Every finding on record at Aviston Countryside Manor

Based on observation, interview, and record review the facility failed to ensure medications were administered as ordered for 1 (R5) of 3 residents reviewed for medication administration in the sample of 5.Findings Include:R5's face sheet documents that R5 was admitted to the facility on [DATE]. The diagnoses listed on the face sheet include unspecified fracture of left pubis, urinary tract infection, heart failure, unspecified atrial fibrillation, essential hypertension, chronic kidney disease, and hyperkalemia. R5's admission MDS (Minimum Data Set) dated 10/13/2025 documented a BIMS (Brief Interview of Mental Status) of 15, indicating R5 is cognitively intact.R5's progress note dated 11/11/2025, timed 12:25 A.M., authored by V12 (Licensed Practical Nurse) documented R5 received Keppra 750mg and Metoprolol 100 mg in error. The on-call nurse practitioner called and notified him of error. Vital signs at 10:39 P.M. were blood pressure 128/52 and pulse of 74. Per nurse practitioner monitor vital signs during the evening. 11:03 P.M. blood pressure 118/56 and pulse 69. On call facility nurse notified of error. R5 currently at nurses' station for monitoring. No adverse reactions noted. Power of Attorney notified. R5's progress note dated 11/23/2025, timed 11:48 A.M., authored by V19 (Licensed Practical Nurse) documented R5 has no adverse side effects from medication error on last shift. R5 able to voice needs. No new orders at this time.R5's Order history with a date range of 10/07/2025-02/10/2026 document no orders for Keppra or Metoprolol. On 02/06/2026 at 9:23 A.M. V2 (Director of Nursing) stated the facility has not had any medication errors and does not have any medication error reports.On 02/06/2026 at 2:02 P.M. V6 (Licensed Practical Nurse) stated there is a nurse on night shift that gave the wrong resident the wrong medications. V6 stated this has been reported to V2 and nothing was done about it. V6 stated the nurse who made the medication error still talks about it occurring. On 02/06/2026 at 2:20 P.M. V8 (Licensed Practical Nurse / Assistant Director of Nursing) stated she is not aware of any medication errors.On 02/08/26 at 4:52 AM V12 (Licensed Practical Nurse) stated there was an incident about two months ago when she was helping another nurse with her mediation pass. V12 stated she was passing the C hallway and the right side of A hallway, and the other nurse was passing B hallway and the left side of A hallway. V12 stated the other nurse was running a little bit behind so she decided to help them out. V12 stated she probably shouldn't have done it but she did. V12 stated she went down and pulled the residents medication out of the med-cart and took it down to the A hallway. V12 stated she had the medication pulled for the resident in the second room on the left and she accidentally gave them to the person in the first room on the left side of the A hallway. V12 stated she reported it immediately to the DON, family, and the doctor. V12 stated she monitored R5's vital signs and they kept R5 up close to the nurse's station so they could monitor them closely. V12 stated she charted and done everything she was supposed to regarding the incident.On 02/10/2025 at 10:58 A.M. V2 (Director of Nursing) stated she asked V12 (Licensed Practical Nurse) when she was in the facility over the weekend about what the surveyor had asked her about. V2 stated V12 told her about medication error questions. V2 stated she asked V12 how she responded and V12 told her that she told the surveyor about when she gave the wrong medications to the wrong resident. V2 stated she was not aware at the time of the incident and was only made aware the other night. V2 stated she is aware that it was a resident on A hall, and the resident had been discharged . V2 stated she is actively reading through charts trying to determine who the resident was.On 02/10/2026 at 11:34 A.M. V2 stated that she has determined that R5 was the resident who was given the wrong medication. V2 stated she looked and V8 (Licensed Practical Nurse / Assistant Director of Nursing) would have been the nursing administration on call. V2 stated she asked V8 and V8 stated she was not made aware of the medication error. V2 stated if she had been notified herself and V8 would have investigated it and followed the facility policy on medication errors.On 02/20/2025 at 12:54 P.M. V1 stated he was not made aware of the medication error until today. V1 stated that it is his expectation for all medication errors to be reported and handled appropriately. V1 stated he expects the facility follow all proper nursing standards to prevent medication errors.Facility policy titled Preventing and Detecting Adverse Consequences and Medications Errors documents J. The following information is documented in an incident report and in the resident's clinical record: 8) factual description of error, 9) name of physician and time notified, 10) physician's subsequent orders, 11) resident's condition for 24 -72 hours or as directed. K. Each incident report is forwarded to the Director of Nursing / Quality Assurance, Medical Director / Consultant Pharmacist.

Based on interview and record review the facility failed to ensure residents were free from verbal and mental abuse from staff for 3 of 5 residents (R2, R4, and R5) review for abuse and neglect in the sample of 10.This failure resulted in harm to R2 and R4 who were observed crying and emotionally distressed at the time of the said incidents, along with R5 who was scared, feeling of being unsecure and wanting to move.The findings include:1.R2's admission Record documents an admission date of 11/23/24 and diagnoses including malignant neoplasm of overlapping [NAME] of left female breast, cerebral infarction, depression, generalized anxiety, unspecified mood disorder, and mild cognitive impairment. R2's Minimum Data Set (MDS) dated [DATE], documents under Section C a Brief Interview for Mental Status (BIMS) score of 5 which indicates severely cognitively impaired. Section B document's ability to hear as adequate.R2's Care Plan documents a focus area of R2 is at risk for abuse/neglect due to residing in a congregate facility with interventions of address all complaints/concerns promptly with grievance and procedures and report any suspected abuse/neglect to administrator immediately.On 01/15/26 at 9:34AM R2 stated that she doesn't remember if anyone has ever yelled at her or told her that her mother has passed. R2 said that if someone did tell her that her mother was dead that it would upset her very much.On 01/15/26 at 10:42AM V7 (Physical Therapy Assistant) stated that she heard that V11 (Licensed Practical Nurse/LPN) was rude to the residents. V7 said that she knows that V15 (Director of Physical Therapy) was the one who has witnessed V11 (LPN) being rude to R2.On 01/15/26 at 12:19PM V15 (Director of Physical Therapy) stated that she witnessed V11 (LPN) being hateful to the residents. V15 said that one day R2 was asking for her mother recently she said that R2 kept asking for her mom and that V11 turned around to R2 and yelled Dead, that is where your mom is at, she is dead. V15 said that R2 got really upset and was crying after V11 said that. V15 said that V11 just isn't nice to all the residents, she is just rude. V15 said that she did not report V11 stating that to R2. V15 said that she did have another time when V11 (LPN) was rude to another resident, and she did report that to V2 (Director of Nursing/DON). V15 said that only thing that happened to V11 when she reported it to V2 was that V2 talked to V11. V15 said that the way that V11 talked to R2 was verbally and mentally abusive. V15 said that when this happened it was on the weekend and there were no managers in the building at the time, so she didn't report the incident to anyone.2.R4's admission Record documents an admission date of 08/01/2021 and diagnoses Alzheimer's disease, unspecified dementia, major depressive disorder, and insomnia.R4's MDS dated [DATE], documents under Section C a BIMS score of 5 which indicates severely cognitively impaired. Section B documents ability to hear as adequate.R4's Care Plan documents a focus area of R4 is at risk for abuse/neglect due to residing in a congregate facility with interventions of address all complaints/concerns promptly with grievances policy and procedure and report any suspected abuse/neglect to administrator immediately.On 01/15/26 at 12:05PM R4 stated that she doesn't remember staff yelling at her, but she said that she forgets things often and she doesn't know. R4 said that she just doesn't have the best memory. R4 said that someone could have yelled at her and that she might have ignored it she really doesn't remember she doesn't really remember anyone yelling, but she isn't saying that it didn't happen. R4 said that she is just trying to stay out of trouble. R4 said that she does remember one time she wanted to call her son, and they wouldn't let her use the phone to call them. R4 said that it made her so upset and mad.On 01/15/26 at 9:53AM V3 (Registered Nurse/RN) stated that the facility has a newer nurse V11 (LPN) who is verbally mean to the residents. V3 stated that it is most of the residents that V11 talks mean to. V3 said that she has seen V11 be not so nice to R4. V3 said that V11 will yell at R4. V3 said that R4 likes to sleep in and V11 will yell at R4 from the hallway and tell her that she needs to get out of bed. V3 said that R4 will want to stay in bed longer and V11 will tell her that she is getting up. V3 said that she did not report V11 when she was yelling at R4 because it will put a target on your back. V3 said that way V11 was yelling at R4 she would consider it verbal and mental abuse.On 01/15/26 at 10:38AM V4 (Licensed Practical Nurse/LPN) stated that V11 is not very nice to the residents. V4 said that a couple of weekends ago R4 was crying and asking V11 to call her son. V4 said that V11 wouldn't call R4's son so she ended up calling R4's son for her and it helped calm R4 down. V4 said that V11 was sitting at the nurse's station one day and R4 was just sitting by the nurse's station and that V11 was yelling at R4. V4 said that she couldn't remember the content of the yelling, but it was very loud and rude. V4 said that it was upsetting R4.3.R5's admission Record documents an admission date of 04/03/25 with diagnoses of cerebral palsy, paraplegia, vascular dementia, bipolar disorder, major depressive disorder, anxiety disorder, and unspecified intellectual disabilities.R5's