 in regular wheelchair, no pommel cushion, R1 wearing black slacks. R1 crescent shape bruise, yellow/light blue under right eye, right arm dressed in what looks like a white ace wrap. On 10/8/24 at 11:05AM V3, Registered Nurse (RN), said on 9/17/24 R1 was in the wheelchair. V10, CNA, said she got R1 up for lunch and she was eating in her room. V3 said V10 said she left the room to care for another patient. V3 said V10 said she left R1 alone about 10 minutes. V3 said R1 said she did not know what she was trying to do when she fell . V3 said R1 probably fell forward. V3 said R1 was a resident at risk for falls. On 10/8/24 at 12:22PM V10, Certified Nursing Assistant (CNA), said on 9/17/24 I got R1 up for lunch and sat her at the side of the bed, with her tray table. V10 said after R1 ate I picked up her tray and went to the bathroom and then I stopped by another resident's room. V10 said in that time a co worker came and told me R1 was on the floor. V10 said the Nurse and coworker were in R1's room when I got there. V10 said when I left the room R1 had been sitting in the wheelchair. V10 said R1 had one cushion in her wheelchair at the time. V10 said I was in the room with R1 while she ate and after I got her tray I left her alone. V10 said I am not sure if R1 could sit in her room alone. V10 said I knew she was a fall risk. On 10/8/24 at 12:09PM V6, CNA, said R1 has confused memory. V6 said R1 is a two person assist for transfer and she can be resistant. V6 said R1 can stand. V6 said I would not recommend R1 be left in her room in her wheelchair alone because she tries to get up unassisted. After interview V6 showed the surveyor R1 sitting on royal blue pommel cushion during meal. Surveyor observed R1 also sitting on black wheel chair cushion. V6 with ace bandage on right wrist. (R1 had not been on this cushion during earlier observation.) At 12:55PM the surveyor observed R1 with only the one blue pommel cushion, the black one had been removed. On 10/8/24 at 1:03PM V9, Fall Coordinator, said R1's intervention since the July fall is to not leave her alone in the room when in her wheelchair. V9 said R1's 2nd fall (9/17/24) they left her in the room and when staff returned R1 was on the floor. V9 said they should have taken R1 to activity and not left her alone in her room. V9 said we place the interventions on the care plan. V9 said I don't put the dates on the careplan interventions. R1 fall report on 7/16/24 stated R1 mental status confused, alert and oriented times one, poor safety awareness. R1 attempting to stand/transfer without assistance. Root cause analysis of fall states R1 stated she was trying to get back in bed when she fell . R1's safety fall care plan initiated on 9/12/22 includes risk factors of poor sitting balance, poor standing balance, poor safety awareness, unsteady gait, and needs assistance in transfer. Interventions dated 9/12/24 include therapy evaluation, floor mats, pommel cushion. R1's hospital emergency department record dated 9/17/24 reads, noted to have large laceration to head. Laceration repair performed to 3cm laceration on forehead, 8 sutures. R1's hospital emergency department record dated 9/19/24 states R1 presenting for evaluation of right hand pain. Sent back for evaluation of right wrist pain that has been going since her fall 2 days ago. Right wrist and right hand x-rays an acute non [TRUNCATED]

Based on interview and record review, the facility failed to ensure that a resident prescribed a mechanical soft diet with thin liquids and gastrostomy tube received enough water to prevent dehydration. This affected one of three residents (R2) reviewed for dehydration. This failure resulted in R2 having a calculated free water deficit of 1.9L (liters), a high sodium level and according to the hospital record a large amount of colonic stool with large amount of stool in rectum compatible with fecal impaction. Findings Include: R2 had the diagnosis of Vascular Dementia, Metabolic Encephalopathy, Severe Protein- Calorie Malnutrition, Adult Failure to Thrive and Encounter for Attention to Gastrostomy (G-tube). Physician order sheet dated 8/1/24 documents diet: mechanical soft, thin liquids and enteral feed Jevity 1.2 via g-tube continuous at sixty-five milliliters per hour (65ml/hr) to total volume 1040ml in twenty-four hour period. Enteral feeding- Flush with one hundred milliliters (100 mL) water every four hours. Care plan initiated 3/20/24 documents: R2 has the following conditions and risk factors that put R2 at risk for dehydration: Increased weakness, medication regimen (i.e., use of diuretics, laxatives, enemas), poor skin elasticity, Presence of infection, fever, vomiting, diarrhea, nausea, excessive sweating. Diagnosis with severe Protein Calorie Malnutrition: Intervention: Review the comprehensive assessment (including the MDS and CAAs) to identify risk factors for dehydration. On 9/27/24 at 9:40am, V17 (dietitian) said, enteral feeding (g-tube) feeding is calculated based on calorie and protein needs of the resident. If a resident has wounds with exudate or a fever more water needs to be added to the flushes unless the doctor has ordered fluid restrictions. All of R2's nutrition was being proved by g-tube feeding. R2 did not have anything documented issues that would suggest she had any water loss conditions (i.e fever). Dehydration can be determined by abnormal/elevated BUN and Sodium level. If R2 was receiving, the enteral feeding and water flushes as prescribed she would not be dehydrated. On 9/27/24 at 1:00pm, V15 (wound nurse practitioner) said, R2 wasn't eating well. R2 had enteral feedings. Enteral feeding will supply all nutritional and hydration needs that are not processed by eating. R2 was malnourished. R2 did not have any edema. Refer to the dietitian for amount of R2's caloric intake and hydration needs which should be provide by the g-tube feeding. V15 said, she sent R2 to the hospital for decondition and worsening wounds. On 9/27/24 at 1:41pm, V19 (dietician) said, R2 was a dual feeder. R2 had g-tube feeding and a diet. R2 would eat a spoon full or bite of food. R2 was receiving Jevity 1.2 at 65ml/hr and 100 ml of water flushed every four hours. R2 was receiving all of her nutrition/hydration from the enteral feed/flushes. R2 received a total of 1439 milliliters (ML) of water daily between the two sources of nutrition prior to being discharge to the hospital. It would be impossible for R2 to be dehydrated with the water from the formula and water flushes. Elevated sodium levels are indicators of dehydration. R2 did not have any fever. R2's diet order dated 5/7/24 documents: Regular diet, Mechanical Soft texture, thin liquids consistency. Stop date 8/29/24. R2's enteral feed dated 2/27/24 documents: Enteral feeding- Flush with 100 mL water every 4 hours. Stop date 8/29/24. R2 enteral feed order dated 7/4/2024 documents: every shift for feeding Jevity 1.2 via g-tube continuous at 65ml/hr total volume 1040ml in a 24 hour period. Start at 2pm. Turn off during activities for daily living (ADL's) and as needed (PRN). Stop date 8/29/2024. R2's Medication Administration Records do not document the administration of 100ml of water at 2200 on 8/27/24 and do not document the administration of Jevity 1.2ml at 65ml/hr on 8/27/24 in the PM. R2's nutritional note dated 8/26/24 documents: RD completed Nestle Mini Nutritional Assessment (MNA). Resident scored a two (2) which is consistent with at high risk of malnutrition category. Resident meets criteria for severe protein calories malnutrition related to diagnosis of metabolic encephalopathy as evident by moderate loss of muscle mass of the temporalis, trapezius and interosseous muscle and moderate loss of subcutaneous fat from Orbital and buccal fat pads and triceps. Resident condition and current decline. No dietary interventions at this time. R2's nutritional note dated 8/6/24 documents: RD monthly enteral note. Resident is a dual feeder and receives a Mechanical Soft, thin liquid diet. During writer's meal rounds, resident had finished ~35% of her breakfast tray, which is consistent with staff report of poor to fair by mouth (PO) intake at mealtimes, thus resident receives the remainder of her nutrition via tube feed (TF). Currently ordered to receive Jevity 1.2 at 65ml/hr over 16 hours, or until a total volume of 1040ml infused. TF provides the resident with 1248kcals/day (39.6kcals/kg), 57g of protein (1.81g/kg) and 839ml of H2O. Additional flush of 100ml every 4 hours, for a total of 1439ml/day (45.7ml/kg). No reported issues tolerating tube feeding. Current TF regimen and protein supplement exceeds resident's estimated nutritional/fluid needs. No significant weight changes noted; weight has fluctuated x past 6 months; however, weight has trended up since last month due to TF adjustment. Current TF regimen and protein supplement exceeds resident's estimated nutritional/fluid needs. No edema noted. Medications noted. No recommended changes present at this time. Resident remains at increased nutritional risk secondary to mechanically altered diet, enteral feeding, BMI (body mass index), diagnosis and medications. Progress note dated 8/29/24 documents: Refer/transfer patient out for an immediate care and a higher level of care for worsening wound. She continues to lose significant weight and increased contracture. Hospital paperwork dated 8/29/24 documents: Emergency department (ED) to hospital admission, Results dated 8/29/24 at 1524 (3:24PM) documents Sodium 154 High reference range (136-145mmol/L, Bun 25 High reference range (10-20mg/dL). ED (Emergency Department) course: CT incidentally notable for large stool burden suggestive for fecal impaction. Large amount of colonic stool with a large amount of stool in the rectum compatible with fecal impaction. Nephrology- follow up note dated 9/4/24 documents: Hypovolemic hypernatremia sodium 158 secondary to volume depletion inadequate G-tube replenishment, calculated free water deficit 1.9 Liters.

Based on interview and record review the facility failed to follow their fall policy by not implementing new and effective fall interventions, completing an incident report/fall investigation following a fall for one resident who was identified as high risk for falls. This affected one of three (R1) reviewed for falls. This failure resulted in R1 sustaining three falls within 30 days and being transferred to the hospital with a diagnosis of a subacute subdural hematoma. Findings include: R1 was admitted to the facility on [DATE] with a diagnosis of unspecified dementia, hypertension, anemia, and atrial fibrillation. R1's Minimum Data Set, dated dated dated [DATE] documents under toilet transfer a score of three which indicates partial moderate assistance. R1's incident report dated 8/12/24 documents: R1 was found by staff on right side of bed near the window. R1 said he got up to go the bathroom and did not remember to use call light. Under predisposing situation factors: improper footwear and unsafe transfer without assist. R1's fall risk evaluation dated 8/12/24 under cognition documents: Resident displays memory problem. Under mobility Resident is not able to walk even with assistance device. Under history documents resident just had a fall. Score 16 which indicates high risk for falls. R1's care plan documents Safety/Fall admitted in the unit on 7/30/24 R1 was observed that he is at risk for fall /self injury related to multiple medical ,functional , mental; shortness of breath, renal disease, Diagnosis SIRS ( Systemic inflammatory respiratory response syndrome; cardiovascular condition; congestive heart failure CHF, hypertension HTN, contributing factors; A. Physical /Functional Status Ambulation : Needs assist in walking poor sitting balance , poor standing balance unsteady gait , needs assistance in Transfer; Pain/discomfort B. Cognition /behavior: Forgetful needs reminders cues; Poor safety awareness regarding prevention to use call light; Call for assistance periods of restlessness and agitation Recent change in condition: newly admitted in the Facility , new environment admitted with a recent decline in function multiple aches and pain. Date initiated 8/13/24. Interventions initiated on 8/13/24 document the following: greetings to resident. Provide privacy, staff to make sure bed in lowest position; staff to give a friendly approach to resident , and to anticipate needs; Provide safe / therapeutic environment ( Free from clutter) Manage pain for comfort and facilitate free movements; administer as needed medications for breakthrough pain see Medication administration record/ physician order sheet (POS) /MD (physician) as directed; If resident is ambulating staff to make sure that: Resident is wearing proper footwear; Bed locks /Wheelchair locks engage for transfer; Use assistive device during ambulation to prevent falls; Keep mostly needed items (i.e remote control, pitcher) within reach Ensure call light, phone, and supplies within reach; Skilled Rehab Therapy evaluation and Treatment as indicates >Signage >Non-skid socks >Transferred to hospital Date Initiated: 08/13/2024. There were no other fall interventions documented in R1's plan of care or any new updates after a fall on 8/17/24. R1's fall risk evaluation dated 8/17/24 under cognition documents: Resident displays memory problem. Under mobility Resident is not able to walk even with assistance device. Under history documents resident just had a fall. Under narrative documents: While I was getting report the CNA (certified nursing assistant) came and told myself (V18) and the morning nurse (V14) that the patient was sitting on the floor. We went into the patients room and he was sitting between the bed and the wall with his back against the wall. He stated that he was trying to go to the bathroom and couldn't find his urinal. Myself (V18) and the other nurse helped him up to the bed and the CNA got his vitals. No bruises or skin tears were noted. Patient stated that he didn't hit his head and he fell due to feeling weakness in his legs. V14 contacted the family and the fall risk manager. I will continue to monitor his vitals and neuro checks. Fall risk Score 15 which indicates high risk for falls. On 9/25/24 at 11:03AM, V11 (Fall Nurse) said R1 had two falls on 8/12/24 and 9/11/24. V11 said there were no other incident reports for R1. R1 upon admission was not a fall risk and did not have any interventions in place prior to the fall. The fall on 8/12/24 documents R1 was trying to go to the bathroom independently without staff or using call light. Root cause that R1 needed to use the restroom. R1 had the following interventions implemented: signage (Call don't fall) , non skid socks, and hospital. V11 was asked if R1 went to the hospital following fall on 8/12/24 and confirmed R1 was not transferred to the hospital. V11 was unable to find any incident report of fall on 8/17/24. V11 was shown fall risk report dated 8/17/24 that documented fall. V11 said she was not informed of fall and there were no interventions put in place following the fall (of 8/17/24). On 9/25/24 at 12:38PM, V18 (Nurse) said recalls assisting V14 (nurse) with fall for R1 on 8/17/24. V18 said it was change of shift and aide reported R1 was on the floor in his room. V18 said she was starting her shift and assisted V14 and other staff from getting R1 for the floor. On 9/25/24 3:31PM, V14 (Nurse) who was identified in report on 8/17/24 said she getting report and standing at nursing station. An aide reported R1 was on the floor. V14 said she was in the doorway and observed R1 on the floor but did not assist with transfer or any documentation of incident. V14 said R1 was trying to get to the bathroom unassisted. R1 was one to two persons assist to the toilet. R1 used a wheelchair but it was not near R1. If there is a fall we do incident report, fall risk, neurochecks, notify family and doctor. R1's incident report dated 9/11/24 documents: R1 was observed on the floor by his bathroom to have a bowel movement and fell when trying to get up from the toilet. A skin tear was noted on his coccyx. He also appeared to have hit his head on the sliding door of the bathroom. R1 was sent to local hospital for evaluation. Under mental status: alert with periods of forgetfulness, lack of safety awareness, oriented to person and situation. Predisposed situational factors documents: toileting needs, ambulating without assist, improper footwear. R1' hospital record dated 9/11/24 documents a CT head scan under impression. Left convexity mixed density subdural collection noted with a width of 15mm (millimeters) compatible with a subacute subdural hematoma. There is mass effect on the left lateral ventricle and approximately 5mm midline shift to the right. On 9/26/24 at 12:40PM, V16 (radiologist) said a subacute subdural hematoma can occur approximately between one to three months prior to the scan. Facility policy titled Fall occurrence revised 7/26/24 documents: It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place and interventions are reevaluated and revised as necessary. An incident report will be completed by the nurse each time a resident falls. The nurse may immediately start interventions to address falls in the unit, even prior to the falls coordinator's investigation. The falls coordinator will add the intervention in the residents care plan.

Based on interview and record review, the facility failure to develop an effective pressure sore prevention plan to reduce the risk of developing wound infection, failed to ensure wound dressings were replaced after being soiled and failed to ensure the air loss mattress were set for according to resident weight. This affected three of three residents (R2 - R4) reviewed for pressure sore protocols. This failure resulted in R2 developing an infected pressure hand wound due to contracted fingernails pressing into the palm of her hand. Findings Include: 1. R2's diagnosis include Vascular Dementia and adult failure to thrive. On 9/25/24 at 1:30pm, V7 (wound director) said, R2 did not a treatment for her hand nor did R2 have a splints or carrot to prevent contraction. On 9/25/24 at 1:51pm, V10 (restorative) said, R2 was on restorative services for range of motion and bed mobility starting on 2/2024 through 9/15/24. Restorative services would include flexion and extension of hands wrists, arms shoulders, knees if tolerable feet ankle and hip abduction if they can tolerate. R2 was receiving upper and lower extremities range of motion. Per restorative assessment R2 did not have any contractures at time of assessment 3/30/24. Restorative UDA completed on admission, annual. Quarterly and with significant change. V10 said she did not see any refusal by R2. If R2 develops a contracture therapy will assess the resident and we will follow orders. On 9/27/24 at 1:00pm, V15 (wound nurse practitioner) said, if she did not document R2's left hand wound in her notes dated 8/29/24, R2's left hand was not being treated. On 9/27/24 at 4:33pm, V2 (don) said, she was not aware of R2's left hand wound until she reviewed the hospital records. R2 was not under hospice or palliative care. Wound Specialist's Assessment of wound/pressure injury avoidability/unavoidabilty date 8/22/24 documents: right/left ear pressure, sacrum pressure, left hip pressure and left shoulder pressure. (A left hand was NOT documented). Progress note dated 8/29/24 documents: Refer/transfer patient out for an immediate care and a higher level of care for worsening wound. She continues to lose significant weight and increased contracture. Wound assessment: Sacrum, left malleolus, left ear, right ear, left hip, left shoulder and left lateral heel. (A left hand was NOT documented). Hospital paperwork dated 8/29/24 documents: patient had a left hand pressure wound in the palm with pus due to her contracted finger nail pressing on her skin. MRI left hand-small skin and superficial soft tissue ulcer and infection at the central palm, second metacarpal level , with second mild infectious tenosynovitis suspected in the deep adjacent index finger flexor tendons. Left palm superficial resolving infection with prior sutures removed, secondary to contracture of hand/nails. X-ray hand dated 8/29/24 documents: Clinical indication: open ulcer. Patient from nursing home with left hand infection. 2. R3 was admitted to the facility on [DATE] with a diagnosis of peripheral vascular disease, acquires absence of right leg below knee and left leg below the knee, hypertension, type II diabetes, pressure ulcer of right buttocks stage three and pressure ulcer of continuous site of back, buttocks and hip stage four. R3's Minimum Data Set, dated dated dated [DATE] documents a brief interview for mental status score of 14/15 which indicates cognitively intact. Section GG for toileting hygiene documents: dependent which indicates helper does all the effort, or the assistance of two or more helpers is required for the resident to complete the activity. Roll left to right documents: substantial/ maximal assistance which indicates helper does more than half the effort to complete the activity. R3's physician orders dated 9/18/24 documents: sacrum site cleanse with normal saline. Pat dry, apply medi-honey and calcium alginate 4 x 4 and cover with dry dressing every day shift every other day for wound care. R3's physician orders dated 9/24/24 documents: right gluteal site cleanse with normal saline. Pat dry, apply medi-honey and calcium alginate cover with dry dressing every day shift every other day for wound care. R3's physician orders dated 9/22/24 documents: right ischium (gluteal site) cleanse with normal saline. Pat dry, apply medi-honey and calcium alginate cover with dry dressing every day shift every other day for wound care. Order discontinued 9/24/24. On 9/24/24 at 1:10pm, R3's body assessment was completed by V4 (nurse). R3 was observed with gauze on her sacrum wound and right buttocks wound. No wound dressing was covering the gauze. V4 (nurse) said, R3 had a gauze covering her sacrum wound, he believed wound care had been in to provide R3's treatment. On 9/24/24 at 1:19pm, V5 (CNA) assigned to R3. V5 said, he provided care around 8:00 am after R3 had a bowel movement. R3's dressing was soiled with feces and removed. V5 said, he placed a clean gauze on R3's wound and informed wound nurse but unable to recall nurses' name. On 9/24/24 at 2:16pm, V7 (wound director) said, the nurse on the floor should have changed R3's dressing when it was soiled or replaced it within two hour after it was removed. On 9/24/24 at 2:36pm, V7 (wound director) changed R3's dressing. During wound care observations V7 cleaned R3's wound and placed calcium alginate to sacral wound and covered with bordered gauze. There was no medihoney applied to site. R3's site to right gluteal/buttocks/ ischium was cleaned and bordered gauze placed. V7 said, she did not have the treatment for this site because the computer kicked her out. V7 then placed a clean dry dressing over area with no other treatment applied to site. On 9/27/24 at 1:00pm, V15 (wound nurse practitioner) said, she would expect all treatment orders to be followed as ordered. R3's braden scale dated 9/20/24 documents a score of six which indicates high risk for skin breakdown. R3's care plan dated 8/31/24 documents: Resident has an actual impairment to skin integrity. Interventions include apply wound treatment as ordered by the physician; monitor/document location, size and treatment of skin injury. Report abnormalities failure to heal, signs and symptoms of infection, maceration dated initiated 8/31/24. R3's wound note on 9/18/24 documents under wound assessment: Wound# 1 Location: sacrum Primary Etiology: Pressure Stage/Severity: Stage 4; Size: 9 cm x 10 cm x 1.6 cm. Wound # 1 sacrum Pressure Treatment Recommendations: 1. Cleanse with normal saline. 2. apply Medical grade honey, Calcium alginate to base of the wound, 3. secure with ABD, Bordered gauze, 4. change Every other day, and PRN (as needed). Wound# 5 Location: right gluteal Primary Etiology: Pressure Stage/Severity: Stage 3 Size: 6.5 cm x 5 cm x 0.3 cm Wound # 5 right gluteal Pressure Treatment Recommendations: 1. Cleanse with normal saline .2. apply medical grade honey, Calcium alginate to base of the wound. 3. secure with ABD, Bordered gauze .4. change Every other day, and as needed. Wound# 6 Location: right hip Primary Etiology: Pressure Stage/Severity: Stage 4 Size: 8 cm x 11.5 cm x 0.1 cm. Wound # 6 right hip Pressure Treatment Recommendations: 1. Cleanse with normal saline. 2. apply Medical grade honey, Calcium alginate to base of the wound. 3. secure with Bordered gauze .4. change 3 times per week, and PRN . Facility physician order policy revised 8/16/24 documents: it is the policy of this facility to ensure that all resident medications, treatments and plan of care must be followed in accordance to the licensed physician orders. The facility shall ensure to follow physician orders as it is written in the physician order sheet. On 9/24/24 at 1:10pm, R3's body assessment completed by V4 (nurse). R3 was observed laying on an air mattress set at 320 pounds, static off with a flat sheet, cloth pad and wearing an incontinence brief. R3's weight for September of 2024 documents 90.8 pounds. On 9/24/24 at 2:35pm, V7 (wound director) was observed turning R3's air mattress knob as she walked passed R3's footboard. V7 said, she just turned R3's air mattress to 120lbs (pounds). It was on 240 pounds. It should have been set on 120lbs. V7 said, the air mattress should be set to a resident's body weight. On 9/27/24 at 1:00pm, V15 (wound nurse practitioner) said, V15 said, mattress setting should be set accordingly to a resident's weight so the mattress is not to hard or to soft. R3's wound note on 9/18/24 documents under preventative measures: The patient continues on an alternating air/low air loss mattress for pressure redistribution. Ensure settings are maintained at an appropriate level based on the patient's needs and body habitus. R3's braden scale dated 9/20/24 documents a score of 6 which indicates high risk for skin breakdown. Air loss mattress operation manual documents: determine the resident weight and set the control knob to the weight setting on the control unit. 3. On 9/24/24 at 2:35pm, V7 (wound director) said, the air mattress should be set to a resident's body weight. On 9/24/24 at 3:00pm, R4's air loss mattress was set to 290 pounds with alternating pressure and confirmed by V7. R4's weight for September of 2024 documents 219 pounds. On 9/27/24 at 1:00pm, V15 (wound nurse practitioner) said, V15 said, mattress setting should be set accordingly to a resident's weight so the mattress is not to hard or to soft. R4's wound note on 9/18/24 documents under preventative measures: The patient continues on an alternating air/low air loss mattress for pressure redistribution. Ensure settings are maintained at an appropriate level based on the patient's needs and body habitus. R4's braden scale dated 9/23/24 documents a score of 9 which indicates high risk for skin breakdown. Air loss mattress operation manual documents: determine the resident weight and set the control knob to the weight setting on the control unit.