MDS dated [DATE] documents under Section C a BIMS score of 11 which indicates moderately impaired cognition. Section B documents ability to hear as adequate.R5's Care Plan does not document a focus area of abuse.On 01/15/25 at 1:57PM R5 state that she did have a day when they got out of bed and made her take a shower. R5 said that V11 told her in a loud voice that she had to get up and take a shower. R5 said that she always takes a bed bath, and she didn't want to get up and take a shower. R5 said that V11 told her that she had to take a shower. R5 said that she has back and spine problems and that she doesn't get up and take showers only bed baths. R5 said that V11 made the staff get her up for the shower. R5 said that she is a mechanical lift, and she had an incident at another facility where she fell out of the mechanical lift sling so now every time, she gets in the mechanical lift it scares her. R5 said that when V11 made her get up to take the shower that she was crying and so upset. R5 said that she is not happy at the facility. R5 said that she doesn't want to be at the facility anymore because they make her do things she doesn't want to do, and they raise their voices at her at times.On 01/15/26 at 10:38AM V4 (LPN) stated that she witnessed V11 (LPN) telling staff that they had to get R5 up out of bed and get her into the shower. V4 said that she couldn't remember the Certified Nurse Assistant that was working that day, but that R5 was saying that she didn't want to get a shower. V4 said that R5 is a mechanical lift and that she came from another facility and they dropped her out of the mechanical lift and now R5 is scared of the mechanical lift. V4 said that V11 was yelling at R5 that she was getting up and taking a real shower not a bed bath. V4 said that staff did get R5 up and she was crying and screaming she was so upset. V4 said that she never reported any of this to V1 (Administrator/ADM) or V2 (DON).On 01/15/26 at 10:50AM V9 (Certified Nurse Assistant/CNA) stated that she gave R5 a shower that usually she gets a bed bath, but V11 told her that R5 needed a shower. V9 said that R5 was refusing to get up out of bed to take a shower, but V11 said that I need to get R5 up and into the shower. V9 said that she doesn't remember if R5 was upset or not.On 01/15/26 at 1:58PM V21 (CNA) stated that on 01/06/26 she was working on her C hall and she could hear R5 yelling out and screaming from B hall. V21 said that was the first time she has ever seen R5 get up out of bed for a shower and V11 was the nurse who made her get up and take a shower. V21 said that R5 was so upset and just yelling out the whole time she was in the shower.On 01/15/26 this surveyor reported allegation of possible abuse to V1 (ADM) on R2, R4, and R5.On 01/15/26 at 2:57PM V2 (DON) stated that she just found out that V15 told V1 (Administrator/ADM) that V11 told R2 that her mom was dead. V2 stated that V15 didn't report anything to her about V11 yelling at R2 or about V11 saying to R2 that her mom was dead. V2 stated that V15 did report to her a while back that she overheard V11 telling another resident who was yelling out to quit yelling that no one needed to hear that. V2 said that she did talk to V11 about the incident, but she hasn't had any more reports about V11 being rude or yelling at any other resident. V2 stated that it is hard to get R5 to take a shower she said that R5 was at another facility and was dropped out of the mechanical lift and that is how she is transported so she is scared to get up out of bed. V2 said that if R5 didn't want to get a shower that V11 should not have made R5 get a shower. V2 said that no staff should yell at any resident. V2 said that no staff should yell at any resident for any reason. V2 said that if a resident such as R4 wanted to use the phone to call her son she should have been allowed to call her son. On 01/15/26 at 3:23PM V1 (ADM) stated that he is currently investigating the allegation of abuse and that he has suspended V11 at this time until the investigation is completed.On 01/16/26 at 9:41AM V11 (LPN) stated that there has been a misinterpretation with R2 that she was asking R2 how old she was and then how old R2's mother would be. V11 said that she never told R2 that her mother was dead. V11 said that she has raised her voice, because R2 is hard of hearing. V11 said that she did have R5 get up out of bed to take a shower, but she never refused. V11 said that R5 was doing her normal yelling when she was in the shower. V11 said that R5 does cry and yell with all care. V11 stated she had been at her medication cart when she told R5 that she needed to take a shower. V11 said that she assists R4 up every day and that she has not yelled at her. V11 said that she feels yelling is being misinterpreted because she is speaking louder for hard of hearing residents. V11 stated she would be across the room helping R4's roommate and she would tell her time to get up and get ready, but she is not yelling at her. V11 stated that she has never told R4 that she could not call her son, she did say that there are times during report that she has told R4 she would come find her to call her son once she had been done with report. V11 said that she has only raised her voice to resident that are hard of hearing not in a yelling or abusive way. V11 stated that yelling or screaming at a resident is considered abuse.The facility policy titled Abuse Prevention Program Facility Procedures (Undated) documents under Establishing a Resident Sensitive Environment: This facility desires to prevent abuse, neglect or misappropriation of property by establishing a resident sensitive and resident secure environment.

Based on interview and record review, the facility staff failed to identify a situation of staff to resident verbal abuse and report to the Administrator immediately, for 3 of 5 residents (R2, R4, and R5) reviewed for abuse and neglect in the sample of 10. The findings include: 1.R2's admission Record documents an admission date of 11/23/24 and diagnoses including malignant neoplasm of overlapping [NAME] of left female breast, cerebral infarction, depression, generalized anxiety, unspecified mood disorder, and mild cognitive impairment.R2's Minimum Data Set (MDS) dated [DATE], documents under Section C a Brief Interview for Mental Status (BIMS) score of 5 which indicates severely cognitively impaired. Section B document's ability to hear as adequate.R2's Care Plan documents a focus area of R2 is at risk for abuse/neglect due to residing in a congregate facility with interventions of address all complaints/concerns promptly with grievance policy and procedures and report any suspected abuse/neglect to administrator immediately.On 01/15/26 at 9:34AM R2 stated that she doesn't remember if anyone has ever yelled at her or told her that her mother has passed. R2 said that if someone did tell her that her mother was dead that it would upset her very much.On 01/15/26 at 10:42AM V7 (Physical Therapy Assistant) stated that she heard that V11 (Licensed Practical Nurse/LPN) was rude to the residents. V7 said that she knows that V15 (Director of Physical Therapy) was the one who has witnessed V11 (LPN) being rude to R2.On 01/15/26 at 12:19PM V15 (Director of Physical Therapy) stated that she witnessed V11 (LPN) being hateful to the residents. V15 said that one day R2 was asking for her mother recently she said that R2 kept asking for her mom and that V11 turned around to R2 and yelled Dead, that is where your mom is at, she is dead. V15 said that R2 got really upset and was crying after V11 said that. V15 said that V11 just isn't nice to all the residents she is just rude. V15 said that she did not report V11 sating that to R2. V15 said that she did have another time when V11 (LPN) was rude to another resident, and she did report that to V2 (Director of Nursing/DON). V15 said that only thing that happen to V11 when she reported it to V2 was that V2 talked to V11. V15 said that the way that V11 talked to R2 was verbally and mentally abusive. V15 said that when this happen it was on the weekend and there were no managers in the building at the time, so she didn't report the incident to anyone.2.R4's admission Record documents an admission date of 08/01/2021 and diagnoses including Alzheimer's disease, unspecified dementia, major depressive disorder, and insomnia.R4's MDS dated [DATE], documents under Section C a BIMS score of 5 which indicates severely cognitively impaired. Section B documents ability to hear as adequate.R4's Care Plan documents a focus area of R4 is at risk for abuse/neglect due to residing in a congregate facility with interventions of address all complaints/concerns promptly with grievances policy and procedure and report any suspected abuse/neglect to administrator immediately.On 01/15/26 at 12:05PM R4 state that she doesn't remember staff yelling at her, but she said that she forgets things often and she doesn't know. R4 said that she just doesn't have the best memory. R4 said that someone could have yelled at her and that she might have ignored it she really doesn't remember she doesn't really remember anyone yelling, but she isn't saying that it didn't happen. R4 said that she is just trying to stay out of trouble. R4 said that she does remember one time she wanted to call her son, and they wouldn't let her use the phone to call them. R4 said that it made her so upset and mad.On 01/15/26 at 9:53AM V3 (Registered Nurse/RN) stated that the facility has a newer nurse V11 (LPN) who is verbally mean to the residents. V3 stated that it is most of the resident that V11 talks mean to. V3 said that she has seen V11 be not so nice to R4. V3 said that V11 will yell at R4. V3 said that R4 likes to sleep in and V11 will yell at R4 from the hallway and tell her that she needs to get out of bed. V3 said that R4 will want to stay in bed longer and V11 will tell her that she is getting up. V3 said that she did not report V11 when she was yelling at R4 because it will put a target on your back. V3 said that way V11 was yelling at R4 she would consider it verbal and mental abuse.On 01/15/26 at 10:38AM V4 (Licensed Practical Nurse/LPN) stated that V11 is not very nice to the residents. V4 said that a couple of weekends ago R4 was crying and asking V11 to call her son. V4 said that V11 wouldn't call R4's son so she ended up calling R4's son for her and it helped calm R4 down. V4 said that V11 was sitting at the nurse's station one day and R4 was just sitting by the nurse's station and that V11 was yelling at R4. V4 said that she couldn't remember the content of the yelling, but it was very loud and rude. V4 said that it was upsetting R4.3.R5's admission Record documents an admission date of 04/03/25 with diagnoses of cerebral palsy, paraplegia, vascular dementia, bipolar disorder, major depressive disorder, anxiety disorder, and unspecified intellectual disabilities.R5's MDS dated [DATE] documents under Section C a BIMS score of 11 which indicates moderately impaired cognition. Section B documents ability to hear as adequate.R5's Care Plan does not document a focus area of abuse.On 01/15/25 at 1:57PM R5 state that she did have a day when they got her out of bed and made her take a shower. R5 said that V11 told her in a loud voice that she had to get up and take a shower. R5 said that she always takes a bed bath, and she didn't want to get up and take a shower. R5 said that V11 told her that she had to take a shower. R5 said that she has back and spine problems and that she doesn't get up and take showers only bed baths. R5 said that V11 made the staff get her up for the shower. R5 said that she is a mechanical lift, and she had an incident at another facility where she fell out of the mechanical lift sling so now every time, she gets in the mechanical lift it scares her. R5 said that when V11 made her get up to take the shower that she was crying and so upset. R5 said that she is not happy at the facility. R5 said that she doesn't want to be at the facility anymore because they make her do things she doesn't want to do, and they raise their voices at her at times.On 01/15/26 at 10:38AM V4 (LPN) stated that she witnessed V11 (LPN) telling staff that they had to get R5 up out of bed and get her into the shower. V4 said that she couldn't remember the Certified Nurse Assistant that was working that day, but that R5 was saying that she didn't want to get a shower. V4 said that R5 is a mechanical lift and that she came from another facility, and they dropped her out of the mechanical lift and now R5 is scared of the mechanical lift. V4 said that V11 was yelling at R5 that she was getting up and taking a real shower not a bed bath. V4 said that staff did get R5 up and she was crying and screaming she was so upset. V4 said that she never reported any of this to V1 (Administrator/ADM) or V2 (DON).On 01/15/26 at 10:50AM V9 (Certified Nurse Assistant/CNA) stated that she gave R5 a shower that usually she gets a bed bath, but V11 told her that R5 needed a shower. V9 said that R5 was refusing to get up out of bed to take a shower, but V11 said that I need to get R5 up and into the shower. V9 said that she doesn't remember if R5 was upset or not.On 01/15/26 at 1:58PM V21 (CNA) stated that on 01/06/26 she was working on her C hall, and she could hear R5 yelling out and screaming from B hall. V21 said that was the first time she has ever seen R5 get up out of bed for a shower and V11 was the nurse who made her get up and take a shower. V21 said that R5 was so upset and just yelling out the whole time she was in the shower.On 01/15/26 this surveyor reported allegation of possible abuse to V1 (ADM) on R2, R4, and R5.On 01/15/26 at 2:57PM V2 (DON) stated that she just found out that V15 told V1 (Administrator/ADM) that V11 told R2 that her mom was dead. V2 stated that V15 didn't report anything to her about V11 yelling at R2 or about V11 saying to R2 that her mom was dead. V2 stated that V15 did report to her a while back that she overheard V11 telling another resident who was yelling out to quit yelling that no one needed to hear that. V2 said that she did talk to V11 about the incident, but she hasn't had any more reports about V11 being rude or yelling at any other resident. V2 stated that it is hard to get R5 to take a shower she said that R5 was at another facility and was dropped out of the mechanical lift and that is how she is transported so she is scared to get up out of bed. V2 said that if R5 didn't want to get a shower that V11 should not have made R5 get a shower. V2 said that no staff should yell at any resident. V2 said that no staff should yell at any resident for any reason. V2 said that if a resident such as R4 wanted to use the phone to call her son she should have been allowed to call her son.On 01/15/26 at 3:23PM V1 (ADM) stated that he is currently investigating the allegation of abuse and that he has suspended V11 at this time until the investigation is completed.On 01/16/26 at 9:41AM V11 (LPN) stated that there has been a misinterpretation with R2 that she was asking R2 how old she was and then how old R2's mother would be. V11 said that she never told R2 that her mother was dead. V11 said that she has raised her voice, because R2 is hard of hearing. V11 said that she did have R5 get up out of bed to take a shower, but she never refused. V11 said that R5 was doing her normal yelling when she was in the shower. V11 said that R5 does cry and yell with all care. V11 stated she had been at her medication cart when she told R5 that she needed to take a shower. V11 said that she assists R4 up every day and that she has not yelled at her. V11 said that she feels yelling is being misinterpreted because she is speaking louder for hard of hearing residents. V11 stated she would be across the room helping R4's roommate and she would tell her time to get up and get ready, but she is not yelling at her. V11 stated that she has never told R4 that she could not call her son, she did say that there are times during report that she has told R4 she would come find her to call her son once she had been done with report. V11 said that she has only raised her voice to resident that are hard of hearing not in a yelling or abusive way. V11 stated that yelling or screaming at a resident is considered abuse.The facility policy titled Abuse Prevention Program Facility Procedures (Undated) documents under Internal Reporting Requirements and Identification of Allegations: Employees are required to report immediately any incident, allegation or suspicion of potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect to the administrator. Serious bodily injury- 2-hour limit if the events that cause the reasonable suspicion result in serious bodily injury to a resident, the covered individual shall report the suspicion immediately, but not later than 2 hours after forming the suspicion. All others withing 24 hours if the event that cause the reasonable suspicion do not result in serious bodily injury to a resident, the covered individual shall report the suspicion immediately but not later than 24 hours after forming the suspicion. Employees shall immediately inform the administrator of all reports of incidents, allegations or suspicion of potential abuse, neglect or misappropriation of property. Upon learning of the report, the Administrator shall initiate an incident investigation.

Complaint investigation: 25812914/2705654 and 25412177/26911261 Based on interview and record review, the facility failed to provide an environment free of accident hazards for 2 (R1, R3) of 3 residents reviewed for accidents in the sample of 10. The findings include:1.R3's admission Record documented an admission date of 4/3/2025 and diagnoses including unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, bipolar disorder, current episode manic severe with psychotic features, schizoaffective disorder, bipolar type, other schizophrenia, unspecified asthma, uncomplicated, cerebral infarction, unspecified, other seizures, unspecified. R3's Minimum Data Set (MDS) dated [DATE], documented under section C- (cognitive patterns) C0100, No (resident is rarely/never understood) a BIMS (Brief Interview for Mental Status) not completed, indicating R3 was severely impaired cognition. This same document under section GG- Mobility documented that R3 is partial/moderate assistance, which means helper does less than half the effort. Helper lifts or holds trunk or limbs and provides less than half the effort for wheel 150 feet: once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. R3's Care plan documented a focus area of R3 having a risk for falls/injuries related to weakness, dementia, and poor safety awareness with an intervention of use proper assistive device (wheelchair/walker) as needed and cue/redirect as needed. This same document had a focus area documented R3 having cognitive loss as evidenced by BIMS Score less than 13, dementia diagnosis with an intervention of allow resident time to process thoughts. Do not rush resident or show impatience when they are making a decision and use a slow/unhurried manner with all care. On 1/15/2026 at 10:48 AM V8 (Physical Therapy Assistant/PTA) stated, R3 is receiving therapy services at this time related to previous falls. V8 stated, she is not aware of the fall events or investigation details for R3. V8 stated, any staff member assisting a resident by pushing them in a wheelchair, then the resident should have foot pedals in place. V8 stated, foot pedals can be adjusted to the side of the wheelchair when promoting self-propelling. On 1/15/2026 at 11:44 AM V10 (Certified Nurse Assistant/CNA) stated, on 11/28/2025 R3 had been self-propelling down the A hallway when she went to help her return to the nurse's station. V10 stated, R3 is known to go down that hallway to try to get in beds and she had been asked to go push her back to the nurse's station. V10 stated, she started to push R3 in her wheelchair back towards the nurse's station when one of R1's foot had got caught in the wheel of the chair causing her to fall forward out of the wheelchair, hitting her head on the floor and reopening the laceration to her forehead. V10 stated, R3 did not have any foot pedals on her wheelchair at the time she had been pushing her down the hall. On 1/15/2026 at 2:35 PM V2 (DON) stated, R3 had fallen from her wheelchair in the hallway on 11/28/2025 while being pushed in her wheelchair by V10 (CNA). V2 stated, R3 had put her feet on the ground while V10 had been pushing her causing R3 to fall out of her wheelchair. On 1/16/2026 at 9:54 AM V11(LPN) stated, she had been notified on 11/28/2025 while in the dining room that R3 had fallen from her wheelchair. V11 stated, R3 had been on A Hall when V10 (CNA) attempted to push her wheelchair back down the hallway. V11 stated, R3 is known to go down A Hall to try to get in another resident's bed. V11 stated, when V10 had been pushing R3 down the hallway, R3 put her feet down to stop V10 from going forward and R3 caught her foot in the wheelchair which caused her to fall forward out of the wheelchair and hitting the left side of her head on the