Based on observation, interview, and record review the facility failed to implement fall prevention intervention to R53 who has history of fall. The facility also failed to ensure individualized fall prevention care plan interventions are in place upon admission for a resident who has history fall and fracture of left femur. This deficiency affects two (R53 and R229) of three residents in the sample of 32 reviewed for Fall Prevention Management. This failure resulted in R229 having an unwitnessed fall and sustained acute comminuted left ischial pubic and tuberosity fractures that required hospitalization . Findings include: 1. On 5/14/24 at 11:28AM, V6 Restorative nurse stated R229 admitted on [DATE] with history of falls from home and fracture of left femur. R229 was admitted to the facility for rehabilitation. R229 is non ambulatory and dependent with activities of daily living. She is alert but confused with poor safety awareness. V6 said that on 1/13/24, R229 attempted to get out from bed to go to the bathroom without assistance. She has unwitnessed fall and was sent out to the hospital for evaluation. V6 said that it is was protocol of the facility that resident with unwitnessed fall and currently on anticoagulant was sent to the hospital for evaluation. V6 said she does not know what happened with R229 after. V6 denied V22 Family member presented concern regarding R229 fall incident. On 5/15/24 at 10:47AM, Review R229's medical records with V6 Restorative Nurse. R229 admitted on [DATE] with diagnosis listed in part but not limited to Repeated falls, Alzheimer's disease, Displaced fracture of greater trochanter of right femur, Fracture of left pubis, Displaced transverse fracture of shaft of left femur, History of falling, Muscle wasting and atrophy, Poly arthritis. Admission fall assessment done on 1/9/24 indicated R229 is at high risk for fall. R229 has history of falls with injury. Interim care plan dated 1/9/24 indicated that R229 is at risk for falls related to current medication use, poor safety awareness, unsteady gait, and disease process. Interventions: Restorative program to prevent further falls. Skilled rehabilitation therapy evaluation. Informed V6 that R229 did not formulate individualized care plan based on admission fall assessment done on 1/9/24 indicating that she is at high risk for falls due to history of falls with injury. Fall care plan was not updated until 1/15/24 after R229 had unwitnessed fall with injury dated 1/13/24. R229's hospital record dated 1/13/24 indicated a [AGE] year-old female with past medical history of Hyperlipidemia, Hypertension, Gastro Esophageal Reflex Disease, Depression, Anxiety, Thyroid, Coronary Artery Disease, Dementia presenting with chief complaint of fall from nursing home on left side present with pelvic pain found to have pelvic fracture. She had right femur intermedullary nail fixation right femur in [DATE]. She complaint of pain 10/10. Ortho consult. Diagnosis: Acute traumatic left pelvic fracture. Imaging: Acute left ischial pubic ramus and tuberosity fractures, minimally displaced. Review Post fall investigation completed by V6 Restorative Nurse dated 1/15/24 indicated: Unwitnessed fall with injury: fracture of left pubis. 1/13/24 at 15:10. Resident's room. Attempting to stand or transfer. Awake, confused, poor safety awareness. At risk for fall. History of falls 12/21/23 from home. Root cause analysis: She was last noted sitting on the bed. R229 attempted to ambulate to the bathroom without assistance or using the call light. Interventions to address incident: The resident was sent to the hospital for evaluation. Upon return her room was moved closer to nursing station, she was given ultra-low bed. On 5/15/24 at 2:10PM, V9 Fall Coordinator said that interim care plan intervention is formulated within 24 hours after resident admission. Resident who is at risk for fall should have fall preventions interventions in placed based on fall assessment and resident needs upon admission. On 5/15/24 at 2:48PM, Informed V1 Administrator and V2 Director of Nursing (DON) of above concerns. On 5/15/24 at 5:58PM, V27 Registered Nurse (RN) said that she completed the unwitnessed fall incident report of R229, but she did not observe R229 on the floor. The agency nurse who worked on 7a-3p shift 1/13/24 was the one who observed R229 on the floor after she fell and assessed her. V27 said that the incident was endorsed to her, and she sent R229 to the hospital for evaluation. On 5/16/24 at 10:12AM, Surveyor requested V2 DON for the nurse and CNA who worked with R229 to be interviewed. On 5/17/24 at 10:45AM, V38 Agency Nurse said that she worked with R229 the day she (R229) fell on 7a-3p shift. V38 said that R229 fell during shift change. V38 said that R229 is high risk for fall. V39 said R229 had unwitnessed fall in her room. She was found sitting on the floor next to her bed, R229 said that she wanted to go to the bathroom. R229 was assisted with 2 persons assist using mechanical lift back to bed. R229 denied any pain. R229 was sent to the hospital for evaluation. V39 Agency CNA who worked with R229 on the day of the fall was not available for interview. 2. On 5/14/24 at 10:48AM, Observed R53 lying in bed on slanting position (R53's head was on the left side of the bed with her forehead touching the side rail and her feet are on the right side of the foot part of the bed). The bed is on high position (approximately 30 inches from the floor) with bilateral floor mats on the side of bed. Called V17 CNA (Certified Nurse Assistant) and V18 Agency RN (Registered Nurse) who are assigned to R53 and showed observation made. Both said that R53's bed should be on the lowest position. V18 took the bed control on the right side of the bed, away and out of reach from R53. V18 adjusted the bed to the lowest position. V18 said that R53 had breakfast in bed and probably who ever pick up her breakfast tray forgot to put her bed in the lowest position after eating. V17 CNA denied that she picks up R53's breakfast tray after she ate. On 5/14/24 at 12:12PM, V9 Fall Coordinator said that she is responsible for ensuring implementation of fall prevention policy. V9 said that one of their fall prevention interventions is providing low bed. Resident on low bed should be always on the lowest position when in bed. V9 said that R53 is at high risk for fall, had history of falls and on fall prevention monitoring risk. Informed V9 of above observation made with R53. V9 said that R53 is on low bed and should be in the lowest position when in bed. On 5/15/24 at 10:12AM, V2 DON said that they are expected to implement fall care plan interventions to prevent falls. On 5/15/24 at 2:48PM, Informed V1 Administrator of above concerns. R53 is admitted on [DATE] with diagnosis listed in part but not limited to Metabolic encephalopathy, Pain in left knee, Dementia. Admission fall assessment dated [DATE] indicated that R53 is at high risk for fall due to history of falls. Care plan indicates that R53 is at risk for falls related to current medication use, poor safety awareness, unsteady gait, and disease process. Intervention: Bed should be in a lowest possible position. R53's most recent fall incident dated 9/11/23 indicated unwitnessed fall without injury from bed in her room. Facility's policy on Fall occurrence revised 7/17/23 indicates: Policy statement: to ensure that residents are assessed for risk for falls, that interventions are put in place and interventions are re-evaluated and revised as necessary. Procedures: 1. A fall risk assessment form will be completed by the nurse or the falls coordinator upon admission, readmission, quarterly, significant change and annually. 2. Those identified as high risk for falls will be provided fall interventions. 3. If resident has fallen, the resident is automatically considered as high risk for falls. Facility's policy on Care Plan Revised 7/27/23 indicates: Policy statement: to ensure all care plans including base line care plans are in conjunction with the federal regulations. Procedures: 1. During admission, the facility may put in place baseline care plans within 48 hours to address resident's care. 2. The baseline care plan at minimum should include initial goals based on admission orders, physician orders, dietary orders, therapy services, social services and PASARR recommendations if applicable.

Based on observation, interview, and record review, the facility failed to ensure that a resident was transferred into bed with the use of a mechanical assistance machine as required. This failure affected one resident (R1) reviewed for accidents and resulted in R1 obtaining a closed fracture of right tibial plateau and experiencing severe pain. Findings include: R1 is an [AGE] year-old female who has resided at the facility since 2020, with past medical history including, but not limited to Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, other fracture of shaft of right tibia initial encounter for closed fracture, polyosteoarthritis, hypertensive heart and chronic kidney disease with heart failure, essential primary hypertension, venous insufficiency, etc. 9/26/2023 at 12:55 PM, R1 was observed in bed, awake, alert and oriented. R1 was asked about her injury, and she stated that she did not fall, two women who she didn't recall ever seeing before were putting her in bed and she told them that she cannot stand or walk and needed to be transferred with a mechanical lift. They told her that they were going to put her in bed anyway. R1 said that both women lifted her, one towards her head and the other one on her feet and tried to transfer her to bed, they stuck her right knee under her bed, she told them that her knee was under her bed, but they would not listen to her. R1 stated that she was in so much pain and was screaming. The nurse gave her pain medicine and someone came and took and x-ray of her right leg. R1 said, I used to get in my wheelchair and go out to the lobby. I also enjoy playing bingo but now I am stuck in this bed, the doctor said I cannot get up until my leg heals. Facility reportable dated 9/14/2023 documented in part, follow up call made to local hospital, facility was notified that resident's X-ray result revealed a closed fracture .On 9/14/2023 at 22:49 PM, R1 complained of pain to her right knee after being transferred to bed, body assessment completed, resident's left and right knee noted edematous, MD notified, order received to send resident to emergency room for further evaluation. Care plan initiated 5/19/2020 stated that R1 has an Activities of Daily Living (ADL) self-care performance deficit and impaired mobility, intervention for transfer stated that R1 requires total assistance x 2 staff participation for transfers via a mechanical lift. Restorative ADLs care plan initiated 01/18/2022 states that R1 should be provided assist with all ADLs as needed including transfer, use gait belt. A written statement by V11 (C.N.A) provided by V4 reads in part: I was told by the off going CNA that the patient was a two person transfer assist, when I got to the room, the resident said you need to get the machine, I went and got someone to assist me with putting resident in bed. V11 no longer works at the facility and surveyor was unable to reach her via phone for interview. 9/27/2023 at 4:11 PM, V9 (RN) said that the day R1 injured herself, she was put in bed by the CNAs, her call light went off and when V9 answered the call light, resident complained of pain to her leg; resident did not want pain medicine and stated that she thinks her leg is broken. R1 said that two CNAs put her in bed and her leg hit the bed, V9 called the supervisor who told her to get an order for an x-ray. V9 added that the incident happened at the end of her shift, she did not get a chance to speak to the CNAs; she gave report to the on-coming nurse ad went home. 9/26/2023 at 3:36 PM, V4 (LPN) said that R1 required the use of a machine (sit to stand) with two staff assistance for transfer at the time of the incident, resident said that she told the staff member that she requires a machine for transfer, but she ignored her. V4 conducted the investigation, and stated that the conclusion from her investigation is that an improper transfer was done by the two CNAs and resident sustained a fracture as a result. 9/27/2023 at 2:42 PM, V6 (Restorative Nurse) said that R1 requires extensive assistance with two people using a sit to stand machine for transfer, she was able to bear weight and get in the wheelchair prior to her injury, but her transfer mode is being changed to mechanical lift after the injury. V6 said that she follows therapy recommendation, R1 was evaluated as requiring sit to stand machine for transfer and that's what they have been following. Restorative Nursing program policy revised 7/28/2023, provided by V2 (DON) states in its policy statement, it is the policy of this facility to assess for comprehensive nursing and restorative needs upon admission. Under procedure, the policy states in part, item 2, appropriate nursing, and restorative services consistent to the resident's functional needs must be provided. If the assessment shows that the resident needs therapy, then therapy should be provided. 4. Nursing and restorative services shall be reflected in the resident's individualized care plan consistent to the completion of resident's comprehensive assessment. 9. Resident assistance with ADLs will be based on the above functional assessment, for example, a resident assessed as in need of manual transfer assistance will be provided with that specific assistance using a gait belt. Mechanical lift transfer policy revised 7/28/2023 also provided by V2 (DON) states in part: 1. Follow manufacturer's guideline on how to operate the machine. 2. Explain the task and purpose to resident. 4. Use sling compatible with mechanical lift and appropriate size. 5. there will be 2 staff to assist resident. 1 staff will control the lift ad the other will guide resident and support back and neck to transfer surface.

Based on observation, interview and record review the facility failed to monitor and supervise residents with impulsive restless behavior and poor judgement, failed to ensure residents at risk for falls wore non-slip footwear, and failed to ensure direct care staff were aware of residents who were at risk for falling. This affected 3 of 3 (R7, R5, R2) residents reviewed for falls and fall prevention. This failure resulted in R5 falling to the floor after an incident of restless behavior sustaining a facial laceration. R2 was involved in a fall incident without wearing non-slip footwear sustaining fractures to the 8th-10th ribs. R7 fell from the bed sustaining an impacted comminuted fracture of the nasal bone. The findings include: On 5/3/23 at 2:38 PM, V7 Licensed Practical Nurse (LPN), said CNAs are notified of fall risk by the red wrist band the resident wears. On 5/5/23 at 12:13 PM, V10 Fall Coordinator, said each resident fall is investigated and an intervention should be added to prevent falls. On 5/16/23 at 12:15 PM, V28 Registered Nurse (RN), said the staff is made aware of who is a fall risk by the use of the care cards inside the residents' closet. V28 said the CNA binder does not include fall risk residents. On 5/16/23 at 1:46 PM, V10 Fall Coordinator, said the CNAs are made aware of residents at risk for falls by the binder at the nurses' station. V10 said the restorative CNA will review the binder with the CNAs. V10 said the nurses should know about the binder. Additionally, V10 said we use blue wrist bands to identify fall risk residents. On 5/16/23 at 1:25 PM, the surveyor observed R5 and R7's closets for safety interventions card. The card observed only shows Activity of Daily Living Status, including transfers, and diet orders. None of the 3 cards includes fall prevention interventions or fall risk status. On 5/16/23 at 2:05 PM, the surveyor observed R7 had no dark blue wrist band. While walking to the unit with V10 she said she has been putting the bracelet on anyone who falls. Observation made with V10, R7 has no dark blue wrist band on. V28 RN, at R7's bedside when V10 asked V28 if R7 has a blue wrist band on and V10 said no. On 5/18/23 at 10:18 AM, V12 Director of Nursing, said a blue band identifies the fall risk residents. 1. R5 is [AGE] years old with diagnosis including but not limited to Gout, Anxiety Disorder, Insomnia, Depression, History of Falling, Dementia, and Seizures. On 5/5/23 at 11:03 AM, V14 Nurse, said R5 has dementia and agitation, and we know to monitor him continuously. V14 said at 5:00 AM, the Certified Nursing Assistant (CNA), was in a room giving another patient care. V14 said at 5:00 AM, I was getting ready to start my medication pass. V14 said while passing medications, I was 3 rooms away from R5's room when I heard the alarm sound. V14 said I went into the room, R5 was agitated and trying to get out of bed. V14 said R5 was really agitated, he wanted his shoes. V14 said I redirected him, he was confused. V14 said R5 laid back down in the bed. V14 said I resumed my medication pass. V14 said I was 4 or 5 rooms away from R5's room and again heard R5's alarm sounding. V14 said this time the CNA made it to the room before me. R5 was laying on the side of the bed on the floor. V14 said R5 had a laceration to his left lateral eye. On 5/5/23 at 12:13 PM, V10 Fall Coordinator, said on 4/21/23 R5 fell and got a laceration over his eye. V10 said the CNA, who V10 does not know by name and thinks may have been agency staff, said R2 was asking for shoes. V10 said R5 was a known fall risk resident prior to 4/21/23. V10 said if a resident is restless, has Dementia, and is a fall risk the staff should not leave him alone in bed. V10 said R5 is persistent if he was awake they should have got him up in the wheel chair. V10 reviewed R5's fall report dated 11/15/22 and R5's fall care plan. V10 said I don't know the cause of R5's fall on 11/15/22 and the care plan has no intervention for November 2022, but June and July 2022 are listed. R5's Fall Risk Evaluation dated 11/14/22 notes a score of 13, high risk. Review of R5's Fall report dated 11/15/22 notes R5 observed laying on mat at bedside. Post Fall Investigation record documents unwitnessed fall without injury. The root cause analysis documents R5 was attempting to transfer without alerting staff. The resident has a BIMS of 3 with poor safety awareness. Interventions documented in care plan is left unanswered [yes/no]. Review of R5's fall report dated 4/21/23 at 5:00 AM documents at 5:00 AM the CNA entered R5's room and observed R5 was falling over onto his left side. Writer observed the patient falling over the onto his left side. Post Fall investigation for the fall on 4/21/23 documents R5's root cause analysis was R5 attempting to get out of bed without assistance. Review of R5's care plan does not have a fall prevention intervention after his fall on 11/15/22. Interventions dates listed include 5/9/22; 6/23/22; and 7/7/22. R5's hospital records dated 4/21/23 impression documents facial lacerations. Physical assessment documents 2cm laceration above the left eyebrow. Emergency Department (ED) Course documents laceration repair performed. 2. R2 is [AGE] years old with diagnosis including but not limited to Metabolic Encephalopahty, Acute Heart Failure, Dementia, Anxiety Disorders, Muscle Wasting and Atrophy, Retention of Urine, Partial Intestinal Obstruction, Alcohol Abuse with Intoxication On 5/3/23 at 12:51 PM, V4 Nurse, said if a new resident is admitted the nurse gets in report if the resident is a fall risk. V4 said if we know the resident is a fall risk, we keep the bed in the lowest position, we can implement floor mats, an alarm, and keep the call light in reach. V4 said on 4/15/23 I think R2 was cleaned by V5, CNA, because R2 had a bowel movement. V4 said I was passing medications and R2's daughter called me to say he was on the floor. V4 said when I saw R2 he was sitting on the floor next to the bed. V4 said R2 was sitting on his bottom with his legs out in front of him. V4 said R2 was confused and had an incontinent brief partially off. On 5/3/23 at 1:39 PM, V5 CNA, said I know R2 fell the first day I met him on 4/15/23. V5 said the CNA before me told me R2 was a fall risk. V5 said on the day he fell his daughter had the light on and she said R2 had to use the bathroom. V5 said the daughter stepped out of the room. V5 said I gave him the bedpan, I waited a few minutes, he said he did not have to use it. V5 said R2 sat on the bedpan for a while, then he was moving around. V5 said I asked him if he was done and he did not say anything. V5 said R2 did not have a bowel movement in the bed pan. V5 said R2 wore briefs. V5 said when he left the room R2 was just lying in the bed. V5 said then I was walking down the hall and R2's daughter had returned to the room and I heard someone say R2 had fallen. V5 said when I saw R2 he had his back up against the wall by the bathroom door, the bed was in the same spot. V5 said R2 would have taken about 3 or 4 steps from the bed before he fell . V5 said R2 was sitting on the floor facing the bed. V5 said R2 didn't say anything. V5 said no one has asked me anything about R2's fall until now. V5 said R2 had bowel on the bed and floor. V5 said R2 had nothing on his feet, he probably should have grippy socks. On 5/4/23 at 11:44 AM, V10 Fall Coordinator, said fall risk should be determined on admission. V10 said according to the Fall Risk Evaluation, the higher the number the higher the risk. V10 said a fall evaluation score of 8 or greater places the resident at risk for falls. V10 said R2 should have been closer to the nurses' station. V10 said R2's daughter was the first to see R2 on the floor. V10 said R2 was sitting by the wall and had slid out of bed. V10 said she did not ask the staff if R2 had socks or shoes on, so she was unable to answer what footwear R2 had on at the time of the fall. V10 said she was unable to determine the cause of R2's fall. V10 said the nurse and the CNA she spoke to did not mention R2 having a bowel movement. On 5/4/23 at 2:43 PM, V13 Nurse Supervisor, said if I had put an alarm on a resident, I would have documented it in the progress notes. On 5/5/23 at 1:49 PM, V22 Therapy Director, said R2 was evaluated by Occupational Therapy. V22 said R2 required extensive assistance from staff and should absolutely have 1 person assist for transfers. On 5/11/23 at 10:54 AM, V23 Admissions Director, said prior to R2's admission she let them know he was a fall risk resident. V23 said she was aware of R2's fall risk because it was on his referral packet. On 5/18/23 at 11:36 AM, V12 DON, said the purpose of using foot wear, like non skid, is to prevent the resident from sliding. A Nursing- Admission/Readmission should be completed before end of shift or responsible admitting nurse leaves the building. V12 said all new residents have an admission assessment completed. Progress Notes dated 4/14/23 at 10:38 PM, documents R2 received at 3:00 PM. Wife requesting bed alarm for resident, nurse supervisor notified. R2's care plan documents he is at risk for falls date initiated 4/14/23. Interventions dated 4/14/23 ensure wearing appropriate footwear when ambulating or mobilizing. No Fall Risk Evaluation dated 4/14/23 was found in the record for R2. No Nursing- Admission/Readmission was found for R2. Fall Risk Evaluation dated 4/15/23 at 12:25 PM (after his fall) for R2 notes a score of 17. R2 not continent of bowel and bladder, medications identified include but not limited to diuretic, antihypertensive, narcotics, antipsychotic. R2 has had medication changes in the last 5 days. R2 has a memory problem. R2 not able to walk and confined to a chair. Evaluation documents R2 had a fall. Fall report dated 4/15/23 at 12:25 PM, notes R2 noted sitting on the floor. Resident unable to give description. Predisposing factors notes ambulating without assist and toileting needs. Post Fall investigation documents Fall Risk Evaluation score is 16, R2 is at risk for falls. R2 has a history of falls, at home before admission. No root cause is listed, only facts of R2's admission and his family saw R2 on the floor. R2's hospital records dated 4/15/23 document CT Lumber spine impression nondisplaced fracture of the 8-10th rib heads. 3. R7 is [AGE] years old with diagnosis including but not limited to Dementia, Difficulty in Walking, Cognitive Communication Deficit, and Cerebral Infarction. R7 was admitted to the facility on [DATE]. Cognitive assessment dated [DATE] documents R7 is severely cognitively impaired. On 5/9/23 at 9:59 AM, R7 observed in bed with floor mat. R7 has no wrist band on. On 5/11/23 9:27 AM, R7 observed, floor mats and bed alarm in place. On 5/11/23 at 1:07 PM, V37 CNA, said R7 is on my assignment today. V37 said this was the first time she has been assigned to R7. V37 said R7 does not try to get up out of bed. V37 said residents at risk for falls are identified when they try to get out of bed or have weakness. V37 said she was told about the CNA binder for showers and assignments today. The surveyor asked V37 if she has a list of people at risk for falls. V37 responded she asks the nurse. On 5/11/23 at 2:32 PM, V25 RN, said she was told on 5/5/23 that R7 was on the floor. V25 said when she entered the room she saw R7 sitting on the floor and R7 said her nose hurt. V25 said she had been assigned to R7 before and she never got of bed before, I was shocked. V25 said R7 had floor mats, the bed was in the lowest position, and she was on an air mattress. V25 said possibly she rolled out of bed. V25 said R7 was barefoot when she saw her on the floor. During a follow up interview, V25 said R7's nose was bleeding and I sent her to the hospital. On 5/16/23 at 9:57 AM, V10 Fall Coordinator, said I got a call on 5/5/23 around 7:00 PM, that R5 had fallen and they were sending her to the hospital. V10 said during her investigation she spoke with V38, Guest Services, who told V10 that as she was passing the room she saw R7 face down on her stomach on the floor. V10 said V38 told her R7 was squirming and got herself sitting when the nurse walked into the room. V10 said I spoke with V28 RN, she told me that R7 tries to get out of bed. V28 said R7 was admitted as a fall risk. V10 said the cause of R7's falls is her Dementia, impulsiveness, and R7 was trying to get out of bed. On 5/16/23 at 12:15 PM, V28 RN, said R7 goes from calm and sleeping to trying to get out of bed and she will scream. V28 said R7 really has no purpose in trying to get out of bed, except that she is confused. V28 said before 5/5/23 we stopped getting R7 out of bed. On 5/16/23 at 1:57 PM, V29 Physical Therapy, said R7 requires assistance to get out of bed. V29 said R7 does not follow verbal cues. V29 said on therapy evaluation (4/28/23) I tried to get R7 to roll in the bed and I had to help her with her arms and legs to roll. R7's Functional Status assessment dated [DATE] documents R7 requires extensive assistant with bed mobility, including turning side to side on the bed. R7's fall care plan initiated on 4/27/23 denotes R7 is at risk for falls related to diagnosis including Dementia and poor safety awareness. Initial interventions do not include interventions of moving R7 closer to the nurses' station, floor mat, blue wrist band, alarm, or list at the nurses station. On 5/11/23 interventions include addition of low bed, floor mats. R7's Progress Notes dated 5/2/23 document fall risk. R7's Progress Notes dated 5/5/23 documented by V25, Registered Nurse, reads R7 on the floor with bleeding. Order received to send R7 to hospital. Post Fall Investigation for R7 dated 5/5/23 notes fall with injury, history of fall at home. R7 went to the hospital. R7 is non-ambulatory. R7 attempted to get out of bed without assistance. The facility provided a Fall Occurrence policy revised on 5/17/22 documents the residents will be assessed for risk for falls and interventions are put in place. A fall risk assessment form will be completed by the nurse or the falls coordinator upon admission. Those identified as high risk for falls will be provided fall interventions. If a resident has fallen the resident is automatically considered as high risk for falls. The nurse may immediately start interventions to address falls in the unit, even prior to the Falls Coordinator's investigation. 40066