floor. V11 stated, R3 did not have any feet pedals on her wheelchair at the time she had been assisted down the hallway by V10. V11 stated, staff should check feet position prior to pushing a resident in a wheelchair.R3's Progress Note dated 11/28/2025 at 12:15 PM by V11 (LPN) documented V10 (CNA) came to get her because R3 had been on the floor bleeding from her forehead and arm. V10 informed her that she had been pushing R3 to her room when R3's foot got stuck under the wheel causing R3 to fall forward. V10 stated that she attempted to catch R3, but it was too late. R3 reopened previous gash on left side of forehead 2cm by 1.5cm then got a skin tar on right elbow.The facility event report dated 11/28/2025 documented R3 got her foot caught in the front wheel while being pushed to hallway with R3 falling forward.On 1/16/2026 at 11:52 AM V15 (Director of Rehab) stated, R3 does require maximum verbal and tactile cues. V15 stated, she can become confused at times and her comprehension is very low.R3's Physical Therapy Evaluation & Plan of Treatment dated 1/4/2026 documented under Initial Assessment/Current Level of Function & Underlying Impairments, Functional Mobility Assessment: Resident uses a wheelchair and/or scooter? = Yes, Wheel 50 feet with two turns = Substantial/maximal assistance, Type of wheelchair or scooter used? = Manual, Wheel 150 feet = Substantial/maximal assistance Type of wheelchair or scooter used? = Manual. The facility policy Wheelchair Use, Safety and Position Policy (undated) documented under Policy Statement-The facility is committed to ensuring that all residents who use wheelchairs do so safely, comfortable, and in a manner that promotes independence, dignity and quality of life. Wheelchairs will be properly assessed, fitted, maintain, and used in accordance with resident-centered care principles and applicable regulations. This same document under Safe Use & Supervision documented staff will ensure proper foot placement on footrests, brakes are engaged during transfers, resident positioning is checked routinely, residents are not left in wheelchairs for prolong periods without repositioning and residents will be encouraged to mobilize and reposition independently when able. 2.R1's admission Record documented an admission date of 8/28/2025 and diagnoses including Cerebral infarction, unspecified-L frontal, chronic obstructive pulmonary disease, unspecified, acute bronchitis, unspecified, acute upper respiratory infection, unspecified, unspecified asthma, uncomplicated, essential (primary) hypertension, other seizures, major depressive disorder, single episode, unspecified, generalized anxiety disorder, primary osteoarthritis, left shoulder. R1's Minimum Data Set (MDS) dated [DATE], documented under section C- (cognitive patterns) a BIMS (Brief Interview for Mental Status) 14, indicating R1 was cognitively intact. This same document under section GG- Mobility documented that R1 required partial/moderate assistance, which means helper does less than half the effort. Helper lifts or holds trunk or limbs and provides less than half the effort. R1's Care Plan documented a focus area of R1 requires assistance with ADLs (Activity of Daily Living) related to weakness with an intervention follow occupational therapy, physical therapy, and speech therapy recommendations. This same document had a focus area of risk for falls and injuries related to weakness, need for assistance with ADLs with an intervention to observe for safety. On 1/15/2026 at 11:02 AM, V4 (LPN) stated, when she arrived to work on 12/15/2025, R1 had complaints of pain to her left shoulder area, with bruising noted and limited movement. V4 stated, R1 did tell her at that time she had fallen the week prior but was not sure if she had been on the toilet or ambulating towards the toilet.On 1/15/2026 at 11:44 AM V10 (CNA) stated, on 12/11/2025 in the evening R1 had put on her call light for assistance to the toilet. V10 stated, she did help R1 ambulate with walker to the bathroom. V10 stated, R1 had gotten off balance, which she does at times, so she grabbed R1's shirt and pants on her left side to help guide her to the floor. V10 stated, R1 had been sitting in the floor with her back against the bathroom door. V10 stated, her and V12 assisted R1 off the floor to the toilet and then back to her chair after using the bathroom.On 1/15/2026 at 1:52 PM V12 (CNA) stated, she did work the evening that R1 did have a fall event. V12 stated, she had been in another room when V10 (CNA) came to her and ask for assistant to get R1 up from the floor. V12 stated, R1 had been sitting in the floor in the bathroom with her back towards the door. V12 stated, she does not recall if R1 had a gait belt on during that time. V12 stated, she and V10 assisted R1 to the toilet and then back to her recliner.On 1/16/2026 at 9:03 AM V10 (CNA) stated, she did not use a gait belt during R1's transfer from her recliner to standing or while assisting her to ambulate to the toilet on 12/11/2025. On 1/16/2026 at 9:06 AM V8 (PTA) stated, she did have direct care with R1 in therapy services. V8 stated, R1 required partial/moderate assistant with self-care and mobility. V8 stated R1 had episodes of being unbalanced and falling backwards when ambulating. V8 stated, it is standard of practice for a gait belt to be used for all transfers and assistance with ambulating.R1's Progress Note dated 12/17/2025 at 9:26 AM by V4 (LPN) documented primary physician notified with new order for imaging to left shoulder. Resident is having uncontrolled pain and very little movement. New order urinalysis to rule out urinary tract infection. R1 is having some confusion. R1's Patient Report dated 12/17/2025 documented under Procedure: Left Shoulder, complete 2+ Views. This same documentation has documented by V18 (Nurse Practitioner) Left shoulder separation-please refer to ortho. May be old injury. Please apply a sling to left arm in the meantime. Arthritis also noted. On 1/16/2026 at 9:17 AM V2 (DON) stated, it is facility policy that a gait belt be in place during a transfer or assisting a resident with ambulating and her expectations would be that all staff follow this policy. On 1/16/2026 at 9:21 AM V1 (Administrator) stated, his expectations are staff to follow the facility policy and procedure for transferring/ambulating assistance with a resident, that included use of a gait belt, and all steps on the facility fall policy and procedure.On 1/16/2026 10:31 AM R1 stated, she did not have a gait belt on during her fall event while transferring or ambulating with assists of V10 (CNA) on 12/11/2025.The facility Gait Belt Use policy and procedure (dated July 2014) documented under Policy: It is the policy of the facility name that gait belts will be used when staff are transferring weight bearing residents or assisting them with walking for the safety of the resident or the employee.The facility Fall Management policy dated (April 21, 2022) documented under Definition: The definition of a fall refers to unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is observed on the floor, a fall is considered to have occurred.

Based on observation, interview and record review the Facility failed to perform safe turning and repositioning during care for 1 of 3 residents (R1) reviewed for falls in the sample of 3. Findings include:On 9/19/2025 at 10:02 AM, R1 was sitting in his wheelchair watching the television. R1's bed has low air mattress on it.R1's Minimum Data Set (MDS) dated [DATE] document R1 was cognitively intact for decision making of activities of daily living. R1 has impairments of one side on both his upper and lower extremities. R1 uses a wheelchair and needs substantial assistance with most activities of daily living. R1's Care Plan: start date of 11/15/2024 documents, Problem: Resident is at risk for falls and injuries r/t weakness, Parkinson's, left hip dislocation. 8/19/2025 fall from bed.On 9/18/2025 at 9:53 AM, R1 stated he remembered when he fell. He had just had a shower and the staff had put him on the bed but there was only one staff member, it was a male staff, and he rolled him because he was putting some cream on him and the staff was grabbing on to the strap under him because he is a (mechanical lift) and there are no bars on the bed except near the head and the staff rolled him too far and kept telling him to roll, which he did, and then he fell off the bed onto the floor.R1's Progress Notes dated 8/19/2025 at 10:45 AM, This nurse was called to room. Resident was turning to side of bed to get cream put on buttocks. Resident slid/fell off the side of the bed. Witnessed. No hitting of the head. fell on Lt (left) knee, an abrasion is visible. Resident is currently taking blood thinners. Sending to hospital for further checkup. R1's Safety Event Fall Report dated 8/19/2025 at 10:51 AM, Resident has low air mattress, resident was wet from shower. Made it slippery for resident to be able to roll to side. Resident slipped out of bed.On 9/18/2025 at 9:54 AM, V4, Licensed Practical Nurse (LPN) stated, (R1's) certified nursing assistant (V8) had just given him a shower and he likes special lotion and the (V8) was rolling him on his side to put lotion on him and he has an air mattress, and he was alone and when he rolled over, he fell off the bed. He is a (mechanical lift).On 9/18/2025 at 10:03 AM, V8, Certified Nursing Assistant (CNA) sated, I remember when (R1) fell I was giving care to him. I had just finished a shower with him and took him back to his room. He is a (mechanical lift), and I was putting cream on his butt and when I turned him over he turned over too far and he slipped off of the bed and onto the floor. Normally, when providing care, I was supposed to have another staff member with me. It was just me that time and we were so busy I provided the care by myself. I did not put anything down on the bed and he fell.On 9/18/2025 at 10:10 AM, V2, Director of Nursing stated, when a resident has a low air mattress because those things are tricky, I expect staff to put a blanket underneath them before laying them down, so they do not fall out. Staff failed to put the blanket down, and with the shower, and lotion he was slippery and slid off the air mattress. (R1) was sent out to the hospital but he did not have any fractures or serious injuries.The Facility Fall Policy with a revision date of July 2014 documents, It is the policy of (facility) to decrease the numbers of falls in the facility. The fall program is designed to facilitate recognition of residents that are at high risk for falls.

Based on observation, interview, and record review, the facility failed to provide proper supervision to prevent falls for 1 of 7 residents (R45) reviewed for supervision to prevent accidents in the sample of 28. Findings include: 1. R45's Face Sheet documents she was admitted on [DATE] with the diagnosis of Orthostatic Hypotension. On 6/23/24 at 9:30 AM R45 has purple bruises to her face around her left eye and a bruised purple underneath her right eye. R45 has purple linear bruises on her neck. R45 stated I had to pee, I thought I could do it, but I hadn't taken my Midrin and I got dizzy and fell from the commode. R45's Physician Order Sheet dated 1/17/24 documents STAT (immediate) cardio referral. R45's Administrative Note dated 1/17/24 documents Called (local) Cardio referring to STAT Cardio referral. Waiting for a call back to schedule appointment. Administrative Note, dated 1/25/24, documents Got in contact with (A local hospital) Cardiology regarding Cardio referral. Faxing all information over and office will review and contact R45 or myself (V11) to schedule an appointment. Phone: (office phone numbers and office fax numbers). R45's Nursing Note dated 1/27/24 documents Resident seen by NP (Nurse Practitioner) with new order Diclofenac gel 1% 4G to L knee 4 x (times) daily PRN (whenever necessary). Draw CBC (complete blood count), BMP (Basic metabolism Panel), lipid panel, vit (vitamin) D, A1C. Obtain orthostatic BP (blood Pressure) daily 3 days, send results. There was no documentation regarding the Cardiology referral. R45's Minimum Data Set (MDS) dated [DATE] documents for transferring R45 requires partial to moderate assist, and when going from sit to stand she is a substantial/maximal assistance. R45's Care Plan dated 1/27/24 documents Resident is at risk for falls due to weakness 1/27/2024 assisted to floor by nurse and 6/2/2024 fall in room. R45's Care Plan Interventions documented Order comprehensive medication review by pharmacist, assess for polypharmacy and medications that increase the fall risk which was created on 1/29/24. The following approaches documented 1/29/24, Assessment and treatment for postural/orthostatic hypotension; 1/29/24, Provide individualized toileting interventions based on needs/patterns; 1/29/24, Resident educated to use her call light and wait for staff assistance; 3/4/24, Falling star program initiated; 6/2/24, Send to ER evaluation as ordered; and 6/2/24, Resident to use her call light and ask for staff assistance when feeling dizzy. R45's Care Plan did not address R45's orthostatic hypotension and what approaches staff should use to address this problem. R45's Safety Events Event Report Fall and Investigation dated 1/27/24 documents resident fell this morning while transferring to BSC (Bedside Commode) This nurse was assisting resident to BSC and caught resident when she fell and assisted her to the ground no injury noted. R45's 6/2/24 Nurse's Note documents Res (resident) observed lying face down on bedroom floor with BSC (bedside commode) to R (right) of her. Res stated she became dizzy and fell forward off of BSC onto floor. Dark purple hematoma to L eye. Gait belt on place, gripper socks in place. Res c/o (complained of) of generalized discomfort. Transferred with 2 assist and gait belt back to BSC as resident requested. CNA (Certified Nursing Assistant) remained with resident. Writer notified PCP (Primary Care Physician) and called EMS (Emergency Medical Service) for transport to Local Hospital Emergency Department) r/t (related to) fall with hematoma to L eye and use of Eliquis & Plavix. Awaiting arrival of EMS. Report called to (Local Hospital Emergency Department) at this time. Awaiting EMS arrival. Nurses note dated 6/3/24 documents Resident returned from (Regional Teaching Hospital following fall with hematoma to L eye. Res was under observation during hospitalization . Returned via EMS with 2 attendants, transferred from stretcher to bed with 2 assists of EMS. Res A&O (Alert and Oriented) x4, able to make needs known. Res to f/u (follow up) with Ophthalmologist per discharge instructions. Plavix and Eliquis on hold x 5 days, then may resume. Discharge orders/instructions reviewed. Re-admission assessments completed. PCP Primary Care Physician notified of return. Will continue current POC (Plan of Care). R45's Safety Events Event Fall and Investigation dated 6/2/24 documents resident observed lying face down on bedroom floor with BSC to the right of her. Resident stated she became dizzy and fell forward off the BSC onto the floor. Dark purple hematoma to left eye gait belt in place gripper socks in place. Resident complained of generalized discomfort transferred with 2 assist and gait belt bake to BSC as resident requested Vital signs CNA (Certified Nurse's Assistant) remained with resident EMS (Emergency Medical System) transported to Local Hospital emergency room ) related to fall. R45's Physician Order Sheet dated 6/24/24 documents referral to cardiology r/t (related to) orthostatic hypertension. R45's Administrative Note dated 6/25/24 documents faxed cardiology referral to (local) Cardio. Will call office to f/u (follow up). Will notify resident, family, and physician. R45's Fall Risk assessment dated [DATE] documents R45 is a moderate risk for falls. On 6/25/24 at 3:16 PM V12 Physician stated, Maybe she became bradycardic I don't see that they could have done anything different if she asked for privacy. On 6/25/24 at 2:00PM V18 CNA stated, that morning she rang to get her on the commode. She is a two person assist. Me (V18) and (V19, CNA) got her on the commode. She likes her privacy, so I gave her the call light and left to go across the hallway to help another resident I heard all of the commotion. I heard later what happened. On 6/26/24 10:00 AM V2 Director of Nursing stated, If I know a resident had falls at home or has a high score on the John Hopkins fall assessment, we put them on the falling stars program. It just indicates the resident is high risk for falls. They called her back about the cardiology appointment and she declined. She likes to go out to eat but she does not like to leave the building. R45's Electronic Health Record was reviewed, and a refusal to go to cardiology was not documented. On 6/26/24 at 11:00 AM V5 Licensed Practical Nurse, LPN, stated, I entered the room. She (R45) was lying on the floor. I assessed her (R45), and she complained of generalized pain. Her (R45) vital signs were normal. She (R45) stated she got dizzy and fell from the bedside commode. Her eye was bruised, and she (R45) had a hematoma. No, I wouldn't expect the staff to stay with her if she asked for privacy. Yes, I did know she had Orthostatic Hypotension. We assisted her back to the bedside commode. We sent her out due to blood thinners. On 6/26/24 at 12:05 PM V19, CNA stated, I got her up and put her on the bedside commode. She (R45) asked me to give her, her phone, because she had to do number two. I gave her the call light and the telephone, and left the room, because she is alert and oriented. She stated she got dizzy and fell from the commode. Facility policy, updated July 2014, documents It is the policy of (the facility) to decrease the number of falls in the facility. The Fall Program is designed to facilitate recognition of residents that are at a high risk of falls. Residents will be placed in the Fall Program if their fall risk assessment identifies them at high risk, or if determined by the interdisciplinary team.

Based on observation, interview, and record review, the facility failed to store food in a manner that prevents foodborne illness. This has the potential to affect all 63 residents living in the Facility. Findings include: On 8/15/23 at 8:07 AM, in the walk-in refrigerator, there was a pitcher containing brown liquid labeled tea and 8/1/23. There was a cart with one tray of individual cups of fruit and three trays with individual cups of dessert. Each tray was covered with another tray, and none were labeled or dated. There was a bag of crumbled sausage that was previously opened and tied up in a knot but was not labeled or dated. There were three bags of shredded cheese that were previously opened and resealed but were not dated. On 8/15/23 at 8:09 AM, in the standing freezer, there was a plastic bag containing yellow, crescent shaped items that was previously opened and resealed, but was not dated or labeled. There was a plastic bag of meat patties with no date or label. V8 (Cook) stated the items in the bags were omelets and hamburgers. On 8/15/23 at 8:11 AM, there were boxes stacked directly on the floor in the storeroom. The first stack was comprised of two boxes of chips. The second stack included pizza sauce, spaghetti sauce, baked beans, cranberry juice, and apple juice. V8 (Cook) stated the boxes just came last night. In the storeroom, there were also four clear bins with oats, thickener, sugar, and flour that were labeled but were not dated. On 8/15/23 at 8:14 AM, in the standing freezer in the storeroom, there were four bags of breaded meat strips that were not labeled or dated. There was a plastic bag of chocolate chip cookie dough inside a cardboard box. The bag was previously opened, but not resealed. The contents were open to air, and package was not dated upon opening. There was an opened plastic bag of buns that was not resealed, labeled, or dated. There was a plastic bag of cinnamon rolls, a bag of breadsticks, and a bag of egg rolls that were all opened and tied up but were not labeled or dated. On 8/15/23 at 8:21 AM, on the tray line there were four clear tubs of dry cereal that were labeled but not dated. On 8/15/23 at 9:23 AM, the refrigerator in the dining room contained four slices of pizza inside a plastic bag with no label or date. On 8/15/23 at 9:24 AM, the entire ice scoop, including handle, was inside the cooler on the beverage cart in the dining room. On 8/18/23 at 8:37 AM, V3 (Assistant Director of Nursing/ADON) stated she expects food service staff to follow their policies and label and date all items. The Facility's Food and Supply Storage Policy revised January 2012 documents, Food and supply storage areas shall be maintained in a clean, safe, and sanitary manner. Food and supplies will be stored six (6) inches above the floor on clean racks or shelves and at least eighteen (18) inched from sprinkler heads. All foods will be covered, labeled, and dated. The Facility's Resident Census and Conditions of Residents Form (CMS 672) dated 8/15/23 documents there are 63 residents living in the Facility.