(A) Based on interview and record review the facility failed to follow the change in condition policy and immediately notify the physician of new onset of pain and abnormal radiology report. This failure affected 1 of 3 residents (R8) reviewed for notification of change. This failure resulted in an over 24-hour notification of onset of ankle pain, and resulted in over a 16 hour delay in notification and treatment of a fractured right tibia. Findings include: R8's face sheet denotes R8 had the diagnosis of orthopedic after care, displaced oblique fracture of right tibia, torus fracture of lower end of right fibula, pancytopenia, anemia, thrombocytopenia, rheumatic tricuspid insufficiency, hypertension, hypertensive heart and kidney disease, atherosclerotic heart disease, pulmonary hypertension, systemic lupus erythematous, infection and inflammatory reaction, dependence on renal dialysis, personal history of sudden cardiac arrest, endocarditis, age related osteoporosis with current pathological fracture, personal history of venous thrombosis, infection following a procedure, and pericarditis in systemic lupus. R8's MDS (minimum data set) dated [DATE] section C denotes BIMS scores is 15 (cognitively intact). Facility final abuse report dated [DATE] denotes in-part R8's name, injury of unknown origin, R8 complained of pain to right ankle. NP (Nurse Practitioner) order received to transport the resident to hospital for further evaluation. X-ray revealed an acute minimally displaced oblique fracture of right tibia and buckling fracture of distal fibula. Family and Doctor notified. R8 is [AGE] year-old female alert and oriented x3. Past medical history (PMH) osteoporosis, systemic lupus, end stage renal disease, secondary to lupus nephritis, [NAME]-sacks endocarditis, status post bioprosthetic tricuspid valve replacement 2020, pulmonary hypertension, Pulseless Electrical Activity (PEA) cardiac arrest, chronic hypoxic respiratory failure, left atrial appendage thrombus, infection at right hip surgical site. On [DATE] NP saw R8 and R8 complained of pain to her right ankle. R8 did not have any fall. R8 stated that during a transfer her right foot got caught unintentionally bent when she was transferred to the chair. She (R8) did not have any pain at the time. R8 was sent to hospital for further evaluation. The Xray revealed an acute minimally displaced oblique fracture of right tibia and buckling fracture of distal fibula. R8 returned to the facility with a right lower extremity (RLE) splint and follow up appointment to ortho [DATE]. R8's progress note dated [DATE] at 3:45 PM, completed by V26 (Agency Nurse) denotes in-part, C/o (complain of) right ankle pain at change of shift. Notified oncoming nurse to follow up with patient/MD (Medical Doctor). R8's progress note dated [DATE] at 5:59 PM, denotes in-part, new order for X-ay of right ankle received from doctor r/t (related to) pain and swelling. X-ray completed and results pending. R8's progress notes dated [DATE] at 11:56 AM, denotes in-part patient is going to hospital for right ankle fracture determined by Xray. Ride called in to ambulance service with last vitals posted. R8's progress note dated [DATE] at 10:48 PM, denotes in-part, resident returned from hospital Dx (diagnosis) right ankle fracture vitals ,d+[DATE] HR (heart rate) 78, RR (respiratory rate) 19, temperature 98.1, no complaints of pain at this time resident did not return with any new orders all needs met at this time resident is currently in bed watching tv all safety measures are in place endorsed to oncoming nurse to continue to monitor. R8's Emergency Department records dated [DATE] denotes in-part impression and plan, acute right ankle pain, [AGE] year-old female with complicated medical Hx (history) as indicated in doctors note, presents with right ankle pain after ankle twisted underneath her while she was being transitioned from her wheelchair into a chair. Lateral and anterior ankle pain, limited ROM due to pain, swelling which is chronic. Xray reveals acute fracture as indicated. Ortho c/s (consult). Plan for splint, pain control, out f/u (follow up) in ortho clinic. Xray ankle 2 views; oblique minimally displaced fracture of the diaphysis of the tibia, buckling fracture distal diaphysis of the fibula. Placed posterior short leg splint, patient still with sensation intact to light touch (SILT) throughout toes of the RLE (right lower extremity), able to wiggle toes, cap refill less than 2 seconds, no numbness/tingling after splint placement. R8's post-acute skilled nursing home subsequent visit notes completed by the provider denotes patient is seen today laying in bed just back from HD (hemodialysis), says she feels well, still with RLE pain and R (right knee immobilizer in place. Patient reports an incident that occurred 4 days ago, while being transferred at dialysis her R (right) leg was bent in an unusual manner; this was reported by her mother who is concerned that she might have another fracture; patient is pointing at her ankle will obtain Xray. [DATE] denotes in-part pt (patient) (R8) c/o pain R (right) ankle to MD (medical doctor) yesterday. Per nursing pt (patient) was being moved to get into HD (hemodialysis) chair and per patient her right foot went the wrong way and since then has been having pain. Xray reviewed and shows acute distal tibial fracture. See below under labs. Pt sent to hospital for further imaging and possible ortho consult. Pt with immobilizer to R (right) knee/leg. NWB to RLE x3 months-right femoral neck fracture s/p hemiarthroplasty ,d+[DATE] and ORIF ,d+[DATE]; R (right) plateau repair done around this time as well. Patient to have wound vac placed to right hip per doctor but has not placed yet and will do once patient returns. [DATE] denotes patient seen laying in bed. Patient went to ER for imaging shows fractures of distal tibia and fibula. Returned with splint to RLE (right lower extremity) and has a f/u (follow up) with ortho ,d+[DATE]. Scheduler changed from ,d+[DATE] since that is a HD day. Patient with pain per therapy and not using Norco as she thought she was receiving it and didn't realize she has to ask for pain meds. Scheduled Norco and script prescribed to pharmacy. Patient also with thrush and ordered nystatin. Max A (assist) for scooting in bed. Pain limiting her progress. Scheduled Norco. On [DATE] at 5:59 PM, V26 (Agency Nurse) said she documented the progress note for [DATE] when R8 had complaints of right ankle pain, V26 said her shift (7am-330 pm) was ending and she endorsed to the oncoming nurse to notify the physician. V26 said she does not remember giving R8 anything for pain, V26 said does not remember asking R8 about what happened to her ankle. V26 describe the nurse as tall, lighter skin female. V26 said she does not know the name of the nurse that she endorsed to. On [DATE] at 5:24 PM, V52 (Agency Nurse) said she was the nurse that sent R8 out to the hospital on [DATE]. V52 said she remembers R8 telling her that staff inadvertently hit her foot or leg during a transfer, and that R8 mentioned it happened days ago. V52 said she talked to the medics when they picked R8 up for transport, R8 medic report reviewed with V52, V52 said yes that was her statement to the medics. V52 said V6 (Restorative Nurse) informed her that R8's X-ray showed a fracture and that R8 needed to go to the hospital. R8's radiology exam report with exam date [DATE] at 7:24 PM, reported date [DATE] 7:25 PM denotes in-part right ankle X-ray, findings- there is an acute displaced fracture at the distal tibia, no dislocated or subluxation. No osteoblastic or osteolytic lesion noted, the other visualized structure appears osteoporotic. Impression un-displaced fracture at the distal tibia. Review of R8's progress notes there is no documentation that the physician was notified on the next shift ,d+[DATE]:30 PM, there is no documentation that an assessment of R8's right ankle was conducted by the nurse, there is no documentation that the physician was notified on the 11:00 PM-730 AM shift. R8 progress notes dated [DATE] at 5:59 PM denotes new orders for Xray of right ankle received from doctor related to pain and swelling. R8's Physician Order Sheet (POS) dated [DATE] documents X-ray right ankle for pain. On [DATE] at 6:30 PM, V12 (Director of Nursing) said the physician should be notified of the residents' complaints of pain/ change in condition before the nurse leave their shift. V12 said the nurse should conduct and assessment, gather information, and notify the physician of the assessment findings and resident complaints of pain. V12 said the nurse should notify the physician for further directives. R8's progress notes reviewed with V12, V12 was asked if there was documentation that the physician was notified of R8's complaints of pain, and documentation that the nurse conducted an assessment, V12 said she did not find any documentation. V12 was made aware of the concern for physician notification for over 24 hours for complaint of pain, and that R8 was not sent to hospital for over 15 hours after the positive Xray results. V12 said R8 transferred with mechanical lift with 2-person physical assist. V12 said the facility did not complete an incident report for R8's fracture to the right ankle. On [DATE] at 6:32 PM, V50 (Consultant) said R8 had a history of multiple fractures, comorbidities, and conditions that could result in a fracture from the slightest bump. V50 was asked should the physician be notified immediately when there's a complaint of pain since R8 has a history of being at risk for fractures from a slightest bump. V50 said that's a good analogy. V50 said V42 (Medical Director) can speak to surveyor regarding R8's health history. On [DATE] at 12:19 PM, V42 (Medical Director) said he agrees with V50's statement that R8 could sustain a fracture from the slightest bump. V42 said R8 was not under his care, and he spoke with the provider from PAN, V42 said R8 has a history of lupus, R8 was on steroids long term, steroids can cause bone loss, R8 had kidney disease, receiving hemodialysis for end stage renal disease and R8 developed osseus dystrophy which cause bone loss of patients with renal disease. V42 said R8 had a hip fracture in the past, where hardware was implanted, V42 said R8's fracture was not healing, and they physician wanted to remove the hardware but R8's bones are so thin. V42 said R8 is highly susceptible to fractures of the bones. V42 said the physician should have been notified of R8 complaints of pain if it was persistent, it did not have to be immediately, because R8 already had a fracture. V42 was informed that R8 had new complaints of pain to her ankle. V42 said he was informed by V12 (Director of Nursing) that R8 did not have any complaints of pain. R8 records reviewed with V42 denoting that R8 complained of pain on [DATE] to the physician, and V42 was informed that R8 complained of pain on [DATE] to the nurse per progress notes. V42 was asked if R8 is susceptible to fractures should the physician be made aware of R8 complaints of pain for directives. V42 said R8 received an Xray. V42 said he was not aware that R8 was not sent out to the hospital for over 15 hours after the Xray showed a fracture. R8's Xray results reviewed with V42 denoting results reported at 7:25 PM on [DATE]. V42 then said there was no delay in care because R8 did not require treatment. V42 was informed that R8's hospital discharge summary denotes that R8 required a splint to the right ankle. V42 clarified that R8 did not require a surgical treatment. V42 said as a medical director that he would have not sent R8 out to the hospital immediately because R8 did not have pain, V42 said it would have been a burden to R8. R8 progress note reviewed with V42, denoting R8 had complaints of pain, R8 and her family was concerned that there may be another fracture. V42 was asked how this could be a burden for R8 when R8 had complaints of pain, and concerns for new fracture. V42 said R8 already had a brace in place. R8 records reviewed and V42 was informed that R8's brace was for the right knee and not the ankle. V42 clarified that he was not R8's physician. V42 said the physician should have been notified of R8 complaints of pain and the physician should have been notified of the Xray results showing a fracture. V42 said he was just saying there was no harm to R8 because of the physician not being notified. V42 was made aware that the facility is surveyed for the care and safety of the residents, and that R8's Xray was not ordered for over 24 hours after complaints of pain, and R8 was not sent to the hospital for over 15 hours after the positive X-ray results. V42 said the care and safety of the residents are his concerns also. On [DATE] at 2:24 PM, V51 (radiology company personnel) said the radiology company was notified at 18:02 (6:02 PM) of request for Xray, V51 said the tech was notified at 18:10 (6:10 PM), V51 said the facility was notified of the X-ray results at 19:25 (7:25 PM), V51 said the results are uploaded to the electronic medical records after completion for the facility to view. V51 said the results are reviewed by the physician and uploaded to the electronic records. V51 said the process is the radiology company should call the facility and inform the facility of the positive results. V51 said the radiology company did not contact the facility and speak to someone and inform the facility of the positive results. V51 said the results were reported to the facility when the results were uploaded to the electronic records. On [DATE] at 1:00 PM, request made to review facility radiology contract; facility failed to present radiology contract for review during this survey. Facility Policy titled change in condition with last revision date of [DATE] denotes in-part the facility will provide care to residents and provide notification of residents change in condition status. The facility must immediately inform the residents; consult with the resident's physician; and if known, notify the residents legal representative, or an interested family member when there is a significant change in in the resident physical, mental or psychosocial status, a need to alter treatment significantly; or a decision to transfer or discharge the resident from the facility. Per federal definition a need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences or commence a new form of treatment to deal with a problem (the use of any medical procedures, or therapy that has not been used on that resident before). (B) Based on interview and record review the facility failed to notify the resident representative of the arrival/ admission to the facility. This affected 1 of 3 residents (R4) reviewed for notification of admission. Findings include: R4 was admitted to the facility on [DATE] at or around 8:50 PM per facility record, R4's fire department record dated [DATE] denotes R4 was pronounced deceased on [DATE] at 12:45 AM. R4's admission report dated [DATE] completed by V13 (Charge Nurse) denotes in-part code status-full code. Primary diagnosis AMS (Altered Mental Status), Fever. History diagnosis IDDM (Diabetes Mellitus) HTN (Hypertension), ESRD (End Stage Renal Disease) CVA (Cardiovascular Accident), Dementia. Mental status x1 only. On [DATE] at 9:46 AM, V20 (R4's Family) said R4 was going to be admitted to nursing home for long term stay after a hospital stay due to altered mental status and infection. V20 said a nurse at the facility contacted her and informed her that R4 had expired. V20 said she immediately got dressed and went to the nursing home. V20 said when she arrived at the facility, she was allowed to see R4, V20 said she notice that R4's dialysis catheter was not in his chest. V20 said V16 (Nurse) informed her that R4 was found unresponsive, and his catheter was observed on the floor at the bed side. V20 said R4 was on restraints at the hospital because he was picking with the dialysis catheter in his chest. V20 said she didn't inform anyone at the facility about R4 picking at his catheter because no one called her and informed her that R4 had arrived and was admitted to the nursing facility. V20 said R4 was a full code, and the facility should have initiated all life sustaining measures for R4. V20 said no one from the facility contacted her to review R4's code status. V20 said she wants R4's death investigated because she believes R4's death was exacerbated by the facility lack of care and supervision. V20 said she was shocked by the report of R4's death when the facility contacted her at midnight. On [DATE] at 12:35 PM, V15 (Nurse) said she was the admitting Nurse for R4. V15 said she was aware that she was receiving a new admission, that was going to be residing on unit (100). V15 said she was assigned to work on unit 500 or 300, she didn't remember. V15 said the aide on the unit that she was working was also going to be assigned to the new admission (R4). V15 said she was the nurse responsible for the care of R4, it was not the responsibility of the nurse on the unit that R4 was admitted to. On [DATE] at 2:08 PM V15 (Nurse) said she did not notify R4's family of his admission to the facility, V15 said she does not normally notify the families of the admissions, V15 said the hospital is supposed to notify the family of the admission to the facility. V15 said she was not aware that R4 was on restraints at the hospital for picking at his catheter, she did not see that in the hospital referral records. V15 said she was not aware of R4 trying to pull out the catheter and mitten applied in the hospital. R4's admission report reviewed with V15, and statement V15 then said she does not remember getting the hospital admission report. V15 said she has not had an in-service on ADL (activity of daily living) care, new admission, readmission process expectation on [DATE]- [DATE]. V15 said she has not had an in-service as to this date of [DATE]. On [DATE] at 10:15 AM, V12 (Director of Nursing) said the nurse should notify the family of the resident admission to the facility after the nurse puts the medication orders in the electronic records and notify the physician of the admission just in case the nurse would have to get consent or something. R4's progress note dated [DATE] time stamp 11:08 PM, completed by V15 denotes in-part this is a new admit to Facility room (number) from hospital, alert and responsive, skin warm and dry, abdomen soft and non-distended, lung sound are clear, bowel sound present in all quadrants, wounds to sacral noted, resting quietly in bed, call light within reach. Review of R4's progress note completed by V15, there is no documentation denoting that V15 notified R4 family of his arrival and admission to the nursing facility. Review of R4's medication order audit, it is denoted that V15 (Nurse) input medication orders for R4 on [DATE] at 9:48 PM. Review of R4's facility admission report, it is denoted that R4 mental status is x1 ONLY. Review of R4's facility face sheet denotes V20's name and phone number as emergency contact and care giver.

Based on observation, interview, and record review, the facility failed to follow their skin care treatment policy by not assessing a resident's skin for breakdown and failed to have a plan of care in place to address assessment and monitoring of a resident's skin with a soft cast in place. This failure affected one (R12) of one resident reviewed for skin breakdown and resulted in R12 developing a vascular injury to the top of his right foot measuring 7.00 x 6.80, with an unknown length and area of 47.60cm. Findings include: R12 is a [AGE] year-old man who has resided at the facility since 8/30/2022 with past medical history including, but not limited to Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, wedge compression fracture of T7 -T8 vertebra subsequent encounter for fracture with routine healing, essential primary hypertension, type 2 diabetes, anemia, etc. Per record review, facility minimum data set (MDS) assessment dated [DATE] section C (cognitive) coded R12 with a BIMS score of 14 (cognitively intact), section G (functional) coded resident as requiring extensive assistance with two-person physical assist for transfer, extensive with one-person physical assist for bed mobility, locomotion non and off unit, dressing, toilet use and personal hygiene. Section H (bowel and bladder) of the same assessment coded resident as always incontinent of bowel and bladder. 04/03/23 11:00 AM, R12 was observed in his room, awake and alert and stated that he is doing okay. R12 stated that he needs to see a podiatrist, he saw one in December and since then no one has been here. R12 said he has wounds to his legs and the one on top of his right foot resulted from him wearing a cast for too long. 4/3/2023 at 2:23 PM, observed wound care for R12 with V4 (LPN/wound care and V21 RN/wound care) and noted a large area of excoriation on top of R12's right foot. V4 was asked how the resident got the injury and she said, the resident had a cast, and the wound was under the cast; it was discovered when he went to the orthopedic doctor on 3/31/2023. He has an order for Betadine on Xeroform to top of the right foot. Wound assessment dated [DATE] documented a facility acquired vascular wound to the top of right foot measuring 7.00 x 6.80 with an unknown depth, with an area of 47.60cm. Review of R12's care plans, did not include any plan of care related to care of the soft cast on R12's right foot. Care plan initiated 2/10/2023 states the following: R12 is at risk for alteration in skin integrity including pressure injury due to impaired mobility, incontinence, repeated falls, and disease process associated with dx: lt side hemiparesis post CVA, anemia, HTN, HLD, DM2, prostate CA, polyneuropathy, and retinal ischemia. Resident will not incur any pressure injuries through the next review as evidenced by absence of pressure injuries. Interventions include Follow facility policies/protocols for the prevention/treatment of skin breakdown. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Turning and Repositioning, Use lifting device, draw sheet, etc. to reduce friction. On 4/4/2023 at 2:00 PM, V16 (LPN) said that she was the assigned nurse for R12 the day he went for an appointment. R12 had two escorts when he left, he did not complain of anything to her, she came back the following day and was told that resident had a cast, she is not sure what happened. V16 added that the cast was wrapped up, she never took care of it, just gave resident his medications. At 2:52 PM, V2 (DON) said that there was no treatment for R12's cast, the skin under the cast should be assessed by the wound care team and it should be documented in the medical record. 4/5/2023 at 10:40 AM, V4 (Wound Care Coordinator) said that she does not know the date the resident got the cast, they were not doing any treatments or assessment of the cast; she was notified of the injury by another nurse on 3/28/2023. Surveyor requested for any documentation of when the resident got the cast and how long it was on the resident, but none was provided. Review of R12's medical records show a hospital after-visit summary dated 2/20/2023 which includes instructions for caring for a knee sleeve or brace and reads: to wear the knee sleeve or brace as told by the doctor. Take it off only as told by the doctor, loosen if toes [NAME], become numb turn cold or blue. Keep it clean, if sleeve or brace is not waterproof do not get it wet . Document presented by V2 (DON) titled, Skin Care Treatment Regimen, (revised 7/28/2022) states that it is the policy of the facility to ensure prompt identification, documentation and to obtain appropriate topical treatment for residents with skin breakdown. The same policy states, in part, that residents who are not able to turn and reposition themselves will be turned and repositioned every 2 hours unless specified in POS (physician order summary).

Based on observation, interview, and record reviewed the facility failed to have identified fall prevention interventions in place, to develop individualized fall prevention interventions, to update the resident care plan post fall with new interventions, and failed to develop a resident specific root cause analysis for falls This affectes 3 of 3 (R1, R12, and R11) residents reviewed for falls. This failure resulted in one resident (R1) sustaining a head laceration requiring 6 sutures. Findings include: 1. R1 is [AGE] years old with diagnosis including, but not limited to Metabolic Encephalopathy, Muscle Wasting and Atrophy, Anemia, Dementia, Bipolar Disorder, Alzheimer's Disease, Hypertension, Acute Kidney Failure, Chronic Kidney Disease, Dysphagia, Altered Mental Status, Gastrostomy Status, and History of Fracture of Left Tibia. R1 was initially admitted to the facility on [DATE]. Functional Mobility on admission documents R1 required total dependence of 1 person for bed mobility. Mobility Criteria notes R1 is completely immobile and does not make even slight changes in body or extremity position without assistance. Fall Risk Evaluation notes R1 is in bed and is non-mobile. R1 received Physical Therapy from 10/5/22 until 11/10/22. Physical Therapy Discharge Summary notes Prior Medical History (in part) lists: altered mental status, fracture of left tibia closed fracture status post 7/9/22, falls. On 1/31/23 at 9:53 AM, V11, LPN said when R1 fell she was told by the CNA that he was giving care and R1 fell from the bed onto the blue mat. V11 said R1's baseline is that she can roll and move back and forth in the bed. V11 said the CNA said he was giving care and she rolled. V11 said R1 had been calm that morning and was in her usual behavior. V11 said she was a fall risk before the fall on 12/5/22. V11 said intervention in place were to have the bed in the lowest position, blue floor mat, bed and chair alarm as well. V11 said I saw the floor mats in place when I assessed R1 from the fall. V11 said she saw R1 had her head split (V11 pointed to the left forehead area of her head). V11 said she stopped the bleeding, got R1 up, made calls to family and doctor, and then sent R1 for hospital evaluation. V11 said when R1 returned she had 6 sutures in her head at the laceration. V11 said after the fall R1 became a 2 person assist for all cares, the newest intervention is she is 2 person assist at all times. On 1/31/23 at 10:46 AM, V13, Restorative and Falls Nurse, said R1 fell on [DATE] during the process of receiving care. V13 said the CNA was washing her and wringing out the towel and R1 rolled off the bed. V13 said the bed was at hip level, and the staff turned at the bedside to wring the towel and R1 rolled off the bed. V13 said R1 had been on her back on an air mattress. V13 said R1 is not very mobile but was able to throw her legs off the bed. V13 said prior to the fall R1 was not a fall risk. V13 said R1 did not have impulsive movements. V13 said following the fall, R1 had bleeding and was sent to the hospital for evaluation. V13 said R1 returned with 6 sutures. V13 said she did not know what R1 hit her head on to cause the open area. On 1/31/23 at 3:17 PM, V23, CNA, said he was in the room with R1 on 12/4/22. V23 said he had seen R1 hanging out of the bed earlier during the shift and repositioned her 3 times. V23 said R1 has put both her legs out of the bed and was in slanted position with her legs out of the bed. V23 said on the third time he decided to get her washed up. V23 said he was washing R1 and he went to the bathroom to get another towel and rinsed a towel. V23 said he turned his back towards R1 and when he turned towards R1 he saw she threw herself out of the bed. V23 said the bed was in the raised position and not in the lowest position when he was in the bathroom. V23 said R1's behavior of moving around is her usual. On 1/31/23 at 12:45 PM, V18, CNA, said R1 requires 2 staff persons when providing care because she resists and grabbed at staff hands. R1's care plan for Focus for falls initiated on 8/18/22 noted R1 is at risk for falls. Undated intervention states bed in a lowest possible position. R1's care plan focus for Activity of Daily Living Restorative Nursing, documents R1's goal will receive assistance from 1-2 CNA for all ADLs. Date initiated is 8/18/22 R1's incident report dated 12/4/22 at 11:11 AM, notes staff reports during care R1 rolled off the bed onto the floor. Nurse observed R1 lying on her left side. R1 bleeding from her left temple/scalp area. Noted R1 with 1cm laceration. Post fall investigation for R1 states she has poor safety awareness and impulsive movements with periods of restlessness due to cognitive impairment. Review of R1's Documentation survey from 1/6/22-1/31/22 denotes 2 person care has been provided 21 days, post the fall. V18 said R1 requires 2 person assist. V11 said her intervention was to always use 2 person care for R1. 2. R12 is [AGE] years old with diagnosis including, but not limited to, of nontraumatic subdural hemorrhage (onset 10/22/22), Difficulty in Walking, Unspecified Fall, Alcohol Dependence with Intoxication, Mild Cognitive Impairment, Seizures, Hypertension, Chronic Obstructive Pulmonary Disease, Osteoarthritis, and Altered mental Status. On 1/31/23 at 1:12 PM, R12 observed in bed with no floor mats on either side of the bed. On 1/31/23 at 1:31 PM, R12 observed with V20, CNA, and no floor mats in place. V20 showed the surveyor R12's wheelchair. The surveyor observed a black wheelchair with a wheelchair cushion in it. There is no nonskid device on top of the wheelchair cushion. V20 lifted the wheelchair cushion, and no non-skid device was in place under the cushion. V20 said she was going to clean R12's wheelchair but had not done it yet. On 1/31/23 at 1:41 PM, V21, RN, said she was assigned to R12 on 1/30/23 and he was sitting up in his wheel chair on 1/30/23. V21 said R12 is a fall risk. On 1/31/23 at 9:53 AM, V11, LPN said R12 is a very high fall risk. V11 said R12 can walk if assisted 3 to 5 steps. V11 said R12 needs a wheelchair. R12 said V11 safety intervention included bed in the lowest position, floor mats, bed and chair alarms. V11 said R12 never used the call light and was placed in a room across from the nurses' station. On 1/31/23 at 10:46 AM, V13, Restorative and Falls Nurse, said R12 is at risk for falls due to his poor safety awareness. V13 said R12's fall on 12/29/23 was due to his poor safety awareness and improper transfers. V13 said R12 was attempting to use the toilet. V13 said the CNA told her that she heard R12's alarm and when she responded she saw R12 on his knees, kneeling by the sink in the bathroom. V13 said R12's safety interventions included a low bed and bed and chair alarms. V13 said R12 was wheel chair bound and did not use a walker. Fall report dated 12/29/22 at 6:43 PM, documents R12 was observed on his knees in the bathroom. R12's statement was that he was trying to get on the toilet and slipped to the floor. R12's care plan fall focus initiated on 10/24/22 notes an undated intervention for bed in lowest position and fall mats. 3. R11 is [AGE] years old with diagnosis including but not limited to Chronic Diastolic (congestive) Heart Failure, Dementia, Alzheimer's Disease, Unsteadiness on Feet, and History of Falling. On 1/31/23 at 2:37 PM, V11 said she was doing rounds at the start of her shift and saw R11 was holding himself from the bed rail. V11 said R11 was sitting on his but on the floor on the right side of his bed. V11 said R11's bed was at regular height, he had a chair alarm and a bed alarm. V11 said R11's bed was not low. V11 said I don't recall hearing it or shutting it off. V11 said R11 was confused and could not tell me what was going on, but he had been trying to get up. V11 said R11 went to the emergency room for evaluation. V11 said at the time of the fall R11 complained of hip pain, but that was from an old injury. V11 said following the fall we added floor mats as an intervention. R11's Admission report dated 1/6/23 states R11 requires extensive assistance with bed mobility, transfers, and toilet use. R1's cognition is documented as impaired. R11 is confused, or in stupor or in coma due to cognitive deficit, resident will be unable to use the call light system effectively. R11's fall report dated 1/28/23 states upon rounds the nurse observed R11 lying on the floor next to his bed with his feet pointing towards the top of the bed, holding on to the side rail. R11's Post Fall Investigation notes R11 has a history of fall in the facility on 1/10/23. Interventions in place state low bed', V11, LPN, said during interview the bed was at a regular height. Root cause notes R11 has poor safety awareness and impulsive movements with periods of restlessness due to cognitive impairment. R11's Baseline Careplan dated 1/6/23 notes R11 has cognitive deficit and with a goal to be free from injury. R11's Baseline Careplan dated 1/6/23 includes fall risk due to poor safety awareness. Intervention includes keep call light in reach when in bedroom or bathroom. (Admission assessment documented R11 is unable to use the call light.) R11's Comprehensive care plan for fall has date initiated 1/17/23 notes intervention to ensure call light is within reach. R11's care plan does not include the use of alarms. R11's care plan received on 1/31/23 does not include new interventions, after 1/29/23, to prevent future falls. The root cause analysis for R1, R11, and R12 all state resident has poor safety awareness and impulsive movements with periods of restlessness due to cognitive impairment. The facility Fall Occurrence policy revised on 5/17/22 states 3. If a resident had fallen, the resident is automatically considered as high risk for falls. 6. The nurse may immediately start interventions to address falls in the unit, even prior to the Falls Coordinator's investigation. 7.Ultimately, the Falls Coordinator may change the interventions provided by the nurse if the Falls Coordinator's investigation identifies a more appropriate intervention for the individual fall. 8. The Falls Coordinator will add the intervention in the resident's care plan. The facility policy on Falls revised 8/5/20 states 2. To gather accurate, objective and consistent data for the purpose of implementing an individualized Plan of Care designated to meet the resident's needs. 6. Residents who have been identified at risk or who have experienced a recent fall have all recommended interventions in place.

Based on observation, interview, and record review, the facility failed to prevent a resident from developing a Stage 3 sacral pressure ulcer and failed to follow their protocol and resident's plan of care by not conducting skin checks every shift and failure to document the identification and assessment of skin breakdown. This failure affected one of four (R2) residents reviewed for pressure ulcers. Findings include: R2 is a [AGE] year old female who has resided at the facility since 2021, with past medical history including, but not limited to: [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting left dominant side, bacterial infection, COVID-19, carpal tunnel syndrome bilateral upper limbs, [CONDITION(S)], jaw pain, essential primary hypertension, mixed [CONDITION(S)], [CONDITION(S)], major depressive disorder, etc. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Skin assessment weekly on shower day every day shift every Monday. Care plan dated 4/7/2022 states: R2 has potential for impairment to skin integrity. According to her Braden score of 13 and Hx: Cerebral Infarction, mixed [CONDITION(S)], and [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting left non-dominant side places her at risk for skin breakdown. Resident will continue to have skin intact through next review date. Interventions include, keep skin clean and dry. Use lotion on dry skin. Skin checks every shift. Report abnormalities to the nurse, Turn and reposition as needed. Facility MDS (Minimum Data Set) assessment dated [DATE], Section C (Cognitive) coded R2 with a BIMS (Brief Interview for Mental Status) score of 5 (severe cognitive impairment); Section G (Functional Status) coded R2 as 3/2, indicating extensive assistance with one-person physical assist for bed mobility, dressing, and personal hygiene. R2 is total dependence with 2-person physical assist for transfer, and limited assist with one-person physical assist for eating and toilet use. Section H (Bladder and Bowel) of the same assessment coded R2 as always incontinent for bowel and bladder. On 7/5/2022 at 2:00 PM, R2 was observed in her room sleeping and could not awake to her name. Urinary drainage bag noted at the bedside, resident was lying on her back, no splints or wedges noted. On 7/6/2022 at 9:45 AM, observed wound care for R2 with V3 RN (Registered Nurse) and V4 LPN (Licensed Practical Nurse), noted a large, darkened area of excoriation on the resident's bottom, resident has a urinary catheter. During observation, V3 stated that the catheter was inserted for wound healing and that (R2) did not have any wounds when she got here but has other health issues that may have led to the skin alteration. R2 developed a stage 3 pressure ulcer to her sacrum, identified as a deep tissue injury on 5/2/2022, measuring 7.50 x 14.00 x unknown (L x W x D), area 105.00 cm, volume unknown. Wound care note dated 6/1/2022 stated in part that the wound is limited to skin breakdown, there is a medium amount of serosanguineous drainage noted. Facility was asked for but did not provide any documented skin assessments/skin checks for R2. On 7/7/2022 at 1:10 PM, V3 said that they do not do skin assessments on residents unless they have a wound; skin checks are supposed to be done during showers. On 7/6/2022 at 12:50 PM, Surveyor inquired about shower schedules for the residents on the 200 unit which V5 (RN/unit manager) provided, stating that showers/bed baths are scheduled once a week and as needed, they are not documented in the computer, rather they use shower sheets which are kept in a binder. Surveyor requested for shower sheets for May and June, V5 looked through the binder and said that she could not find any for R2, she will go to her office and check. V5 later presented some shower sheets that showed that R2 never had any showers, just some bed baths. Document presented by V2 DON (Director of Nurses) titled skin care treatment regimen with a revision date of 7/28/2021 states as its policy statement that it is the policy of the facility to ensure prompt identification, documentation and to obtain appropriate topical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Furthermore, topical skin treatment must be obtained from the patient's physician.