Based on interview and record review, the facility failed to answer call lights and address resident's needs in a timely manner for 4 of 4 residents (R9, R29, R30, and R52) reviewed for dignity in the sample of 37. Findings include: On 8/16/23 at 12:38 PM, during the Group Resident Council Meeting, R9, R29, R30, and R52 all stated it often takes more than an hour to get help, especially around bedtime. R9's Minimum Data Set (MDS) dated [DATE] documented R9 was cognitively intact. R29's MDS dated [DATE] documented R29 was moderately cognitively impaired. R30's MDS dated [DATE] documented R30 was cognitively intact. R52's MDS dated [DATE] documented R52 was moderately cognitively impaired. On 8/17/23 at 12:21 PM, V10 (Certified Nurse Aide/CNA), stated sometimes residents have to wait a while for assistance. On 8/17/23 at 12:24 PM, V11 (Licensed Practical Nurse/LPN), stated each hallway could use an extra CNA to help out with call lights. On 8/17/23 at 12:26 PM, V12 (Certified Nurse Aide/CNA) stated, I'm a little preoccupied right now. I've got somebody in bed trying to get them on the bed pan, and I'm helping with a transfer, and somebody else needs to get in the shower. On 8/27/23 at 12:28 PM, V4 9 Certified Nurse Aide/CNA) stated, I've had residents crying because it takes so long for us to help them, and it's not fair for them to wait 45 minutes to use the bathroom or whatever it is they need to do. On 8/16/23 at 1:57 PM, V9 (CNA Scheduler) stated sometimes there is no CNA on A Hall, so the nurses on B and C Halls have to split up A Hall. The Facility's Resident Council Meeting Minutes dated 8/24/22 documents, Residents stating takes 40 plus minutes to have call light answered to use toilet. (More than 2 residents reported this.) The Facility's Resident Council Meeting Minutes dated 10/21/22 document, Residents state that they are having slow response to answering call lights. The Facility's Resident Council Meeting Minutes dated 11/21/22 document, Lack of availability to respond to call lights, getting meals timely, environment cleaned, etc. On 8/18/23 at 9:32 AM, V3 (Assistant Director of Nursing/ADON) stated she expects staff to answer call lights as promptly as possible. The Facility's Call Light Policy, undated, documents, The facility will have all call lights in working order. These call lights will be accessible to the residents and will be answered promptly by staff. All nursing personnel must be aware of call lights at all times. Answer ALL call lights promptly whether or not you are assigned to the resident. Answer all call lights in a prompt, calm, courteous manner.

Based on interview and record review, the facility failed to provide sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of 4 of 4 residents (R9, R29, R30, and R52) reviewed for staffing in the sample of 37. Findings include: On 8/16/23 at 12:38 PM, during the Group Resident Council Meeting, R9, R29, R30, and R52 all stated nurse aid staffing has become a problem. They stated it often takes more than an hour to get help, especially around bedtime. R9's Minimum Data Set (MDS) dated [DATE] documented R9 was cognitively intact. R29's MDS dated [DATE] documented R29 was moderately cognitively impaired. R30's MDS dated [DATE] documented R30 was cognitively intact. R52's MDS dated [DATE] documented R52 was moderately cognitively impaired. On 8/17/23 at 12:21 PM, V10 (Certified Nurse Aide/CNA) stated she was assigned to C Hall but was helping out with a resident on A Hall. She stated sometimes residents have to wait a while for help due to CNA staffing. On 8/17/23 at 12:24 PM, V11 (Licensed Practical Nurse/LPN) stated each hallway could use an extra CNA to help out with things like showers and call lights. On 8/17/23 at 12:26 PM, V12 (CNA) stated, I'm a little preoccupied right now. I've got somebody in bed trying to get them on the bed pan, and I'm helping with a transfer, and somebody else needs to get in the shower. On 8/27/23 at 12:28 PM, V4 (CNA) stated weekend staffing is atrocious. She stated CNAs get residents up and ready, take them to the dining room, help serve and feed them, then clean them up and put them in bed or take them to activities or whatever they want to do. V4 stated the hallways have four or five showers to be given each morning on top of everything else. She stated, I've had residents crying, because it takes so long for us to help them, and it's not fair for them to wait 45 minutes to use the bathroom or whatever it is they need to do. V13 (CNA) agreed that the facility needs more CNAs. On 8/16/23 at 1:57 PM, V9 (CNA Scheduler) stated typically there is one CNA on A Hall and two CNAs on B and C Halls, but sometimes there is no CNA on A Hall so the nurses on B and C Halls have to take A Hall and split it. On 8/17/23 at 9:44 AM, V1 (Administrator) stated the facility meets minimum staffing requirements, but the residents want more staff, and that has been ongoing. The Facility's Resident Council Meeting Minutes dated 8/24/22 documents, Residents stating takes 40 plus minutes to have call light answered to use toilet. (More than 2 residents reported this.) The Facility's Resident Council Meeting Minutes dated 10/21/22 document, Residents state that they are having slow response to answering call lights. The Facility's Resident Council Meeting Minutes dated 11/21/22 document, Residents feel that staffing shortages are affecting quality of care. Lack of availability to respond to call lights, getting meals timely, environment cleaned, etc. On 8/18/23 at 9:32 AM, V3 (Assistant Director of Nursing/ADON) stated she expects staff to answer call lights as promptly as possible. The Facility's Staffing Policy revised 7/2019 documents, Our facility provides adequate staffing to meet needed care and services for our resident population. Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan.

Based on interview and record review, the facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use in 5 of 5 residents (R5, R16, R35, R50, and R217) reviewed for antibiotic stewardship in the sample of 37. Findings include: 1. The Facility's Infection Tracker documents R50's 6/29/23 onset infection type as Prophylaxis. R50's Order History documents order for Trimethoprim tablet; 100 mg (milligrams); Take one tablet by mouth at bedtime for long term abx (antibiotics) for tx (treatment) of frequent UTI (Urinary Tract Infection) with start date of 4/1/22 and end date of 8/15/23. R50's Medication Administrator Record (MAR) for the months of May 2023 through August 2023 document R50 received 106 doses of Trimethoprim. R50's Progress Note dated 7/28/23 at 2:44 PM documents, This nurse informed NP (Nurse Practitioner) of resident long-term use of antibiotic for history of UTI (Urinary Tract Infection). At this time, NP wants to continue and let hospice address. Waiting callback from hospice. R50's Progress Note dated 8/11/23 at 3:01 PM documents, This nurse called hospice in regarding long-term antibiotic use. awaiting callback. On 8/17/23 at 8:40 AM, V3 (Assistant Director of Nursing/ADON and Infection Control Preventionist/ICP) stated R50 was on Trimethoprim prior to admission, and the Facility does not have a culture. On 8/18/23 at 8:37 AM, V3 stated she expects the Facility to obtain a culture for any residents receiving antibiotics to treat urinary infections. 44953 2. R5's Face Sheet undated documents diagnosis as Enterocolitis due to Clostridium difficile, recurrent. R5's Minimum Data Set (MDS) dated [DATE] documents R5 is cognitively intact is occasionally of bladder, frequently incontinent of bowel, is not on a bowel or bladder training program. R5's MDS documents antibiotics are documented as a medication that R5 received in past 6 days. R5's Physician Order Report undated documents orders Dificid (fidaxomicin) tablet 200 milligram (mg), 1 tab twice a day for 11 days. Start date 5/27/23 and End date 6/7/23. Cephalexin 500 milligram (mg) capsule 1 tab four times a day. Start date 5/27/23 and End date 6/3/23; Vancomycin 125 mg tablet every 6 hours (four times a day) for 14 days. Start date 6/22/23 and End date 7/6/23; Vancomycin 125 mg tablet, twice a day for 7 days. Start date 7/7/23 and End date 7/14/23; Vancomycin 125 mg tablet, once a day for 7 days. Start date 7/15/23 and End date 7/22/23 and Vancomycin 125 mg tablet, 1 tablet every other day for 28 days. Start date 7/23/23 and End date 8/16/23. R5's electronic Medication Administration Record (eMAR) dated 01/01/23-01/31/23 documents R5 received 8 out of 8 doses of 500mg of Levofloxacin with a Start date 1/10/23 and End date 1/17/23. R5's (eMAR) dated 03/01/23-03/31/23 documents R5 received 18 out of 18 doses of 500 mg of Cephalexin three times a day with a Start date 03/26/23 and End date 04/01/23. R5's (eMAR) dated 04/01/23-04/30/23 documents R5 received 3 out of 3 doses of 875-125 mg of Amoxicillin-pot Clavulanate with a Start date 04/14/23 and End date 04/15/23. R5's (eMAR) dated 04/01/23-04/30/23 documents R5 received 18 out of 18 doses of 875-125 mg of Amoxicillin-pot Clavulanate with a Start date 04/15/23 and End date 04/23/23. R5's (eMAR) dated 04/01/23-04/30/23 documents R5 received 3 