Based on observation, interview, and record review, the facility failed to ensure that agency hired nursing staff (V17) was trained on facility emergency procedures prior to allowing her to work on the unit and provide care to residents. This failure affected one resident (R12) in the sample. As a result of this failure, V17 did not immediately response to call a code and start (CPR) for R12, who was found unresponsive in her bed. This situation was identified as an immediate jeopardy. The immediate jeopardy began on [DATE] and was removed on [DATE]. V1 (Administrator) was informed of the immediate jeopardy on [DATE] at 10:07AM. However, the deficiency remains at a level 2 harm until the facility can evaluate the effectiveness of the implementation of their removal plan. Findings include: R12 is a [AGE] year old female, admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of medical record, documents that R12's advanced directive lists her as a full code. R12's current care plan includes Focus: Code Status, FULL CODE and Interventions (include): As indicated, document the code status on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Date Initiated: [DATE]; Scan the original POLST form into the EMR chart and consider placing one or more copies of the POLST form in a notebook on the unit for easy access during a medical emergency or when transferring the resident. Date Initiated: [DATE]; The EMR chart should identify FULL CODE status. Date Initiated: [DATE]. [DATE] at 1:11pm, surveyor entered R12's room and saw resident lying in bed, her right eye was open and her left eye was closed, her mouth was open and she appeared stiff and not to be breathing (chest was not visibly rising). Surveyor called resident's name and she did not respond. Surveyor immediately stepped out to the hall and called over V16 (CNA), who was coming out of another resident room, and asked her to come to R12's room. When CNA entered the room, at 1:12pm, surveyor advised her to do what she would normally do. V16 called the resident name and shook R12, R12 was not responding and V16 said, Is she breathing? Again, surveyor reiterated to V16 to please proceed as she should per her facility's protocol. V16 left the room to get the nurse. At 1:13pm, V16 (CNA) and V17 (RN/Agency) came back into the room and V17 proceeded to assess R12; she checked her pulse, checked to see if she was breathing, did sternal rub - all while calling the resident's name. V17 said (talking to V16), she's (R12) not responding, I think she's a full code; that's what the nurse said this morning but I don't trust anything because this place is a mess; I've been getting wrong information all day. I'm not putting my license on the line, I need to make sure she is a full code before doing anything. V16 and V17 then stepped out of the room. Surveyor stayed in the room conducting observations. At 1:17pm, V16 and V17 came back in the room. Discussion continued amongst staff on whether the resident was a full code or not. At 1:18pm, V18 (CNA/Agency) came in the room and said, I swear, I just saw her 30 minutes ago. I fed her lunch. Discussion continued amongst nursing staff in the room. At 1:19pm, more staff starting coming into the room [V19 (RN), V21 (RN), and V20 (Nurse Practitioner)], with the crash cart. V20 started to assess the resident and stated, we should start CPR. At that point, V17 initiated chest compressions. It had been six minutes since V17 entered the room and found R12 unresponsive before she initiated CPR. At the same time, V20 could be seen trying to get vitals on R12 and R12 was given glucose and hooked up to the AED (Automated External Defibrillator) machine. At 1:22pm, a CPR board was placed under the resident. At 1:24pm, V9 (Assistant Director of Nursing/RN) entered the room with some papers in her hand and told the staff to use the bag valve mask (to provide oxygen). At 1:25pm, V20 (Nurse Practitioner) stated she was going to call the family and left the room. At 1:27pm, V21 (RN) was observed checking R12's glucose level. At 1:28pm, the local fire department/paramedic arrived and took over. V22 (Paramedic) asked who was responsible for the resident and what is her medical history. V17 (RN/Agency) provided the paramedics with some information regarding R12's medical history and then stated, I'm not sure how accurate that is because this is my first time working here and reports in this place are terrible. At 1:36pm, surveyor still in the room, overheard paramedics continue asking V17 questions and V17 stated, I don't know anyone's name, again, this is just my first time here, I don't even know their protocol. V22 (Paramedic) was heard telling V17, I'm not placing blame, I'm just letting you know that she (R12) already has rigor in the jaw and that tells me that she's been dead for more than 30 minutes and CPR should not be started if there are obvious signs of death but since it was started we have to continue the process; it's just that then the hospital gets upset at us. Surveyor overheard V22 on phone call (apparently giving a report) and stating that R12 was maintaining rigor and heart rhythm was asystole. Since paramedics had taken over, facility staff were disbursing and leaving the room. Surveyor went out to talk to staff. [DATE] at 2:07pm, V17 (RN/Agency) stated that this was her first time working in this building. She stated that she saw R12 this morning when she gave her, her meds at around 10am but hadn't had time to go in the room since. V17 stated that she almost didn't stay when she came in this morning because she could tell it was unorganized because they were going to give her 28 residents because another nurse wasn't coming but then they got someone to cover the other 14 residents; so she was left with 14. She stated that she didn't feel the report she received in the morning was adequate and that she even came in early so that she would have time to be oriented before she started her shift from 6:30am - 2:30pm but that the only orientation she received was the report from the outgoing nurse; she did not receive any special instructions regarding facility protocols, emergency procedures, how to determine a resident's code status, COVID precautions, or nothing else. Again, she emphasized that all she got was a report from the nurse. She stated that they are clearly short staffed and she's been busy all day and trying to help out the CNA's when she can because they need help too. V17 stated, I'll never come back. [DATE] at 2:20pm, V16 (CNA) stated that she had been in R12's room earlier today but not for R12; she was not assigned to her. V16 was asked if she had received any training on what to do in the event of an emergency in the facility such as finding a resident unresponsive and/or CPR and she stated that she has not received any training on what to do. She also stated that her CPR certification is not current. [DATE] at 2:27pm, V18 (CNA/Agency) stated that she was assigned to R12 today. She's worked at this facility before. She stated that she had been in the room with R12 for lunch because she had to feed her but she could tell that R12 wasn't right because she was pocketing her food and not really eating. She decided to stop trying to feed her and then shortly after, R12 coded. When asked what type of training or orientation she had received from the facility, she stated that the other CNA just walked her thru her set and that's it. She stated that she did not receive any training on the facility's emergency protocols or code policies. V18 confirmed that her CPR certification was current. [DATE] at 2:56pm, V2 (Director of Nursing) stated that in regard to the code called for R12, it was already going on when she got to the room. When asked what roles staff played in the code, she stated that generally, whoever calls the code is the lead and then the other nurses would be able to help with everything else that needs to be done. She continued to state that in this case, V9 (Assistant Director of Nursing) was the lead and the nurse practitioner was also in the room and that V17 (RN/Agency) was the recorder (documenting events during the code). V2 stated that V17 documented her report of the code in R12's medical record. Surveyor asked V2 how it was possible that V17 was recording during the code if the surveyor observed V17 performing chest compressions throughout the code, at which point V2 stated that V3 (RN) was also taking notes. Surveyor informed V2 that surveyor was in the room during the code and had observed that there was a 6 minute time frame from when the nurse first assessed R12 to when CPR was initiated and V2 stated I would expect them to start CPR as soon as they verify the code status which they can verify by the computer, the book at the nurses station, or wristband on the resident. The wristbands identify the DNR (Do Not Resuscitate) residents. I would not expect there to be a delay; waiting six minutes to start is too long. [DATE] at 3:56pm, V9 (Assistant Director of Nursing) stated that she initiated the code. Per V9, when she went into the room, the agency nurse was in the room and when she saw that the resident was unresponsive, she told her (V17) to start CPR and told someone else to go get the crash cart. V9 stated, I was the lead, I called the family, and I called 911 and I announced the code. V17 (RN/Agency) was the recorder and V3 (RN) was also recording, V3 took vitals. Usually the Director of Nursing would be responsible for ensuring that the code is documented and post-mortem care is provided. Surveyor then presented V9 with information that surveyor was in fact the first person in the room and alerted staff and that after initially entering the room, V17 and V16 had left the room before coming back and then eventually initiated CPR and that surveyor did not observe V9 (Assistant Director of Nursing) enter the room until five minutes after CPR had already been initiated. In which case, V9 stated that the resident should have never been left unattended. V17 should have initiated CPR at that point when she saw the resident unresponsive .it's not acceptable to wait 6 minutes to start CPR .6 minutes is unacceptable. V9 was asked how are agency staff oriented to the facility and policies/protocols when they arrive to work in the building and V9 stated that there is a binder at the front desk with all of the policies and procedures and when the agency nurses come in, they are to review it and sign an attestation sheet affirming that they have reviewed the information before they start their shift. Surveyor asked V9, who is responsible for ensuring that new agency staff review this binder before starting their shift and V9 could not confirm who was responsible for doing so, but added that the scheduling coordinator is the one who assigns agency staff. At this time, surveyor obtained the aforementioned binder from the front desk and confirmed with V9 that there was no attestation sheet signed by V17 (RN/Agency), even though it was the first time (V17) had worked in the facility. [DATE] at 4:18pm, V2 (Director of Nursing) came into the conference room, where V9 (Assistant Director of Nursing) was being interviewed - V9 presented V2 with the binder and asked if she had any attestation sheets for V17 and V2 responded, What's this? V2 then stated that she had some papers on her desk from V17 this morning and that she would check if she had the attestation sheet at which time she went to her office and came back with a password protocol form signed by V17. V2 stated that she did not have the attestation sheet for V17, just the password form. V2 was asked who is responsible for ensuring that agency staff are oriented before they start their shift and that they have reviewed the policies and sign off on the attestation sheet and V2 stated that it's at the front desk so she guesses that is the responsibility of the supervisor on duty but that she would check and get back to surveyor. V2 was asked about staff training regarding emergency protocols/procedures and she stated that all staff are trained monthly on different topics .emergency code procedures in-services are done annually and as needed. She stated that after a code, they look at their videos and do a de-briefing. V2 was also asked if there was any type of debriefing done after the code with R12 to identify any issues or concerns and to discuss how the code went. V2 responded that they had not had a chance to debrief because surveyors were in the building, but that the only concern was that the agency nurse did not know how to verify the code status. Progress Note written on [DATE] at 14:24, written by V17 (RN/Agency) reads: 0730 Night nurse (named) gave report, when I entered the room the pt was moaning, per (night nurse) this is her baseline. She's been steadily declining. And her arms and legs are always contracted. 0800 Morning vitals were taken. BP ,d+[DATE], HR 74, RR 18, O2 95% RA. 1030 Morning meds were given crushed with apple sauce. 1115 checked in on patient she presented the same; moaning and contracted. The CNA (V18/Agency) stated, she really hasn't eaten much. I informed her the per the night nurse her appetite is poor. 1305 The CNA (V16) came out of the room and stated, (R12) is unresponsive. I left the pt room I was in and did a pulse check and sternal rub on (R12) and she didn't respond. The NP (V20) advised to begin compressions. Compressions were started and AED pads were placed on the pt. 911 was called by the nurse manager. EMS took over when they arrived roughly at 1317. They begin to run the code from that point. They were unable to revive her and she was pronounced dead at 1350. ME released body to the family per officer (local police officer). [DATE] at 11:20am, V19 (RN) stated that there is no reason to delay CPR, it should be done immediately. Only time you don't do CPR is if there is a DNR. [DATE] at 12:28pm, V21 (RN) stated that if a resident is found unresponsive the emergency procedure would be to check for breathing and a pulse and if there is no response, then you call for help and call 911. The book should be checked or the computer to see if the patient has a DNR, if not, CPR should be started right away. There should not be a delay. You cannot wait even five minutes, the person can be dead by waiting that time. [DATE] at 12:15pm, as surveyor was walking down the hall, V23 (CNA/Agency) asked surveyor if she was a nurse, surveyor identified herself and V23 said, oh, okay. Surveyor then asked V23, what her role was and she stated that she was a CNA. Surveyor asked if she was working thru an agency and if she had been in the facility before, V23 stated that she was with an agency and had been here before. Surveyor asked V23 what type of training she had regarding the facility's emergency protocols and/or what to do during a code and V23 stated that she had not received any, the other staff on duty just walked her thru her set when she started her shift. Facility was asked to provide any CPR or Advanced Directive policies and they only provided a copy of their Code Blue policy. Per V1 (Administrator) on [DATE] at 2:22pm, there are no other policies. Facility policy titled, Code Blue (Revised: [DATE]) reads: Policy Statement To maintain a well-coordinated and organized emergency care to a resident at any given time while emergency medical interventions are managed according to the established standard of care. Procedure 1. An Emergency Code Blue Team will be established. When a Code Blue and (location) is announced, it will be responded to by the following staff: a. Supervisors/Nurses will respond to the code and coordinate the medical emergency protocol. b. Emergency crash cart will be brought to the site of emergency. c. The assigned nurse will initiate the medical emergency interventions (for full code status) per facility's protocol after evaluating the sign and symptoms of cardiopulmonary arrest. d. The nurse/other staff will start the CPR if indicated. e. One staff will lead the team by assigning staff while CPR is in progress: i. Call 911 ii. Notify the primary physician iii. Call the family / guardian iv. Prepares the transfer form, copies of POS, list medications, face sheet and notifying the hospital of transfer v. Recorder (minutes of the event, vital signs, etc.) f. Other staff will initiate other emergency procedures such as IV line, suction secretions, take turns with the CPR intervention. g. The Nursing Supervisor or designee will facilitate in maintaining a non-chaotic emergency care environment (not overcrowding the room, hallways, etc.) h. The nursing assistant assigned to the resident involved must be present during the emergency procedures. i. Other nursing assistants on the same floor must redirect residents to their rooms and will continue to provide care to their residents to meet its skilled needs. The surveyor confirmed via observation, record review, and interview that the facility did the following to remove the immediacy: Education: Started by and will continue to be provided by the Director of Nursing, Assistant Director of Nursing, and Regional Consultants. Education that has been provided: 1) Mock Code Blue drills started on [DATE]. These will be conducted monthly by the DON or designee. 2) In-service facility nursing and agency nursing staff on CPR/Code Blue policy started on [DATE]. 3) All new hires will be oriented on the CPR and Code Blue policies. This will be reviewed on a quarterly basis. The DON will be responsible for monitoring this. 4) DON, ADON, or nursing supervisor/designee will in-service the staff prior to the start of their shift on all emergency procedures including Code Blue. This will be ongoing and will continue as long as there is usage of agency staff in the facility. Policy and Procedure 1) A house-wide audit was conducted and completed by EMR Specialist on all orders for Code Status on [DATE]. 2) A house-wide audit was conducted on all Care Plans for Code Status on [DATE] by MDS department. 3) A house-wide audit was conducted on all residents to ensure they are wearing DNR wristband (if applicable). This was conducted by Social Services Director on [DATE]. 4) Five staff members will be randomly selected and quizzed weekly x 12 weeks to ensure knowledge of facility CPR and Code Blue policies. This will be conducted by ADON/designee. Policies Provided on [DATE] 1) CPR Policy 2) Advanced Directives 3) Code Blue

Based on observation, interview, and record review, the facility failed to ensure that nursing staff had the necessary competencies required to care for a resident during an emergency situation. This failure applied to one of one (R12) residents reviewed for staff competence and has the potential to affect all 122 residents currently in the facility. Findings include: R12 is a [AGE] year old female, admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of medical record, documents that R12's advanced directive lists her as a full code. R12's current care plan includes Focus: Code Status, FULL CODE and Interventions (include): As indicated, document the code status on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Date Initiated: [DATE]; Scan the original POLST form into the EMR chart and consider placing one or more copies of the POLST form in a notebook on the unit for easy access during a medical emergency or when transferring the resident. Date Initiated: [DATE]; The EMR chart should identify FULL CODE status. Date Initiated: [DATE]. [DATE] at 1:11pm, surveyor entered R12's room and saw resident lying in bed, her right eye was open and her left eye was closed, her mouth was open and she appeared stiff and not to be breathing (chest was not visibly rising). Surveyor called resident's name and she did not respond. Surveyor immediately stepped out to the hall and called over V16 (CNA), who was coming out of another resident room, and asked her to come to R12's room. When CNA entered the room, at 1:12pm, surveyor advised her to do what she would normally do. V16 called the resident name and shook R12, R12 was not responding and V16 said, Is she breathing? Again, surveyor reiterated to V16 to please proceed as she should per her facility's protocol. V16 left the room to get the nurse. At 1:13pm, V16 (CNA) and V17 (RN/Agency) came back into the room and V17 proceeded to assess R12; she checked her pulse, checked to see if she was breathing, did sternal rub - all while calling the resident's name. V17 said (talking to V16), she's (R12) not responding, I think she's a full code; that's what the nurse said this morning but I don't trust anything because this place is a mess; I've been getting wrong information all day. I'm not putting my license on the line, I need to make sure she is a full code before doing anything. V16 and V17 then stepped out of the room. Surveyor stayed in the room conducting observations. At 1:17pm, V16 and V17 came back in the room. Discussion continued amongst staff on whether the resident was a full code or not. At 1:18pm, V18 (CNA/Agency) came in the room and said, I swear, I just saw her 30 minutes ago. I fed her lunch. Discussion continued amongst nursing staff in the room. At 1:19pm, more staff starting coming into the room [V19 (RN), V21 (RN), and V20 (Nurse Practitioner)], with the crash cart. V20 started to assess the resident and stated, we should start CPR. At that point, V17 initiated chest compressions. It had been six minutes since V17 entered the room and found R12 unresponsive before she initiated CPR. At the same time, V20 could be seen trying to get vitals on R12 and R12 was given glucose and hooked up to the AED (Automated External Defibrillator) machine. Surveyor continued to make observations as facility staff proceeded to run the code. At 1:28pm, the local fire department/paramedic arrived and took over. V22 (Paramedic) asked who was responsible for the resident and what is her medical history. V17 (RN/Agency) provided the paramedics with some information regarding R12's medical history and then stated, I'm not sure how accurate that is because this is my first time working here and reports in this place are terrible. At 1:36pm, surveyor still in the room, overheard paramedics continue asking V17 questions and V17 stated, I don't know anyone's name, again, this is just my first time here, I don't even know their protocol. V22 (Paramedic) was heard telling V17, I'm not placing blame, I'm just letting you know that she (R12) already has rigor in the jaw and that tells me that she's been dead for more than 30 minutes and CPR should not be started if there are obvious signs of death but since it was started we have to continue the process; it's just that then the hospital gets upset at us. [DATE] at 2:07pm, V17 (RN/Agency) stated this was her first time working in this building. She stated she saw R12 this morning when she gave her, her meds at around 10am but hadn't had time to go in the room since. V17 stated she almost didn't stay when she came in this morning because she could tell it was unorganized because they were going to give her 28 residents because another nurse wasn't coming but then they got someone to cover the other 14 residents; so she was left with 14. She stated she didn't feel the report she received in the morning was adequate and that she even came in early so that she would have time to be oriented before she started her shift from 6:30am - 2:30pm but that the only orientation she received was the report from the outgoing nurse; she did not receive any special instructions regarding facility protocols, emergency procedures, how to determine a resident's code status, COVID precautions, or nothing else. Again, she emphasized that all she got was a report from the nurse. She stated that they are clearly short staffed and she's been busy all day and trying to help out the CNA's when she can because they need help too. V17 stated, I'll never come back. [DATE] at 2:20pm, V16 (CNA) stated she had been in R12's room earlier today but not for R12; she was not assigned to her. V16 was asked if she had received any training on what to do in the event of an emergency in the facility such as finding a resident unresponsive and/or CPR and she stated that she has not received any training on what to do. She also stated her CPR certification is not current. [DATE] at 2:27pm, V18 (CNA/Agency) stated she was assigned to R12 today. She's worked at this facility before. She stated she had been in the room with R12 for lunch because she had to feed her but she could tell R12 wasn't right because she was pocketing her food and not really eating. She decided to stop trying to feed her and then shortly after, R12 coded. When asked what type of training or orientation she had received from the facility, she stated the other CNA just walked her thru her set and that's it. She stated she did not receive any training on the facility's emergency protocols or code policies. V18 confirmed that her CPR certification was current. Surveyor informed V2 that surveyor was in the room during the code and had observed there was a 6 minute time frame from when the nurse first assessed R12 to when CPR was initiated and V2 stated I would expect them to start CPR as soon as they verify the code status which they can verify by the computer, the book at the nurses station, or wristband on the resident. The wristbands identify the DNR (Do Not Resuscitate) residents. I would not expect there to be a delay; waiting six minutes to start is too long. [DATE] at 3:56pm, V9 (Assistant Director of Nursing)ADON stated she initiated the code. Per V9, when she went into the room, the agency nurse was in the room and when she saw that the resident was unresponsive, she told her (V17) to start CPR and told someone else to go get the crash cart .V9 stated that the resident should have never been left unattended. V17 should have initiated CPR at that point when she saw the resident unresponsive .it's not acceptable to wait 6 minutes to start CPR .6 minutes is unacceptable. V9 was asked how are agency staff oriented to the facility and policies/protocols when they arrive to work in the building and V9 stated that there is a binder at the front desk with all of the policies and procedures and when the agency nurses come in, they are to review it and sign an attestation sheet affirming that they have reviewed the information before they start their shift. Surveyor asked V9, who is responsible for ensuring that new agency staff review this binder before starting their shift and V9 could not confirm who was responsible for doing so, but added that the scheduling coordinator is the one who assigns agency staff. At this time, surveyor obtained the aforementioned binder from the front desk and confirmed with V9 that there was no attestation sheet signed by V17 (RN/Agency), even though it was the first time (V17) had worked in the facility. [DATE] at 4:18pm, V2 (Director of Nursing) came into the conference room, where V9 (Assistant Director of Nursing) was being interviewed - V9 presented V2 with the binder and asked if she had any attestation sheets for V17 and V2 responded, What's this? V2 then stated that she had some papers on her desk from V17 this morning and that she would check if she had the attestation sheet at which time she went to her office and came back with a password protocol form signed by V17. V2 stated that she did not have the attestation sheet for V17, just the password form. V2 was asked who is responsible for ensuring that agency staff are oriented before they start their shift and that they have reviewed the policies and sign off on the attestation sheet and V2 stated that it's at the front desk so she guesses that is the responsibility of the supervisor on duty but that she would check and get back to surveyor. V2 was asked about staff training regarding emergency protocols/procedures and she stated that all staff are trained monthly on different topics .emergency code procedures in-services are done annually and as needed. She stated that after a code, they look at their videos and do a de-briefing. V2 was also asked if there was any type of debriefing done after the code with R12 to identify any issues or concerns and to discuss how the code went. V2 responded that they had not had a chance to debrief because surveyors were in the building, but that the only concern was that the agency nurse did not know how to verify the code status. [DATE] at 11:20am, V19 (RN) stated that there is no reason to delay CPR, it should be done immediately. Only time you don't do CPR is if there is a DNR. [DATE] at 12:15pm, as surveyor was walking down the hall, V23 (CNA/Agency) asked surveyor if she was a nurse, surveyor identified herself and V23 said, oh, okay. Surveyor then asked V23, what her role was and she stated, she was a CNA. Surveyor asked if she was working thru an agency and if she had been in the facility before, V23 stated, she was with an agency and had been here before. Surveyor asked V23 what type of training she had regarding the facility's emergency protocols and/or what to do during a code and V23 stated that she had not received any, the other staff on duty just walked her thru her set when she started her shift. Facility was asked to provide any CPR or Advanced Directive policies and they only provided a copy of their Code Blue policy. Per V1 (Administrator) on [DATE] at 2:22pm, there are no other policies. Facility policy titled, Code Blue (Revised: [DATE]) reads: Policy Statement To maintain a well-coordinated and organized emergency care to a resident at any given time while emergency medical interventions are managed according to the established standard of care. Procedure 1. An Emergency Code Blue Team will be established. When a Code Blue and (location) is announced, it will be responded to by the following staff: a. Supervisors/Nurses will respond to the code and coordinate the medical emergency protocol. b. Emergency crash cart will be brought to the site of emergency. c. The assigned nurse will initiate the medical emergency interventions (for full code status) per facility's protocol after evaluating the sign and symptoms of cardiopulmonary arrest. d. The nurse/other staff will start the CPR if indicated. e. One staff will lead the team by assigning staff while CPR is in progress: i. Call 911 ii. Notify the primary physician iii. Call the family / guardian iv. Prepares the transfer form, copies of POS, list medications, face sheet and notifying the hospital of transfer v. Recorder (minutes of the event, vital signs, etc.) f. Other staff will initiate other emergency procedures such as IV line, suction secretions, take turns with the CPR intervention. g. The Nursing Supervisor or designee will facilitate in maintaining a non-chaotic emergency care environment (not overcrowding the room, hallways, etc.) h. The nursing assistant assigned to the resident involved must be present during the emergency procedures. i. Other nursing assistants on the same floor must redirect residents to their rooms and will continue to provide care to their residents to meet its skilled needs.

Based on observation, interview, and record review, the facility failed to provide incontinence care as needed and in according to the plan of care for two residents (R8 and R9) reviewed for incontinence care. This failure resulted in (R8) developing MASD (moisture associated skin damage) and (R9) developing a Stage 2 sacral pressure ulcer. Findings include: R8 is a [AGE] year old female originally admitted on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS (Minimum Data Set) assessment dated [DATE] document: TOILET USE: require(s) Extensive Assistance x2 staff participation. BIMS dated 11-18-2021 score of 4/15 (Severely Impaired Cognition) 1/19/22 at 1:10pm, R8 was observed in her bed on a low air loss mattress with a flat sheet, a pad under her, and an incontinence brief (three layers of padding). V30 (CNA/ Restorative Aide) said I started here one year ago. (R8) is supposed to have only a flat sheet and incontinence brief, but no pad because it defeats the purpose of the mattress. I do not know who did that. At this time, observed V30 provide incontinence care for R8. V30 stated, R8 is soaked in urine. R8 has an open area with no dressing in place. Observation made of R8 with open area to the sacrum, no dressing in place, open area noted over a scar tissue approximately 2x1 superficial. V31 (LPN/EMR Nurse) said, I can see R8 has a wound to the sacral area, the upper layer is gone. I am going to check and see if she has any orders in place. V31 said, I cannot see any wound care orders in R8's record, I will call the wound care nurse to come and evaluate the patient. R8 should not have multiple layers under her; only the flat sheet and incontinence brief since she is incontinent. R9 is a [AGE] year old male admitted to the facility on [DATE]. His medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission Summary, effective date 12/27/21 23:47, note text documents that R9 was admitted to the facility with skin intact. R9's MDS (Minimum Data Set) Assessment documents that R9 requires extensive assistance/2+ person physical assistance (3/3) for bed mobility and requires extensive assistance with one person physical assistance for toilet use (3/2). R9's current care plans include focus areas related to requiring assistance with ADL's (activities of daily living), including toileting. Interventions include: Keep call lights within reach; If incontinent, apply moisture barrier to the peri-area after incontinent episode; Remind, offer and assist with toileting as needed. 1/15/22 at 2:45pm, as surveyor walked past R9's room, R9 was heard calling out he needed to use the bathroom. Surveyor stood outside of R9's room as V41 (CNA/Agency) walked into R9's room at 2:50pm could be heard telling R9 to go ahead and use the bathroom in his incontinence brief then she would be back in to change him and she walked out of the room. As V41 walked out of the room, R9 could be heard saying, I don't understand and he kept saying he had to use the bathroom. Surveyor stayed in hall, outside of R9's room. At 2:55pm, another staff member entered R9's room and said something that could not be heard clearly and walked right back out. At 3:04pm, the call light went on in R9's room and surveyor entered the room V41 came in right after. R9 stated, My diaper is totally wet from one end to another. R9 was asked if he was provided with care this morning and he stated he couldn't remember exactly but could only remember being changed once today. Surveyor continued to observe V41 provide incontinence care. V41 was clearly disgruntled and voicing the previous CNA should have changed the resident because it was clear that he had not been changed at all today because he is soaked. Surveyor observed R9's gown was wet, his incontinence brief drenched in urine and the sheets on his bed visibly wet and soiled - the urine had soaked thru the sheets and the mattress was wet underneath where R9 was laying. When R9 was rolled over during care, a beefy red, open area was noted to his sacrum. The area was approximately 3x3cm in size and appeared to have a whitish cream that was wiped off. R9 winced as V41 was cleaning him and surveyor asked if he had pain in that area and he said, yes. V41 finished providing care, and changed the bed sheets. She added a flat sheet under the fitted sheet and stated, I know there's not supposed to be this sheet under here but I have to put it under him because the mattress is still wet and if I just lay the (clean) sheet, it's just going to get wet. I will come back later and pull it out. Surveyor asked if that was a new open area on R9's sacrum and V41 stated that she believed so but would notify the nurse. Review of R9's medical record on 1/15/22 did not document that R9 had any current wounds. 1/16/22 at 10:41am, surveyor observed R9 in bed, slumped over, with his call light on the floor near his bedside table (out of reach). R9 stated no one's been in today. At 10:49am, V42 (CNA/Activity Aide) and another staff member repositioned R9 in bed and V42 stated she was going to check on his CNA and acknowledged R9 was in need of incontinence care. At 10:57am, V16 (CNA) came in to R9's room and confirmed she was assigned to R9 for the day. V16 was asked if she had provided incontinence care today and V16 stated, I haven't changed him this morning - I didn't have time. I just gave him breakfast. At 11:05am, V42 (CNA/Activity Aide) came back into R9's room and stated, I am the activity aide but I'm also a CNA so I will change him since his CNA didn't get to him yet. Surveyor observed V42 provide incontinence care and noted there was a gauze applied to R9's sacrum that was soaked in urine. The writing on the gauze was unreadable because it was smeared from being wet. V42 removed the gauze and stated she would tell the nurse it needs to be changed. 01/21/22 at 1:47pm, V4 (CNA/Staffing Coordinator) stated CNA's do skin checks on all residents daily and on every shift. They do it every shift because things can change from one shift to the next. If the CNA finds something, they are to notify the nurse. Once the skin checks are done and showers given, the shower sheet is filled out and if there are any new areas of concern it is documented on the shower sheet. When asked what the circled areas are on the sheet with Treatment written next to it, V4 stated, means the area is covered because of a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The CNA's should also document in the EMR (electronic medical record system). Daily skin checks (R9) provided with multiple days missing (only provided for 1/14/22 PM, 1/17/22 AM and PM, 1/19/22 PM, 1/20/22 PM, and 1/21/22 Midnight). Facility provided Wound Assessment Details Report for R9 includes: Assessment Date: 1/15/22 4:20PM Wound: Sacrum Type: Pressure Classification: Ulceration Source: Facility-acquired Clinical Stage: 2 Tissue Types: Pale Pink Non-granulating = 100% Exudate: Amount - Scant, Type - Serosanguineous Size (cm): 5.00 x 5.00 x 0.10 (L x W x D) Current Plan & Comments: 1/15/22 05:53PM by V8 (Registered Nurse/Wound Care): Writer was called to see patient regarding open wound and upon wound assessment per writer patient is seen with Stage 2 pressure injury to his sacrum, 100% non-granulating tissue with very scant amount of serosanguineous drainage with mild discomfort per patient upon touch. Treatment order was given per MD and medical honey gel applied to patient's sacral wound after NSS cleanse and covered with [MEDICATION(S)] dressing to be change 3x a week. Treatment applied as ordered. Floor nurse at bedside and aware of patient's new wound. Repositioned patient. Will continue to monitor patient's wound. Facility policy titled, ADL Care (Date: October 31, 2018) reads: Care Guidelines: ADL care is provided for each resident in the facility in accordance to the comprehensive assessment. Interpretation and Implementation (include) . 2. Nurses and CNAs are trained in providing general /routine ADL care to the residents . 4. ADL nursing care is performed daily for the residents based on the plan of care. Such care may include as appropriate, but is not limited to .b. Encouraging and assisting bedfast residents to change positions at least every two (2) hours (day and night) to stimulate circulation and to prevent decubitus ulcers, contractures, and deformities .g. Incontinent care and Bowel and bladder training as indicated; and h. Daily assistance in eating; grooming/hygiene; transfer, locomotion and mobility; 6. General/Routine ALD Care of the residents are included in the orientation program and the ongoing Staff Development Program.

Based on observation, interview, and record review, the facility failed in multiple failures related to their Wound Care protocol, including: failure to follow the interventions they put in place for a resident to promote healing and prevention of the worsening of a pressure wound by not monitoring the skin daily, per shift; not conducting and documenting shower/bath skin audits; not establishing turning and repositioning schedule for resident dependent on staff for bed mobility and not including the schedule as part of the residents' plan of care; failed to use low air loss mattress with the correct settings for the resident and with multiple layers of padding; failed to prevent a resident from developing a new facility-acquired pressure ulcer (R9); and failing to refer a resident to the facility's wound care specialist in a timely manner once a wound was identified as a Stage III wound and/or once the wound was deteriorating (R7). This failure affected two of three (R7 and R9) reviewed for pressure ulcers and resulted in R9 developing a facility-acquired, Stage 2, sacral pressure ulcer and R7's wound progressing to Stage 4 and being hospitalized with Fournier's gangrene, requiring emergent surgical intervention. Findings include: R7 is a [AGE] year old female admitted to the facility on [DATE] from local hospital for physical and occupational therapy. R7 has medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress note dated [DATE] 14:08 documents that R7 was admitted to local hospital for rapid heart rate and shortness of breath. Hospital record documents that R7 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital Admission History & Physical (includes): In ER, found to be septic, elevated LA (lactic acid), WBC's (white blood cells), UA (urinalysis) positive for [CONDITION(S)] (urinary tract infection) .(Objective Assessment) SKIN: sacral wound with fecal contamination limiting exam, minimal periwound [CONDITION(S)], +ttp .ASSESSMENT - [CONDITION(S)] - differential includes [CONDITION(S)] and wound infection, c/n exclude pulmonary source or C.diff .Sacral wound infection. ED notes continue to include: Per radiologist, the patient has red flags of Fournier's gangrene (infection in the scrotum, which includes the area between the anus and vulva; with dead/dying tissue). ED physician note ([DATE] 9:56PM) includes, I explained the gravity of the situation and the patient may spend many days in intensive care unit and may never come off of the ventilator. I explained her other comorbidities put her at serious risk for significant complication including death. The husband understood all of this and gave consent to me over the phone which was then confirmed by other staff members. We will proceed urgently to the emergency room for wide debridement of the perineum. CT Abdomen and Pelvis, 1. Extensive soft tissue gas within visualized perineum, left greater than right, and extending superiorly into the left ischiorectal fossa and posterior to the coccyx and compatible with sequela of acute of acute Fournier gangrene. Urgent surgical consultation management is recommended. 3. Large amount of fecal material in the rectum with associated mild rectal wall thickening and presacral [CONDITION(S)] and indicative of fecal impaction with associated stercoral [CONDITION(S)] (occurs when a patient has chronic constipation leading to stagnation of fecal matter). Operative Report reads: Date of Procedure: [DATE], Pre-operative Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .Procedure .The patient has a decubitus ulcer that measures approximately 10 cm in diameter. We debrided all the necrotic skin, subcutaneous fat, and necrotic muscle down to the bone itself. We removed a lot of the fascia on top of the bone using sharp scissors or cautery. This excisional debridement was done until we could go no further and the hemostasis was achieved with cautery. On the CT, we knew the patient had abscesses tracking on either side of the anus and tracking toward the labia. These areas both had crepitus. We opened both sides with cautery and purulent fluid was expressed. We obtained cultures. We achieved hemostasis at these new counter incisions and easily tracked and connected to the main decubitus ulcers. [DATE], admission facility skin breakdown assessment for R7 documented R7 was at risk for skin breakdown (Braden score 16). physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Evaluate patient for falls and skin ulcer prevention by the nurse and implement protocol. Care plan includes: Focus: (R7) has dx of Diabetes Mellitus (Date Initiated: [DATE]) Interventions: Check skin when assisting with ADLS (Date Initiated: [DATE]) Focus: (R7) is AOx3, Incontinent of B/B, with decreased mobility. (R7) has an actual impairment to skin integrity and is at risk for further breakdowns based on a BRADEN Score of 16 AND related to PMHX of HLD, DM Type 2, [CONDITION(S)], GOUT, UNSTEADY GAIT, HX Pressure injury, [CONDITION(S)]. Coccyx: Pressure Ulcer (Date Initiated: [DATE]) Interventions: - Evaluate and monitor for pressure ulcer potential, review profile quarterly (q 3 months) and PRN (as needed). (Date Initiated: [DATE]) - right buttock: cleanse with normal saline, apply medicated ointment & cover with dressing as prescribed. (Date Initiated: [DATE]) - Skin check Q Shift. Pay special attention to bony prominences. Assess skin during bath and routine care. (Date Initiated: [DATE]) - skin inspection: The resident requires skin inspection. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. (Date Initiated: [DATE]) Progress Note [written by V12 (Nurse Practitioner)] dated [DATE] at 10:35 includes, A/P: #11 At risk for skin breakdown, Plan: Because of her decreased mobility, she is at risk for skin breakdown. Her skin should be monitored daily and be kept clean and dry. Plan was discussed with pt's nurse. [DATE] at 1:47pm, V4 (CNA/Staffing Coordinator) stated, the CNA's do skin checks on all residents daily and on every shift. They do it every shift because things can change from one shift to the next. If the CNA finds something, then they are to notify the nurse. Once the skin checks are done and showers given, the shower sheet is filled out and if there are any new areas of concern it is documented on the shower sheet. When asked what the circled areas are on the sheet with Treatment written next to it, V4 stated, means that the area is covered because of a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The CNA's should also document in the EMR (electronic medical record system). [DATE] at 4:20pm, V2 (DON) stated showers/baths are given twice a week and as needed. When residents are showered, the CNA completes the Shower Sheet/Skin Audit Form. Surveyor requested facility to provide all shower/skin audit forms for R7 while in the facility and only three were provided ([DATE], [DATE], and [DATE]). All three forms have only the sacral area circled and labeled treatment. No other documentation was provided to confirm that R7 received shower/skin audits done as scheduled. Surveyor asked for documentation that skin checks were done daily, every shift as listed in the plan of care for R7 and facility was not able to provide such documentation during the course of this survey. Review of wound documentation in R7's medical record includes the following nursing wound assessments: Wound assessment detail report dated [DATE] 1:20PM (includes): Wound: Coccyx Clinical Stage: 2 Tissue Types: Pink or Red Non-granulating = 100% Exudate: Amount - Scant, Type - Serosanguineous Wound Edge: Distinct & Attached Odor: No Signs of Infection Present: No Size (cm): 3.40 x 2.70 x 0.20 (L x W x D) Undermining: None Tunneling: None Current Plan & Comments: Skin alteration to right buttock. Measurements 3.4x2.7x0.2. TX provided. Wound assessment detail report dated [DATE] 10:06AM (includes): Wound: Coccyx Clinical Stage: 3 Tissue Types: Pink or Red Non-granulating = 5%, Slough White Fibrinous = 95% Exudate: Amount - Scant, Type - Serosanguineous Wound Edge: Distinct & Attached Odor: No Signs of Infection Present: No Size (cm): 3.40 x 3.00 x Unknown (L x W x D) Undermining: None Tunneling: None Current Plan & Comments: [DATE] 06:01PM by V28 (Wound Care Nurse/LPN): Patient medicated for pain before wound care by wound nurse there is 95% slough white fibrinous issue and 5% pink none granulating tissue with a scant amount of serosanguinous exudate length 3.40cm width 3.00cm patient educated on pressure reduction on low air loss bed. Length 3.40c width 3.00 cm. will follow the plan of care. Wound assessment detail report dated [DATE] 3:18PM (includes): Wound: Coccyx Clinical Stage: 3 Tissue Types: Slough White Fibrinous = 100% Exudate: Amount - Scant, Type - Serosanguineous Wound Edge: Distinct & Attached Odor: No Signs of Infection Present: No Size (cm): 4.00 x 3.00 x Unknown (L x W x D) Undermining: None Tunneling: None Current Plan & Comments: [DATE] 07:24PM by V32 (Previous Wound Care Coordinator/LPN): Coccyx assessed noted with 100% Slough White Fibrinous tissue, Scant - Serosanguinous exudate, No signs of infection noted Periwound are Normal, Wound Edge are Distinct and Attached. Length - 4.00cm Width - 3.00 cm Depth - Unknown, Patient was educated on pressure reduction and repositioning patient assisted by staff with repositioning. Patient has LAL Mattress in place. Will continue to follow plan of care. Wound assessment detail report dated [DATE] 7:21AM (includes): Wound: Coccyx Clinical Stage: 3 Tissue Types: Epithelial (Pale Pink or Red) = 100% Exudate: Amount - Scant, Type - Bloody Wound Edge: Distinct & Attached Odor: No Signs of Infection Present: No Size (cm): 4.00 x 4.00 x 1.50 (L x W x D) Undermining: None Tunneling: None Current Plan & Comments: [DATE] 05:27PM by V28 (Wound Care Coordinator/LPN): Patient coccyx with 100% pale pink epithelial tissue there is a scant amount of bloody exudate. Peri wound is normal there is no sign of infection length 4.00 width 4.00cm depth 1.50cm patient educated on pressure reductions assisted with turning by staff will follow the plan of care. Wound assessment detail report dated [DATE] 4:54PM (includes): Wound: Coccyx Clinical Stage: 3 Tissue Types: Bright Pink or Red = 85%, Slough Loosely Adherent = 15% Exudate: Amount - Moderate, Type - Serosanguineous Wound Edge: Distinct & Attached Odor: No Signs of Infection Present: No Size (cm): 4.00 x 4.00 x 2.20 (L x W x D) Undermining: Present Location/Avg Extent: 12 o'clock to 12 o'clock / 1.50 cm Tunneling: None Current Plan & Comments: [DATE] 01:45PM by V32 (Previous Wound Care Coordinator/LPN): Coccyx wound assessed noted with Bright Pink or Red: 85%, Slough Loosely Adherent tissue: 15%, No signs of infection, Moderate - Serosanguinous exudate, Periwound is Normal, Wound Edge are Distinct and Attached, Undermining Present at 12 o'clock to 12 o'clock / 1.50cm, Length - 4.00cm Width - 4.00cm Depth - 2.20cm. Patient has lal mattress in place to assist with pressure reduction. Patient is being followed by wound care DR. Will continue of follow plan of care. TAR (Treatment Administration Record) for [DATE], documents that V36 (RN) provided wound care treatments for R7 on ,d+[DATE], ,d+[DATE], ,d+[DATE] - [DATE]. On, [DATE] at 2:35pm, V36 (RN) was asked about the condition of R7's wound. R7 stated she did not remember this resident or the condition of the wound. However, R7 stated in general, when doing wound care, she observes for any issues with the wound, like dark in color, pain, and it if looks infected. Signs of infection would be pus, green color, warm to touch. V36 was shown a photo from R7's wound documentation in the facility's EMR (electronic medical record) dated [DATE] and was asked to describe the wound that she saw in the photo, V36 stated, I would have notified the doctor because it does look like there are signs of infection and the tissue along the edges looks necrotic and there is slough - but I don't remember doing the treatment on this resident and I don't remember this wound. TAR (Treatment Administration Record) for [DATE], documents that V37 (RN) provided wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . [DATE] at 2:47pm, V37 (RN) stated, I don't remember this resident and I don't remember this wound but if my name is on the TAR, that means that I did the treatment. When I do a treatment, I look for drainage, odor, pain, changes if I've seen it before, and how the resident tolerates the procedure. I notify the MD of any changes and inform the family. I also notify the MD if there is any infection, if the wound is not healing, if there is pain, and if it looks like the current treatment is not working. V37 was shown a photo from R7's wound documentation in the facility's EMR (electronic medical record) dated [DATE] and was asked to describe the wound that she saw in the photo, V37 stated, looking at this wound I can see there is slough and necrotic tissue around the edges. It looks like it's starting to get infected. I would notify the doctor about this and I would have documented it. But again, I don't remember this resident. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's wound care specialist did not see R7 for evaluation until [DATE] - almost a month after the resident was admitted with pressure ulcer on the coccyx. [DATE] at 1:30pm V29 (Registered Nurse/Wound Care Nurse) said, I do not remember the patient (R7). I do not recall how the wound was, (looking at the picture of R7's wound). I do not recall (R7) wound. I see I did an admission and I documented the patient had an open area. I do not remember if it was getting better or worse. I did the assessment, took the pictures and reported to the coordinator (V32, Previous Wound Care Coordinator) and the full time wound care nurse (V28, Wound Care Nurse/LPN). [DATE] at 3:30 PM V28 (Wound Care Nurse/LPN) is the former wound care nurse and said, I left the facility at the end of [DATE]. I do remember R7, she was a hemo-[CONDITION(S)] patient that had a big wound to the sacral area. I told the wound care manager the patient needed to be seen by the wound care doctor because the wound was getting worse. I would have put R7 for V33 (Wound Care Doctor) to see her immediately before the wound deteriorated. The wound doctor (V33) comes every Wednesday in the morning at 6am. I would have completed the admission by putting an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The manager was responsible for referring any wounds to the doctor; we do not have any criteria to follow but definitely stage 3, 4, DTI (Deep Tissue Injury), and unstageable wounds are definitely a must to be seen by the wound care doctor. [DATE] at 8:00am V32 (Wound Care Coordinator/LPN) said, I was the wound care coordinator at the facility for 4 months, I left at the end of [DATE]. I remember R7, the patient was totally dependent on staff for all ADL's (activities of daily living), she was incontinent, had [CONDITION(S)] on Monday, Wednesday, and Friday. I remember R7 was on my list to be seen by the wound care doctor but she was in [CONDITION(S)]. I do not remember if I documented in R7's file. I know the patient wound was a stage 2 when she was admitted but when V33 (Wound Care Doctor) saw her the wound was stage 4. The wound had developed necrotic tissue while at the facility, a sign the wound was deteriorating compared to the admission wound. [DATE] at 4:10pm V34 (Doctor/Medical Director) said, I do remember R7, but I am not in front of a computer to give you full details. I saw the patient but the wound care assessment is done by the wound care team and the wound care doctor. V34 was asked if he had considered referring the patient to the wound doctor since he had wound orders in place for almost a month and the wound was deteriorating, V34 stated, I was never informed the wound was deteriorating. I give my orders based on the report and information that the wound nurse reports to me. I do not remember seeing the wound. If the nurses were to report the wound was not improving or getting worse or infected, I would start antibiotics, order laboratory tests, and make sure the wound doctor sees the patient for further recommendations. If the dietitian recommends any supplements I do not have any problem giving the order to improve the healing process. Medical record includes a Dietary Evaluation conducted on [DATE] for R7. The evaluation includes documentation R7 has skin alteration related to a Stage 3 pressure ulcer on the coccyx. Dietary recommendations include: Protein Drink's 30 ml BID (twice a day). Two different kinds of Protein Drinnks. R7's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Protein drink, two times a day for Wounds, Start Date: [DATE] protein drink, two times a day for Wounds, Start Date: [DATE] [DATE] at 4:37pm, V38 (Dietician) stated, she makes dietary evaluations, she puts it in the chart and puts the orders directly into the EMR, the nurse is supposed to go in and approve the orders. It's the nurses' responsibility to check the record to see if there are orders that need to be approved. V38 stated, I usually go back the following day to make sure they were approved. I don't know what happened that these did not get started until [DATE]nd. When reviewing R7's dietary evaluation, V38 stated, I wrote this on [DATE]. V38 was asked how soon orders should be started once she makes the recommendation and she stated that they are usually started within a day or two. In this case, she recommended the Pro-Stat and the Juven for R7 to promote wound healing since she had a Stage 3 pressure ulcer. When asked if there could be any negative outcomes of not starting the recommended supplements soon after they were ordered and waiting until [DATE] to start, V38 stated, it could delay and prolong wound healing. During this interview, V38 did not confirm that she went back to verify the nurses confirmed the orders for the supplements. Review of medical record confirms that R7 was initially seen by V33 (Wound Care Doctor) on [DATE] at 6:00AM and Visit Report reads: New patient being seen for wounds .Wound #1 status is open. The wound is currently classified as a Category/Stage IV wound with etiology of Pressure Ulcer and is located on the coccyx. The wound measures 4cm length x 4 cm width x 2.3cm depth .There is muscle and Fat Layer (Subcutaneous Tissue) exposed. There is a small amount of serosanguineous drainage noted. There is a large (,d+[DATE]%) amount of necrotic tissue within the wound bed including Eschar, Adherent Slough and Necrosis of Muscle. The periwound skin appearance exhibited: Ecchymosis. The periwound skin appearance did not exhibit: Callus, Crepitus, Excoriation, Induration, Rash, Scarring, Dry/Scaly, Maceration, Atrophie Blanche, Cyanosis, Hemosiderin Staining, Mottled, Pallor, Rubor, [CONDITION(S)] .Active Problems ICD-10 pressure ulcer of sacral region, stage 4 .General Notes: comorbidities affecting wound healing and prevention include: impaired mobility - reposition q 2 hours; incontinence - evaluate q 2 hours; [CONDITION(S)]; protein malnutrition . Visit Report completed by V33 (Wound Care Doctor) on [DATE] at 6:00AM reads: Follow up for wounds .Wound #1 status is open. The wound is currently classified as a Category/Stage IV wound with etiology of Pressure Ulcer and is located on the coccyx. The wound measures 4cm length x 4 cm width x 2.2cm depth .There is muscle and Fat Layer (Subcutaneous Tissue) exposed. There is a small amount of serosanguineous drainage noted. There is a large (,d+[DATE]%) amount of necrotic tissue within the wound bed including Eschar, Adherent Slough and Necrosis of Muscle. The periwound skin appearance exhibited: Ecchymosis. The periwound skin appearance did not exhibit: Callus, Crepitus, Excoriation, Induration, Rash, Scarring, Dry/Scaly, Maceration, Atrophie Blanche, Cyanosis, Hemosiderin Staining, Mottled, Pallor, Rubor, [CONDITION(S)] .Active Problems ICD-10 pressure ulcer of sacral region, stage 4 .General Notes: comorbidities affecting wound healing and prevention include: impaired mobility - reposition q 2 hours; incontinence - evaluate q 2 hours; [CONDITION(S)]; protein malnutrition . [DATE] at 3:10pm V33 (Wound Care Doctor) said, I am in the facility every Wednesday at 6:00am. I saw R7 on [DATE], she had a stage 4 wound to the sacral area. I do not have any idea why I was not consulted as soon as the patient was admitted on [DATE], I cannot tell you the wound was better or worse, since I only saw her on two different occasions, but the patient was in the building for several weeks before. V33 was made aware R7 was sent to the hospital on [DATE], the same day he saw her, and his description and wound measurements were significantly different than the assessment from the ER. V33 stated, I did not measure the wound, the nurse was the one responsible for the measurements. I just copy her measurements. I remember telling them they need to change the staging of the wound from stage 3 to stage 4 because the wound had necrotic tissue. I do not remember if the wound had any signs of infection. The one that referred the patients to me is the wound care coordinator, she gives me a list every Wednesday when I come into the building. [DATE] at 1:15pm, V45 (Family Member) stated, (R7) expired on [DATE]. V45 stated, after R7 was discharged from the hospital she went to a different long term care facility. When asked (R7's) cause of death, V45 stated, (R7) never really cleared the infection. Facility Wound Care Program (Adopted: [DATE] and last Reviewed: [DATE]) reads under Procedures: 1. Timely identification of residents assessed to be at risk for skin breakdown. a. The Braden Scale must be completed by a licensed nurse on admission/re-admission and weekly for the first 4 weeks of admission/re-admission in the facility . c. Each risk factor and potential cause(s) identified should be reviewed individually and addressed into the resident's care plan . 3. Prevention of skin breakdown includes but not limited to: c. Inspection of the skin every shift with care for signs of breakdown .h. Administration of scheduled shower/bath and completion of Shower and Skin Audit Form and document findings. 4. Activity, Mobility, and Positioning . b. Establish an individualized turning and repositioning schedule if the resident is immobile or with impaired physical functioning. c. While in bed or in wheelchair, resident should be turned/repositioned at least every 2 hours or as indicated in the residents' plan of care . 9. Documentation a. (Named electronic wound documentation software) - using an (name brand) phone device connected to the internet that allows nursing staff to evaluate, monitor, track and treat residents and/or patients at risk for pressure ulcers while providing one-step wound assessment documentation. b. Shower and Skin Audit Form shall be completed by designated nursing personnel on shower days or other designated day. If shower is refused by the resident/patient, the nursing staff needs to indicate the resident's refusal on the sheet and notify the charge nurse. c. The care plan shall be evaluated and revised based on resident's response to treatment; treatment goals and outcomes . 10. Pressure Ulcer Treatment . c. Timely referral to the facility's Wound Care Specialist for stage III/IV pressure ulcers and/or any recalcitrant wounds . 11. Wound assessment for pressure, diabetic, venous, and arterial wounds: Wound assessment documentation shall include but are not limited to: type of wound and/or ulcer, location, date, stage, (if applicable), length, width and depth; wound bed description, wound edge description and if present, exudates, undermining, tunneling, and wound related pain. R9 is a [AGE] year old male admitted to the facility on [DATE]. His medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission Summary, effective date [DATE] 23:47, note text documents that R9 was admitted to the facility with skin intact. R9's MDS (Minimum Data Set) Assessment documents that R9 requires extensive assistance/2+ person physical assistance (,d+[DATE]) for bed mobility and requires extensive assistance with one person physical assistance for toilet use (,d+[DATE]). R9's current care plans include focus areas related to requiring assistance with ADL's (activities of daily living), including toileting. Interventions include: Keep call lights within reach; If incontinent, apply moisture barrier to the peri-area after incontinent episode; Remind, offer and assist with toileting as needed. [DATE] at 2:45pm, as surveyor walked past R9's room, R9 was heard calling out he needed to use the bathroom. Surveyor stood outside of R9's room as V41 (CNA/Agency) walked into R9's room at 2:50pm and could be heard telling R9 to go ahead and use the bathroom in his incontinence brief and she would be back in to change him and then she walked out of the room. As V41 walked out of the room, R9 could be heard saying, I don't understand and he kept saying he had to use the bathroom. Surveyor stayed in hall, outside of R9's room. At 2:55pm, another staff member entered R9's room and said something that could not be heard clearly and then walked right back out. At 3:04pm, the call light went on in R9's room and surveyor entered the room and V41 came in right after. R9 stated, My diaper is totally wet from one end to another. R9 was asked if he was provided with care this morning and he stated he couldn't remember exactly but could only remember being changed once today. Surveyor continued to observe V41 provide incontinence care. V41 was clearly disgruntled and voicing that previous CNA should have changed the resident because it was clear that he had not been changed at all today because he is soaked. Surveyor observed R9's gown was wet, his incontinence brief was drenched in urine and sheets on his bed were visibly wet and soiled - urine had soaked thru the sheets and the mattress was wet underneath where R9 was laying. When R9 was rolled over during care, a beefy red, open area was noted to his sacrum. The area was approximately 3x3cm in size and has a whitish cream stubstance that was wiped off. R9 winced as V41 was cleaning him and surveyor asked if he had pain in that area, he said, yes. V41 finished providing care and changed the bed sheets. V41 added a flat sheet under the fitted sheet and stated, I know there's not supposed to be this sheet under here but I have to put it under him because the mattress is still wet and if I just lay the (clean) sheet, it's just going to get wet. I will come back later and pull it out. Surveyor asked if that was a new open area on R9's sacrum and V41 stated, she believed so but would notify the nurse. Review of R9's medical record on [DATE] did not document that R9 had any current wounds. [DATE] at 10:41am, surveyor observed R9 in bed, slumped over, with call light on the floor near his bedside table (out of reach). Surveyor observed R9 was on a low air loss mattress, which he did not have during observations the previous day. The low air loss mattress was set to Upright Mode, 140 pounds. R9 appears to weigh more than 140 pounds. R9 stated no one's been in today. At 10:49am, V42 (CNA/Activity Aide) and another staff member repositioned R9 in bed and V42 stated, she was going to check on his CNA and acknowledged R9 was in need of incontinence care. At 10:57am, V16 (CNA) came in to R9's room and confirmed she was assigned to R9 for the day. V16 was asked if she had provided incontinence care today and V16 stated, I haven't changed him this morning - I didn't have time. I just gave him breakfast. At 11:05am, V42 (CNA/Activity Aide) came back into R9's room and stated, I am the activity aide but I'm also a CNA so I will change him since his CNA didn't get to him yet. Surveyor observed V42 provide incontinence care and noted there was a gauze applied to R9's sacrum that was soaked in urine. The writing on the gauze was unreadable because it was smeared from being wet. V42 removed the gauze and stated, she would tell the nurse it needs to be changed. At 11:20am, V19 (RN) confirmed she was the assigned nurse for R9. She stated she thought the wound nurse was responsible for the settings on the low air loss mattress but she would check it. V19 pulled up R9's medical record and confirmed that his current weight is 178 pounds and stated I will go check it and proceeded to the room to adjust the mattress settings. [DATE] at 2:29pm, V39 (Wound Care Nurse/LPN) stated, when there is a new resident, I assess them, to see what wounds they have. Get initial wound care order from the primary care MD and I always call the family. I document the orders and treatment in the medical record. New patients are assessed weekly. Floor nurses are supposed to contact doctor and family and asked for a wound consult (if needed). Surveyor asked facility to provide all initial and weekly assessments for R9 and skin audit forms per their policy. Facility provided weekly Braden scale scores indicating that R9 was At Risk for wounds and provided three shower/skin audit forms dated [DATE], [DATE], and [DATE]. Surveyor noted [DATE] shower form indicates there is a treatment on R9's sacrum. On [DATE] at 4:20pm, V2 (DON) was asked why there was documentation of treatment on R9's sacrum on the shower form if the wound was just identified on [DATE] and V2 responded, I know you identified it on the 15th, I don't know why that's on there or what that means. [DATE] at 1:47pm, V4 (CNA/Staffing Coordinator) stated, the CNA's do skin checks on all residents daily and on every shift. They do it every shift because things can change from one shift to the next. If the CNA finds something, they are to notify the nurse. Once the skin checks are done and showers given, the shower sheet is filled out and if there are any new areas of concern it is documented on the shower sheet. When asked what the circled areas are on the sheet with Treatment written next to it, V4 stated, that means that the area is covered because of a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The CNA's should also document in the EMR (electronic medical record system). Daily skin checks provided with multiple days missing (only provided for [DATE] PM, [DATE] AM and PM, [DATE] PM, [DATE] PM, and [DATE] Midnight). Facility provided Wound Assessment Details Report for R9 includes: Assessment Date: [DATE] 4:20PM Wound: Sacrum Type: Pressure Classification: Ulceration Source: Facility-acquired Clinical Stage: 2 Tissue Types: Pale Pink Non-granulating = 100% Exudate: Amount - Sca [TRUNCATED]