out of 3 doses of 500 mg Cephalexin with a Start date 03/36/23 and End date 04/01/23. R5's (eMAR) dated 05/01/23-05/31/23 documents R5 received 4 out of 4 doses of 500 mg Cephalexin with a Start date 05/21/23 and End date 05/22/23. R5's (eMAR) dated 05/01/23-05/31/23 documents R5 received 18 out of 18 doses of 500 mg Cephalexin with a Start date 05/27/23 and End date 06/03/23. R5's (eMAR) dated 05/01/23-05/31/23 documents R5 received 4 out of 4 doses of 200 mg Dificid (fidaxomicin) with a Start date 05/27/23 and End date 06/07/23. R5's (eMAR) dated 05/01/23-05/31/23 documents R5 received 1 out of 1 dose of 1-gram Ertapenem injection (administer 1,000 mg-3.57 mL) with a Start date 05/27/23 and End date 05/28/23. R5's (eMAR) dated 05/01/23-05/31/23 documents R5 received 3 out of 3 doses of 1-gram Ertapenem injection (administer 1,000 mg-3.57 mL) daily for 4 days with a Start date 05/28/23 and End date 05/30/23. R5's (eMAR) dated 05/01/23-05/31/23 documents R5 received 3 out of 3 doses of 100 mg Macrobid (Nitrofurantoin) twice a day with a Start date 05/23/23 and End date 05/27/23 (DC date). R5's (eMAR) dated 07/01/23-07/31/23 documents R5 received 16 out of 16 doses of 125 mg Vancomycin for seven days with a Start date 07/07/23 and End date 07/14/23. R5's (eMAR) dated 07/01/23-07/31/23 documents R5 received 13 out of 14 doses of 125 mg Vancomycin capsule for 7 days with a Start date 07/15/23 and End date 07/22/23. R5's (eMAR) dated 07/01/23-07/31/23 documents R5 received 12 out of 12 doses of 125 mg Vancomycin capsule four times a day with a Start date 06/22/23 and End date 07/06/23. R5's Urinalysis collected 6/21/23 documented the presence Toxigenic C. difficile DNA detected (Positive). R5's Urinalysis dated 7/25/23 did not document the presence of any organisms and collection of another sample was requested due to possible contamination. R5's Urinalysis dated 7/28/23 did not document the presence of any organisms. On 8/18/23 at 12:35 PM, V3 (Assistant Director of Nursing/Infection Control Preventionist-ADON/ICPC) stated the doctor has begun a taper of the antibiotics. Efforts have been made to encourage providers to adhere to the Antibiotic Stewardship Program. R5 is currently not experiencing any loose stools but remain on isolation. 3. R16's Face Sheet undated documents a pertinent diagnosis as a personal history of Urinary Tract Infections. R16's MDS dated [DATE] documents R16 has moderate cognitive impairment is frequently incontinent of bowel and bladder, is not on a bowel or bladder training program. Antibiotics are not documented as a medication that R16 received in past 7 days. R16's Physician Order Report dated 06/01/2022-08/18/2023 documents orders for antibiotics: sulfamethoxazole-trimethoprim 400-80 mg, 1 tablet once a day on Monday, Wednesday and Friday (order on hold from 4/24/23 to 5/02/2023) Start date: 06/09/2022- End date: Open Ended; Vibramycin (doxycycline hyclate) 100 mg capsule, 1 tablet, twice a day for 3 days, Start date: 07/11/2022- End date 07/14/2022; Vibramycin (doxycycline hyclate) 100 mg capsule, 1 tablet, twice a day. Start date: 12/13/2022- End date 12/20/2022; Azithromycin 500 mg, 1 tablet once a day. Start date: 4/18/2023-End date: 4/20/2023; Bactrim DS (sulfamethoxazole-trimethoprim) 800-160 mg, 1 tablet twice a day x 7 days, Start date: 4/24/2023- End date- 5/01/23. R16's eMAR dated 01/01/2023-01/31/2023 documents R16 received 13 out of 13 doses of sulfamethoxazole-trimethoprim. R16's eMAR dated 02/01/2023-02/28/2023 documents R16 received 12 out of 12 doses of sulfamethoxazole-trimethoprim. R16's eMAR dated 03/01/2023-03/31/2023 documents R16 received 14 out of 14 doses of sulfamethoxazole-trimethoprim. R16's eMAR dated 04/01/2023-04/30/2023 documents R16 received 9 out of 9 doses of sulfamethoxazole-trimethoprim (order on HOLD from 4/24/23-5/2/23). R16's eMAR dated 05/01/2023-05/31/2023 documents R16 received 13 out of 13 doses of sulfamethoxazole-trimethoprim. R16's eMAR dated 06/01/2023-06/30/2023 documents R16 received 13 out of 13 doses of sulfamethoxazole-trimethoprim. R16's eMAR dated 07/01/23-07/31/2023 documents R16 received 13 out of 13 doses of sulfamethoxazole-trimethoprim. R16's eMAR dated 08/01/23-08/18/2023 documents R16 received 8 out of 8 doses of sulfamethoxazole-trimethoprim. R16 urinalysis specimen collected 4/21/23 was positive for the organism proteus mirabilis and was resistive to the drug sulfamethoxazole-trimethoprim. R16's Nurse's Progress Notes dated 07/28/2023 04:58 PM documents discuss long-term use of Bactrim DS antibiotic with Nurse Practitioner (NP). Resident takes medication for personal history of UTI and at this time the NP wants to keep this drug regimen related to it has decreased hospitalization s and has improved quality of life and patient is therapeutic at this time. On 8/18/23 at 10:30 AM, R16 stated she was on long-term antibiotics because of her getting a lot of urinary tract infections (UTIs). 4. R35's Face sheet undated documents pertinent diagnosis as history of Urinary Tract Infections (UTIs), and Neuromuscular Dysfunction of Bladder, Unspecified. R35's MDS dated ,d+[DATE] documents R35 is cognitively intact, has an indwelling catheter, urinary incontinence was not rated but R35 is frequently incontinent of bowel, is not on a bowel or bladder training program. R35's MDS documents antibiotics are documented as a medication that R16 received in past 7 days. R35's Physician Order Summary dated 07/01/2022-08/18/2023 documents physician orders for Amoxicillin-Potassium Clavulanate 875-125 mg, 1 tablet twice a day Start date: 1/20/23- End date 1/20/23 (DC date); Amoxicillin-Potassium Clavulanate 875-125 mg 1 tab twice a day, start date: 1/21/23- End date: 1/28/23; Sulfamethoxazole-trimethoprim 800-160 mg, 1 tab twice a day, Start date 6/26/23-7/8/23. UA with C&S if indicated, once 6/6/23-6/6/23; UA with C&S if indicated, once 6/14/23. R35's eMAR dated 01/01/2023-01/31/2023 documents R35 received 1 out 1 dose of Amoxicillin-Potassium Clavulanate 875-125 mg. Start Date:1/20/23- End Date: 1/21/23 (DC Date) R35's eMAR dated 01/01/2023-01/31/2023 documents R35 received 15 out 16 doses of Amoxicillin-Potassium Clavulanate 875-125 mg. Start Date:1/21/23- End Date: 1/28/23. R35's eMAR dated 06/01/2023-06/30/2023 documents R35 received 10 out of 10 doses of Bactrim DS (sulfamethoxazole-trimethoprim) 800-160 mg. Start Date: 06/26/23- End Date: 07/06/23. R35's eMAR dated 07/01/2023-07/31/2023 documents R35 received 12 out of 12 doses of Bactrim DS (sulfamethoxazole-trimethoprim) 800-160 mg. Start Date: 06/26/23- End Date: 07/06/23. R35's eMAR dated 08/01/2023-08/18/2023 documents R35 received 17 out of 18 doses Bactrim DS (sulfamethoxazole-trimethoprim) 800-160 mg. Start Date: 07/08/23- End Date: Open Ended R35's urinalysis specimen collected 6/21/23 was positive for 2 organisms ((1) Escherichia Coli and (2) Proteus Mirabilis. Bactrim DS (sulfamethoxazole-trimethoprim) was sensitive to both organisms. R35's Nurse Progress notes dated 7/7/23 documents R35 will be started on Bactrim DS long-term daily related to re-current urinary tract infections. On 8/18/23 at 12:35 PM, V3 stated R35 is on hospice and hospice has stopped all lab work and testing. 5. R217's Face Sheet undated documents pertinent diagnosis as Obstructive and Reflux Uropathy and history of Urinary Tract Infections. R217's Minimum Data Set (MDS) dated [DATE] documents Cognitive Skills for Daily Decision Making is moderately impaired. R17 has an indwelling catheter and is frequently incontinent of bowel. R217 is not on a bowel or bladder toileting program. Antibiotics are documented as a medication that R217 received in past 6 days. R217's Physician Order Summary dated 06/01/2023-06/30/2023 documents orders for Macrobid (nitrofurantoin monohydrate-macrocrystalline) 100 mg capsule once a day. Start date: 6/24/2023- Open Ended. R217's eMAR dated June 2023 documents 7 out of 7 doses of Macrobid 100 mg. Start date: 6/24/23 -open ended. R217's eMAR dated July 2023 documents 1 out of 1 dose of Macrobid 100 mg. Start date: 6/24/23-open ended. On 8/18/23 at 12:39 PM, V3 stated R217 was placed for respite stay. V3 stated R217 was unable to talk and walk and required total care. V3 stated R217 arrived on antibiotics for frequent Urinary Tract Infections (UTIs) and was under Hospice care. The Facility's Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes revised October 2017 documents, Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. Therapy may require further review and possible changes if: (1) The organism is not susceptible to the antibiotic chosen; (2) The organism is susceptible to narrower spectrum antibiotic; (3) Therapy was ordered for prolonged surgical prophylaxis; or (4) Therapy was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include a. Resident name and medical record number; b. Unit and room number; c. Date symptoms appeared; d. Name of antibiotic (see approved surveillance list); e. Start date of antibiotic; f. Pathogen identified (see approved surveillance list); g. Site of infection; h. Date of culture; i. Stop date; j. Total days of therapy; k. Outcome; and l. Adverse events.