Based on interview and record review the facility failed to provide respiratory services in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure applied to one (R1) of one resident reviewed for respiratory services. This failure resulted in R1 requiring an emergent transfer to local hospital and being admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R1 one is a [AGE] year-old admitted to the facility on [DATE] for aftercare of Covid-19, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's hospital discharge orders document the following: Vital signs dated 8-31-2021 at 4:12pm - blood pressure: 120/75, Heart Rate: 82, Temperature: 99.1, respirations: 20 and oxygen saturation: 98% with oxygen at 2 liters per nasal cannula. Includes an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . ([CONDITION(S)] is a type of positive airway pressure machine used to maintain a consistent breathing pattern; has two pressure settings). Facility Progress Note dated 8-31-2021 at 10:48PM reads: (R1) arrived at 10:40pm 8-31-2021 assessed R1, no visible bruising, patient came in on 4 liters of oxygen. (R1) Facility Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility Documentation for Oxygen Saturation includes: 8-31-2021 at 10:51pm 94% 9-1-2021 at 2:06am 96% 9-1-2021 at 9:00am 84% Facility Progress Note dated 9-1-2021 at 9:44am reads: R1 was having problem breathing, Oxygen level was check and was 84%, R1 was put on tank oxygen, and non-rebreather mask. Oxygen went to 96%. Switch out oxygen mask to nasal cannula oxygen dropped to 53%. R1 sent to local hospital for evaluation via 911. Hospital record includes: 9-2-2021 (under admission and physical) R1 did not have her [CONDITION(S)] machine at the facility and had to be sent out 911 from the facility because she was short of breath and her oxygen saturation was in the 50% oxygen saturation. (Oxygen saturation below 92% requires medical attention). 10/26/2021 at 1:58pm V7 (Licensed Practical Nurse) stated I did not do the admission I just did the vitals. The [CONDITION(S)] machine was not here in R1's room. R1 didn't come with the [CONDITION(S)] machine. 10/25/2021 at 1:59pm, V3 (Central Supply Clerk) stated The admission department or the director of nursing will tell me what machine ([CONDITION(S)] or [CONDITION(S)]) to order and the settings. I will give it to the company and the company brings the machines with them, with the settings already programed. Sometimes they will send me an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A [CONDITION(S)] machine was delivered on 9-2-2021 for R1 instead of the [CONDITION(S)]. ([CONDITION(S)] is a type of positive airway pressure machine used to maintain a consistent breathing pattern; has one pressure setting). 10/26/2021 at 2:17pm, V9 (DON/Director of Nursing) stated I recall R1; upon admission we needed to verify the orders and make sure the orders were correct for the patient and we also needed to verify the settings on the machine. The nurse can call the doctor to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse should call the company for a fast (STAT) machine delivery. Our cut off time is 8:00pm. We will call the company right away so the machine will be here and in place when the patient gets here. We need to make sure the equipment is here before the patient gets here. If they don't have one, we have two standby [CONDITION(S)] machines in storage that they can use, if they are available for use. If there is not a [CONDITION(S)] machine available, I expect the nurse to call the doctor and let them know that the patient's [CONDITION(S)] is not here and see if the patient is stable enough to use oxygen until it comes or if we should send them back to the hospital. I don't know why R1's machine was not here. The nurse should check to make sure it's the right machine, on the right settings, and that the machine is working. 10/26/2021 at 10:24am V4 (Advance Nurse Practitioner) stated, I didn't see (R1) initially because she was sent back to the hospital in a very short period of time. I did see R1 while she was in the hospital. I did not know that the [CONDITION(S)] was not there when R1 was admitted to the facility. It's possible that not having the respiratory equipment ([CONDITION(S)]) caused her to be readmitted to the hospital. With post Covid-19 patients, they can become hypoxic (oxygen deficient); not having the [CONDITION(S)] definitely affected her. I was not notified that R1 didn't have a [CONDITION(S)] while in the facility. Review of medical record does not include any documentation that R1's physician was notified that the [CONDITION(S)] machine was not available and there is no documentation that a new STAT order was placed for the [CONDITION(S)] machine to be delivered. 10/26/2021 at 2:46pm, V1 (Administrator) stated My expectation of the nurses is to make sure they follow state and federal regulation and follow physician orders. They are supposed to check the order with the physician and if the order is correct, they are supposed to follow it. I didn't find out about R1 not having her [CONDITION(S)] machine until she went back into the hospital. V9 (DON) was supposed to follow up with the [CONDITION(S)] machine. If we don't have all the equipment to meet the patient needs, the nurses are supposed to call me or the DON, to call the hospital to tell them we don't have the equipment to meet the patients' needs. The admission will be put on hold until we get the necessary equipment. If a patient comes and we don't have the equipment they should call the doctor and ask if they should send the patient back to the emergency room or if the patient can stay here with oxygen therapy until the [CONDITION(S)] comes. The DON and the Unit Managers should go behind the nurses and check new orders. The nurses need to make sure it's the right machine if it's a [CONDITION(S)] or [CONDITION(S)] and make sure that the settings are pre-programmed in the machine correctly from the company. Facility policy titled, Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] It is the policy of this facility to ensure that all resident/patient medication, treatment and plan of care must be in accordance to the licensed physician orders. The facility shall ensure to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility document titled, [CONDITION(S)]/[CONDITION(S)] Support (undated) includes: Purpose. 1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2. To improve arterial oxygenation (PaO2) in residents with respiratory insufficiency, obstructive sleep apnea or restrictive/obstructive lung disease. 3. To promote resident comfort and safety.

Based on interview and record review the facility failed to follow the plan of care and utilize a half side rail during care for 1 of 3 residents (R3) reviewed for safety intervention implementation. This failure resulted in R3 falling from the bed during direct resident care and sustaining a linear bruise measuring 32 cm x 6 cm to residents left side (under his left arm down to his waist), bruising, swelling to left ear, additional bruising to left arm, left hip and a verbalizing of increased fear of falling. .Findings include: R3 was admitted to facility on 10/31/19 with a diagnosis of cerebral infarction, presence of left artificial hip joint, [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting left dominant side, [CONDITION(S)], hypertension and [CONDITION(S)]. R3's minimum data set (MDS) dated [DATE] documents a brief interview for mental status score of 11/15 which indicates moderately impaired. Under section G titled functional status under bed mobility documents self-performance score of 3, which indicates extensive assistance. Resident involved in the activity; staff provide weight-bearing support. Under support documents score of 2, which indicates a one person physical assist. On 5/19/21 at 12:04PM, R3 who was alert and oriented said V3 (CNA) came into my room to provide care. V3(CNA) let the half side rail down on the right side of the bed, rolled me onto my right my side, while I was on my side V3(CNA) walked to the other side of the bed, put his hand on my back and turned me some more causing me to roll out of bed. I fell out of bed on my left side. I landed on my left side. I hit my head on the floor. V3 tried to get me off the floor by himself, putting me on his knee to lift me up. V3 (CNA) hit my head three times on the bedside table while trying to get me up off the floor by himself. The bedside table was on the side of the bed by the window. It was parallel to the bed. I was not assessed by staff/nursing. A week past, when two CNAs(one restorative aide and another CNA) came into to change me and saw my side. V13 (previous Administrator) came to speak to me and I was discharge to the hospital and returned back to the facility around 3am. I have a fear of falling. I fell prior to coming to the facility and hurt my hip. R3 said his fear of falling has increased since incident. V3 (CNA) has not worked with me since but I heard him in the hallway which made me feel uncomfortable. On 5/26/21 at 900am, R3 alert and oriented, reported same incident as above with no changes. On 5/20/21 at 12:40pm , R3 was observed to have bruising to left side (under arm to waist) measured by V15 (wound nurse) 32 cm long x 6 cm wide areas dark purple with shades of yellow around the edges. On 5/19/21 at 327PM, V3 (CNA) said he is familiar with R3 and care needs. V3 said he was performing incontinence care, bed bath and changing his linen for R3, unsure exact day. V3 denied placing side rails down during care. V3 said he turned R3 to the window on right side and R3's legs started to hit the bed side table, next to the bed. V3 said no other part of his body hit the bedside table. V3 said he reported to nurse on duty but unable to describe or name the nurse. V3 said R3 is alert and oriented and able to communicate needs. V3 said he took care of R3 following the incident with no observations of any injuries, bruising or changes in skin. V3 unable to describe how R3 sustained bruising to left side and unsure of previous interview in facility reportable stating R3's back hit the bed side table. V3 said R3 is on blood thinner and that is how he sustained bruising. On 5/21/21at 324PM, V18 (nurse) said V3 (CNA) reported to him that R3 was about to fall but didn't fall. V18 said it was unusual because R3 is not mobile, so he went to check R3's vitals. R3 said he was ok. V18 said he did not ask R3 if he fell or do a body assessment. V18 said there was no injury to R3's face and R3 said he had no pain. V18 said it was not documented because there was no change or reported fall. On 5/19/21 at 232PM, V8 (restorative aid) said R3 is alert and oriented and able to communicate needs. V8 reported she was provided care to R3 and observed dark purple bruising to left side and left ear. R3 reported that last week V3(CNA) dropped him out of bed. On 5/21/21 at 127PM, V24 (NP) said R3 is alert and oriented and knows what is going on. V24 said V2 (DON) requested R3 to be seen due to bruising. V24 said what is documented in her progress note is accurate to description. V24 said R3 reported V3 (CNA) put right side rail down and he fell out of bed about a week ago. The injury to left ear appeared older due to bruising was yellow which indicates healing but unable to determine the exact time of incident. The injuries did not appear to be have recently occurred. V24 said she had no comment on if the facility staff should of observed bruising prior to 4/28/21. On 5/21/21at 1125am, V2 (DON) said Residents use half side rails to help with repositioning and turning. V2 said it would not be expected for staff to put down half side rails during care. V2 said R3 did not fall and maybe thought that he fell . The investigation revealed that there was an incident because the resident sustained bruising but there was no intentional harm to the patient. V3 (CNA) reported that R3's leg slipped out of the bed and R3 did not fall. V3 (CNA) said he reported to V18 (nurse) that R3 leg slipped out of bed. V2 said V3 should have turned R3 to him first prior to turning to side to ensure he was positioned properly in bed which caused R3 to hit bed side table. V2 said the incident could have been avoided. R3's progress note dated 4/28/21 at 1615 by V24 (NP) Late Entry: Note Text: Was asked by V2 (DON) to see patient for concerns of bruising to his back and his left ear bruised and swollen. R3 seen this afternoon resting in bed. R3 states that he is fine. Noted his left ear is swollen and bruised (blue/black/yellow in color). Left side of chest from under left arm straight down to above waist dark blue line straight down about 3/4 inch in width and full length of his side. R3 was also noted to have a small yellowed bruise to left clavicle. R3 states that he is ok, asked if he notified anyone of his fall he said nope. R3 denies any pain at this time. When asked what happened. R3 states that he was dropped on the floor. When asked how it happened, he stated that the CNA left the side rail down when changing him and have fell out of the bed. He states that the CNA then picked him up and he put him back in the bed by himself. Asked when this occurred he told me last Wednesday. Informed patient that he needs to go to the hospital for a CT scan and chest X-rays to check his ribs. R3 verbalized understanding. Asked if I could do anything for him he said nope he will go to the hospital. Informed staff will call your family. R3 verbalized understanding. Informed V2 (DON) R3 needs to go to the hospital for further evaluation. ? R3's progress note dated 4/28/21 at 1645 pm Text: CNA reported that resident had a bruise to his back (left side of trunk) and left ear. Skin assessment done, bruise noted to back and left ear. He did not complain of any pain. Skin is intact. ADL care rendered by staff and made comfortable in bed. Daughter made aware. V24 (NP) made aware with order to send R3 to the hospital for further evaluation. Facility abuse reportable dated 4/28/21 documents injury of unknown origin. Staff reported bruise to R3's trunk and left ear. R3 had no complaints of pain. R3 sent to hospital for further evaluation. Final report undated documents V3 said that when performing AM care to R3, V3 turned R3 to his right side toward the window when R3's leg slipped out of bed. V3 said he caught R3 preventing him from falling But R3's back hit the tray table next to the window. Under summary documents R3 who is alert and oriented x3 said that a week ago when V3 (CNA) was completing his am care, V3 turned him to his right side toward the window when his leg slipped out of the bed hitting his back to the tray table next to his bed towards the window. V3 was able to catch him from falling. R3 did not report incident to any staff. Under findings document that there is no evidence to support an allegation of abuse or neglect. Under corrective action documents in-serviced staff to round more frequently and after providing care, staff to ask residents if they need anything else before they leave the room. Witness statement dated 4/28/21 documents R3 said a few days ago staff was changing him, he fell on to ta table out of bed. R3 described V3 (CNA). R3 said he did not tell anyone. R3 usually takes good care of him so he doesn't know why this happened. R3 denied any pain and that's why he did not say anything Local hospital record dated 4/28/21 documents bruising to left eat, left upper arm, left rib cage. emergency room diagnosis documents injury of head. Under physical exam documents patient has bruising of left ear and mild swelling that appears a few days old. Patient is alert and oriented x3. R3 sent to emergency room from nursing home for evaluation for head injury that occurred 2 days prior. According to family nursing home dropped him on his head and did not tell us until today. R3's plan of care dated 12/06/2019 documents potential for falls, R3 is at risk for falls. The following interventions: Keep blow call light within reach at all times. Date Initiated: 05/20/2021. Keep immediate environment free of clutter. Date Initiated: 12/06/2019. Maintain bed in lowest position Date Initiated: 12/06/2019. R3's plan of care dated 11/22/2019 may need to use two partial rails to enhance functional independence and promote skin integrity. Interventions included: I would like to use 2 side rails as assistive device to help me to turn and reposition and/or transfer. Date Initiated: 11/22/2019; I would like to use 2 side rails as an enabler during bed mobility and transfer Date Initiated: 11/22/2019; I would like staff to give me feedback and praise my efforts in demonstrating increased independence through the use of one or two side rails. Date Initiated: 11/22/2019; I would like my blow call light cord within easy reach. Date Initiated: 05/20/2021. R3's restorative UDA dated 1/21/21 documents under side rail/other devices used 2 half side rails used as assistive device to turn and reposition. Under mental status documents oriented to self, time, environment, able to use call light to make needs known, and aware of inability to stand or ambulate.

Based on interview and record review, the facility failed to follow their weight management policy by not obtaining weights as ordered, assessing and addressing weight loss for 2 of 3 residents (R1 and R9) reviewed for g-tube feeding and unplanned weight loss. The facility also failed to ensure the G-tube feeding infused consistently at a rate of 50 ml/hour for 1 of 3 residents (R8) reviewed for enteral feeding infusions This failure resulted in a significant unplanned, weight loss greater than 5 percent in one month for R1and R9 , leading to hospitalization .for weight loss of R1. Findings include: R1 was admitted on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimum dated set (MDS) section K (nutritional status) dated 4/23/21 documents: R1 weighs 156 pounds, not on a physician weight loss regiment, weight loss of 5% or more in last month or loss of 10 % or more in last 6 months and receives fifty-one percent or more via an abdominal feeding tube while as a resident. R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Enteral feeding of 75ml/hour goal 1500ml-active (5/19/21) weights three time a week on Monday, Wednesday and Friday. On 5/25/21 at 2:12pm, Surveyor requested, that R1 be weighed. Surveyor observed, R1's weight at 97.5lbs. On 5/25/21 at 2:56pm, V33 (Dietician) said R1 had a weight loss. R1 should not be losing weight. I walked into R1's room the other day and the feeding was not running when it should have been. R1 may not be getting all of the g-tube feeding as ordered. R1's weight lost was not planned. R1 had a significant weight loss. I clarified R1's water flush and added the sugar free protein to R1's profile. R1 remained on the same enteral feeding. No other intervention were in place other than weekly weight, clarifying the water flush and adding protein, I am responsible for the care plan. I don't see any care plan intervention for nutrition for R1. On 5/26/21 at 2:01pm, V36 (medical doctor) stated I asked R1 to be weighed more frequently after the 5/11/21 weight was recorded. Not monitoring R1's weight may cause a delay in care. We could have identified R1's weight loss sooner and implemented a plan of care. They called me yesterday to report R1's weight loss. I ordered R1 weights to be taken three times a week which wasn't done. My expectation is for my orders to be followed. The importance of monitoring the weight is, the weights reflects the resident's nutritional status. If a resident is getting g-tube feeding and not gaining weight something has to be changed. I was wondering if R1 was actually getting the g-tube feeding. Weight Summary documents: R1's weight for April/May 2021: 4/23/21 - 156.4 pounds (lbs.), 5/11/21 - 113.0 lbs., 5/14/21 - 112.0 lbs., 5/19/21 - 105.0 lbs., 5/24/21 - 101.0 lbs. and 5/25/21 - 97.5 lbs. On 5/26/21 at 2:36pm, V35 (wound doctor) said, R1's low [MEDICATION(S)] levels show malnutrition. On 5/26/21 at 4:25pm, V2 (DON, Director of Nursing) said, the water flush is calculated in the pump. Both the water flush and the g-tube will run at the same time. R1's lab dated 5/12/21 documents: [MEDICATION(S)] 2.2 low (normal range 3.4 -4.8) Pre-[MEDICATION(S)] 7 low (normal range 12-35). Dietary note dated 5/14/21 documents: R1 with unintended weight loss of 28.3% in the past month. Current weight of 112 lbs. R1's usual weight is 145 -150lbs. R1 estimated needs based on current weight 1275-1800 calories/day. R1 is tolerating current feeding well at 75ml/hr starting at 4pm and infusing to 1500ml per day is reached. Pre-[MEDICATION(S)] 7 (low) Plan: monitor tolerance to diet and supplement. Add liquid protein 30 ml twice a day via g-tube. Weigh R1 weekly and change protein powder to one packet twice a day r/t unintentional weight loss. Dietary note dated 5/19/21 documents: R1 with continued weight loss of 6.25% in the past five days. Seven percent weight loss in the past eight days. R1's current weight of 105 pounds. R1 17.5 BMI is underweight status. Plan Continue to monitor tolerance to g-tube feeding regimen. Recommendation: Continue current by mouth and G -Tube feeding regimen. Clarification of feeding water flush. Transfer Form dated 5/25/21 documents: R1 was discharged to the hospital for weight loss. R9 was admitted to facility on 1/29/21 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimum data set (MDS) section K (nutritional status) dated 5/3/21documents: R9 weighs 136 pounds, not on a physician weight loss regiment, weight loss of 5% or more in last month or loss of 10 % or more in last 6 months and receives fifty-one present or more via an abdominal feeding tube while as a resident. R9 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Order dated 2/6/21 -5/21/21 documents: g-tube feeding 60ml/hour is tolerated. On 5/26/21 at 11:04am, V33 (Dietician) said R9 loss weight. I assessed R9 on 5/5/21. Prior to 5/5/21, I was not notified of any weight loss between March and April. There should have been an assessment for R9 weight loss. Between January and May, R9 had an 11.4% weight loss which was significant. I changed R9's g-tube feeding from 60ml/hr to 65ml/hr on 2/1/21. The next change was on 5/5/21, I increased the water flush frequency per day. R9 was receiving the same amount calories from 2/1/21 to 5/20/21. We did not made any changes or add any interventions between March and April when R9 loss 7.5%. I don't know why R9 is not being weighed weekly. Weight Summary documents: R9's weight for January, April and May 2021: 1/30/21 - 144.5 pounds, 3/4/21 - 146.0, 4/2/21 135.0 lbs., and 5/17/21 - 128.0 lbs. R9's dietary evaluation dated 2/1/21 documents a weight loss of 5%or more in last month or 10% in last 6 months. Discontinue feeding 1.2 @ 60 ml/hr continuous. Begin feeding 1.2 @ 65 mls/hr, start at 4 pm and infuse until 1440 mls per day is infused (provides 1728 calories, 86 gm protein and 1159 mls free water). Continue current water flush of 200 mls q 8 hours (600 mls/day). R9's care plan dated 2/5/21 documents R9 receives enteral nutrition due to malnutrition related to preexisting nutritional deprivation; unplanned or unexplained weight loss of 8% in body weight; anticipated or actual inadequate energy intake by mouth for 7 days or more. Interventions initiated 2/5/21 include: check vitals every shift after initiating infusion; weigh patient as ordered (weekly); monitor lab values and report results to MD. R9's dietary evaluation dated 5/5/21 documents a weight loss of 5% or more in last month or 10% in last 6 months and weight loss of 7.5% in the last 3 months. R9's current weight of 136 is 6.8% less than R9's weight one month ago and 13.9% weight loss in the past three months. R9 may benefit from increase in current G-tube feeding. Begin g-tube feeding at 65 mls/hr, start at 4 pm and infuse until 1300 mls per day is reached (provides 1560 calories, 78 gm protein and 1053 mls free water per day). Begin water flush of 300 mls q shift (900 mls/day). R9's progress note dated 5/20/21 documents: R9s weight of 128 lbs on 5/17/21 is (8 pounds) less than weight one month ago and 11.7% weight loss in the past three months. R9 may benefit from increase in current G-tube feeding. Estimated needs: 1450-2050 calories, 58-64 gm protein (1-1.1 g/kg) and 1450-1750 mls (25-30 ml/kg) per day Begin 1.2 G-tube feeding at 65 ml/hr, start at 4 pm and infuse until 1300 ml/day is infused (provides 1560 calories, 78 gm protein and 1053 ml free water per day. Begin water flush of 250 mls q shift (750 ml/day). On 5/26/21 at 11:21pm, with V39 (Assistance Director of Nursing) it was observed that R8 had 400ml of feeding remaining in the bottle. V39 said, she didn't hang any g-tube feeding for R8, she verified it was is 400ml left in the liter bottle. V39 said at the prescribed rate the bottle contained more feeding that it should have based on the time the feeding was started yesterday 4pm running at a rate of 50ml/hour. On 5/26/21 a review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Enteral Tube Feeding Care Policy dated 2/2/15: Enteral Tube -is an avenue of feeding and nutritional support. Weight Policy dated 12/3/2015-to obtain resident's weight unless otherwise ordered differently by the physician. #3) The significant weight changes monthly (5%) quarterly (7.5%) and every six months (10%) will be assessed and addressed by the IDT which includes but not limited to the Dietician, Physician, Nutritionist and Nurses.

Based on interview and record review the facility failed to allow a resident to wear his or her hair in a manner of choice. This applies to one of four residents (R2) reviewed for resident's right in a sample of four. As a result, R2 became emotionally upset, displayed aggressive behaviors and the resident's family member (Z4) provided support to resolve the problem. Findings include: According to a face sheet R2, a ninety-one year old resident, admitted to the facility for a short term stay on 7/28/2016. R2's Admission Summary progress note dated 7/29/2016 at 00:42 hours documented: Pt (patient) is stable and alert & oriented times three. On 8/04/2016 at 10:29pm, E1 (administrator) reported E3 (Nurse Supervisor) stated the family member of R2 was upset that her hair was cut, the resident was ok with it. On 8/04/2016 at 10:48am, E4 (CNA) stated R2's hair was all matty. I got my co-worker E5 (CNA) who is African American because she did not feel comfortable with me touching her hair. (E5) said what am I gonna do with it, I can't brush it. We decided to cut it. The resident said it was ok after she cut it. On 8/4/16 at 1:05pm, R2 stated my hair was down to here (pointing to her bicep) when I came. I woke up and it was gone. I wish they would have asked me, but that's what happened. Surveyor inquired who cut her hair R2 replied somebody in here. When I came here I had all my hair. I don't know. I don't know why they did it, it's my hair. My son asked me what happened to my hair I was asleep when they cut it. That's what happened. I had 3 or 4 people ask me what happened I told them I don't know what happened I was asleep. R2 was adamant that she did not give staff permission to cut her hair. On 8/08/2016 at 10:02am, surveyor inquired about R2's hair E7 (Licensed Practical Nurse) stated When I admitted her, her son said he did not want her hair cut. He made that clear. On 8/10/2016 Z1 (R2's family member) reported he made it known on 7/28/16 to E7 (nurse) his mother (R2's) hair should not be cut. Z1 stated, he received a call from a social worker (E6) discussing the condition of R2's hair and possibly cutting it. Z1 told E6 under no circumstance to cut his mother hair. Z1 stated, he came to the facility on the Sunday (7/31/16) to find R2's hair was off. Z1 reported his mother was very upset. One of his other brother had to come and stay with my mother one night. R2's Health Status progress notes dated 8/01/2016 at 19:26 hours documented: Resident became increasingly verbally aggressive and unable to be redirected from believing staff were intruders in her home. Resident son (Z4) informed of the above behavior and was unable to deescalate the resident over the phone. Z4 came to the facility to provide 1:1 supervision until the resident fell asleep. Z3 (attending physician) updated on resident's condition and new order received for [MEDICATION NAME], and psych evaluation. On 8/11/2016 at 10:08am, R2 was interviewed about the cutting of her hair and how she felt about the situation. R2 stated, it hurt me so bad. They couldn't hurt me any more. I just have to get use to not having hair back there. I just want to go home. It took me a long time to grow my hair.

Based on observation, record review and interview, the facility failed to follow the care plan and facility policy and procedure for safe transfer for one resident (R1) of three residents (R3, R4) reviewed for resident's injury. This failure caused R1 to sustain a fracture. Findings Include: R1 ' s medical record indicated an [AGE] year old readmitted to facility on 8/28/2012 with [DIAGNOSES REDACTED]. R1's " Care Card " kept behind R1 ' s bathroom door dated 2/16/2015 noted " two person assist with sit to stand equipment " . The Minimum Data Set (MDS) for R1 dated 1/28/2015 documented; two person extensive assistance for transfer. R1's care plan dated 1/28/2015 noted intervention for two person assistance for transfer with sit to stand machine. On 2/24/2015 at 10:30AM, R1 was cheerful and sat in a wheelchair in room with right leg in a cast and elevated on leg rest. R1 was alert and answered all questions appropriately. R1 said, E8, (Certified Nursing Assistant, CNA) picked her up under her arms and turned her around to sit her in wheelchair and her right foot was caught between the wheels and twisted. Facility's incident report of 2/16/2015 documented E8 (Certified Nursing Assistant, CNA) transferred R1 from bed to wheelchair by himself when R1's right foot twisted. The right foot became swollen and R1 complained of pain. The facility's staff medicated R1 for pain and notified the Physician. An x-ray was ordered and done in the facility on 2/16/2015. The results revealed acute fracture of the distal tibia of the right leg. R3 was sent to the community hospital on [DATE]. On 2/24/2015 at 11:55AM, E6 (Restorative Nurse) stated on 2/16/2015, E8 transferred R1 alone when it should have been a two person transfer using the sit to stand machine. E6 further said E8 and all other CNAs are in-serviced on how to use the sit to stand machine for residents. E8 was not available for interview and E2 (Assistant Administrator) indicated E8 had been terminated. E3 (Director of Nursing, DON) interviewed E8, (Certified Nursing Assistant, CNA) on 2/17/15. E3 documented E8 transferred R1 by himself by holding R1 under the arms and placing R1 in the wheel chair. E8 then noticed R1 ' s " right foot was between the front wheel " . Facility's policy " Safe Handling Protocols " documented, "The caregiver at any time can increase the level of transfer from what is stated in the care plan based on the patient's ability to assist or comprehend the transfer (i.e. sit to stand transfer could be increased to a total lift transfer) however, the caregiver can never reduce the level of device used. "

Based on observation, interview and record review the facility failed to assess/communicate range of motion for post fall for 1 (R1) in 4 residents reviewed for falls/fractures in the sample of 8. This deficient practice resulted in delayed treatment and intervention after R1 sustaned a [MEDICAL CONDITION] which required surgery. Findings Include: R1 was seen on initial tour on 11-4-2011 at 10:03 AM in physical therapy sitting in a wheelchair stating "I'm ok now" R1 was on the Alzheimer unit on 11-4-2011 at 1:45PM sitting in a wheelchair participating in activity. On 11-4-2011 at 1:45PM at the nursing station on the Alzheimer unit (Nurse) stated "R1's family member approached me on 9-15-2011 and stated that R1 has not been the same since her fall and has not been walking. I called the doctor to get a bilateral hip x-ray because the knee x-ray that was done on 9-13-2011 was negative for fracture." On 11-4-2011 at 2PM (Certified Nursing Assistant) E7 stated, "I have worked here for [AGE] years and I am familiar with R1. R1 fell on her knees in September, the nurses ordered an x-ray. After R1's fall, R1 was hesitant to move/walk, so I told the nurses. I cannot remember who, but they told me that R1 had an x-ray to the knees and it was negative. I wondered why R1 was not moving if the x- ray to the knees was negative." On 11-4-2011 at 3 PM in the conference room (Nurse) E8 stated,"On 9-13-2011 at 12 midnight R1 fell on her knees. I remember because the alarm went off. I completed an injury report and paged the doctor. Now I know that the x-ray should have been for more than just the knees." On 11-8-2011 at 10:00AM (Nurse) E12 stated, "E8 (Nurse) gave me report on the day of R1's fall. I called the doctor that day and read the injury report to the doctor. The injury report did not have range of motion assessment to limbs on it. The doctor ordered an x-ray to both knees. I did not assess for range of motion. R1 was sitting in the wheelchair. If it were my grandmother I would be upset that a hip x-ray did not get ordered right away." On 11-8-2011 at 2 PM via telephone (Medical Doctor) E13 stated, "Nurses are my eyes and ears, I base what I order on what they tell me. R1's family member called me and told me that R1 was not walking. I then called the nurse and ordered a bilateral hip x-ray. R1 had a [MEDICAL CONDITION] for which she had surgery." Nurses Progress Notes dated 9-13-2011 states, R1 was observed on the floor sounded by bed alarm, resident was on lower knees, resident was assessed further with no evidence of bruise or swelling. Resident complained of pain and received Tylenol. Nurses Progress Notes dated 9-13-2011 at 2PM documents, X-ray of right and left knee ordered carried out. Nurses Progress Notes dated 9-15-2011 documents, "Resident current not walking status/post fall MD made aware with orders to do x-ray of bilateral hip." Nurses Progress Notes dated 9-16-2011 documents that R1 has a right [MEDICAL CONDITION]. Bone and Joint Physicians document dated 10-4-2011 states R1 is post operative open reduction , internal fixation of intertrochanteric right [MEDICAL CONDITION]. Incidents and Accidents Policy (undated) states, Handling Accident Occurrences Assess resident injury, pain, range of motion, bruising, bleeding and lacerations. R1's Minimum Data Set comparison of 8-23-2011(pre-fall) and 9-28-2011(post fall) documents bed mobility decreased to extensive assist with one person as compared to pre-fall supervision with one person. Transfer decreases to extensive assist with two persons as compared to pre-fall limited assist with one person.