Based on observation, interview, and record review, the facility failed to provide distilled water and cleaning for Continuous Positive Airway Pressure (CPAP) machines for 2 of 2 residents (R2, R25) reviewed for respiratory therapy in the sample of 37. Findings include: R2's Physician Order Sheet (POS) dated 3/8/23 documents CPAP home setting with 2 liters of oxygen bled into CPAP apply at HS (Bedtime) remove upon rising. R2's Care plan dated 6/22/23 and revised on 8/2/23 documents resident (R2) will have an effective respiratory rate and depth and rhythm. R2's Care Plan intervention is assessing signs of ineffective breathing. The CPAP Care Plan does not document the cleaning of the CPAP machine or the changing of the filters. R2's July and August 2023 Medication Administration Record (MAR) documents CPAP at home setting with 2L 02 bled into CPAP twice a day apply at HS and remove upon rising. This MAR did not document cleaning of the CPAP machine. On 8/17/23 at 9:50 AM, V3 (Assistant Director of Nursing/ADON) stated the CPAP was not found on the treatment sheet, but it is found on the MAR. On 8/17/23 at 11:00 AM, R2's (Company name) CPAP machine was on his nightstand. The CPAP machine was on and running. V12 (Certified Nursing Assistant/CNA) turned it off when it was brought to her attention. The (CPAP Company's) Website dated 2021 documents R2's CPAP machine had been recalled due a defective foam. 08/17/23 10:21 AM, V15 (Registered Nurse/RN) and V11 LPN (Licensed Practical Nurse) both stated they think the night should be cleaning R2's CPAP machine. They both noted it comes up on the MAR to put the water in and place it. V15 (RN) also stated, The family comes in to clean the machines. Although we shouldn't rely on them. On 08/17/23 12:04 PM, V16 (R2's Power of Attorney/POA) stated, I've been bringing in the water (distilled) because they (the facility) want 6 dollars a gallon. I've been cleaning his machine. On 08/18/23 at 2:00 PM, V3 (ADON) stated, I called the family about the recall, and they stated the company sent out a new machine, but they didn't like it and instead sent the old machine to the facility. The family will bring out the new machine. V3 (ADON) stated, I talked with the family and let them know that we will now supply water and clean the machine. The (CPAP Company) User Manual dated 2018, which states, Rinse the blue pollen filter at least every two weeks and replace with a new one every six months. The disposable light blue filter should be replaced after 30 months. The tubing and mask adapter should be washed with warm water and liquid dish soap before the first use and daily. 2. R25's POS dated 4/24/23 documents CPAP at HS (hour of sleep) at home setting, apply at HS, and remove upon rising bleed 2L 02 into CPAP. R25's Progress Note dated 1/18/23 documents Family in office at this time upset that resident does not have distilled water for her CPAP. Aggressive with V20 (CNA) telling her that she will not leave until V20 (CNA) brings distilled water to her. CNA told family member we do not have distilled water for CPAP, and she requested to speak with myself (V21-ADON). Discussed with family that if we are to supply distilled water, we will have to order from (Supply Company), and it is $18 for 6 gallons to be billed to family. Stated understanding and took my card and said she would discuss with family and let me know if they want us to supply the distilled water. Will follow up with family. On 8/17/23 at 10:00 AM, V17 (R25's POA) stated, We bring in the distilled water, because the facility wants to charge us 6 dollars a gallon for the water. I bring in a vinegar solution to clean the machine, but I doubt they are cleaning the machine. R25's CPAP Care Plan dated 12/16/22 and revised 7/26/23 documents goal the resident will state feeling rested her (R25) intervention or approach is assure CPAP is applied and in working order. (This CPAP Care Plan does not document cleaning of the CPAP or changing of the filters.) The undated (R25's CPAP Company) Clinical Guide documents empty the humidifier tub and wipe it thoroughly with a clean disposable cloth. Allow it to dry out of direct sunlight. refill the humidifier tub with distilled water daily. Weekly wash the components using one of the following options: wash the humidifier tub, air tubing, and outlet connector with warm water using a household dishwashing liquid. The air tubing should not be washed in temperatures higher than 149 Fahrenheit or wash the humidifier and outlet connector in a solution of 1 part vinegar and 9 parts water wash the air tubing in warm water using a household dishwashing liquid. the air tubing should not be washed in temperatures higher than 149 Fahrenheit. rinse each component thoroughly in water and allow to dry out of direct sunlight and heat. wipe the exterior of the device with a dry cloth. The air filter is not washable or reusable. The facility policy entitled CPAP Support dated July 2014 documents To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. To improve arterial oxygenation in residents with respiratory insufficiency, obstructive to sleep apnea or restrictive/obstructive lung disease.

Based on interview and record review, the facility failed to provide consecutive 8 hour Registered Nurse (RN) coverage daily in the facility. This has the potential to affect all 64 residents in the facility. Findings include: On 7/12/2023 at 3:00 PM, the Nursing Working staffing schedule from 6/1/23 through 7/10/23 was reviewed with V2, Director of Nurses and V3, Staffing Coordinator. There was no consecutive 8-hour RN coverage in 24 hours in the Month June 2023 for the following dates: 6/3, 6/6, 6/8, 6/17, and 6/18. There was no consecutive 8-hour RN coverage in 24 hours in the Month July 2023 for the following dates: 7/1, 7/8, and 7/9. On 7/10/2023 at 9:45 AM V2 stated that the facility has had some staffing problems but no more than anyone else. V2 stated that the weekends are where they struggle. V2 stated that they had call offs on the weekend. V2 stated that if they don't have enough staff the management staff works the floor. On 7/12/2023 at 3:00 PM V3 stated that there was not RN coverage on 6/3, 6/6, 6/8, 6/17, 6/18/2023, 7/1, 7/8, and 7/9/2023. On 7/10/2023 at 9:38 AM V1, Administrator, stated that the census in the facility was 64. The facility's Staffing Policy, dated 7/2019, documents Our facility provides adequate staffing to meet needed care and services for our resident population. 1. Our facility maintains adequate staffing on each shift to ensure that our resident's needs as services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services.

Based on record review and interview, the facility failed to ensure a 2-person assist when providing bathing and bed mobility and preventing fall for one of 4 residents (R2) reviewed for accidents and supervision. This failure resulted in R2's fall and was transferred to a local hospital after sustaining multiple skin tears to left upper arm, left lower leg and right neck, ecchymosis on the right neck, left hand and forearm. Findings include: R2's Minimum Data Set, (MDS), dated [DATE] documents R2's cognitive skills for daily decision making is moderately impaired. R2 requires extensive assistance 2-person assist in bed mobility, transferring and bathing. No fall history documented. R2's Physician Order Sheet, (POS), dated 3/6/23-3/17/23 documents pertinent diagnoses as Age-related cognitive decline, Unsteadiness on feet, Difficulty in walking, not elsewhere classified and History of falling. R2's Care Plan dated 10/27/22 documents, R2 is at risk for falls related to glaucoma. Personal history of falls, Diabetes Mellitus, and weakness. 3/17/2023-witnessed fall out of bed with injury Interventions: 3/17/2023 documents R2 was sent to ER for evaluation; Observe for safety; Invite/escort to activities of choice as tolerated as desired; Rest periods as needed; Cues/redirect as needed, use proper assistive device wheelchair/walker as needed; Proper footwear as indicated; Clutter free environment; Call light within reach while in room and remind resident to call for assistance as needed. R2's Fall Risk assessment dated [DATE], documents R2 is High Risk for Falls. R2's Fall Investigation dated 3/17/23 documents, while CNA was attempting to change resident, she reached over to grab the (Brand) incontinence underwear, and the resident, continued to roll out of the bed. The resident hit her head on the dresser next to bed. R2's face, arm, and leg have skin tears. Bruising and pain noted. R2's medical records, dated 3/17/23, documents that R2 presented to a local hospital after a fall from bed unwitnessed at nursing home. Patient found on floor by staff wedged between bed and wall, Unknown if there was a loss of consciousness, (LOC). Has multiple skin tears: Left upper arm, left lower leg and right neck, has ecchymosis right neck, left hand and forearm. Patient is poor historian and oriented x 1. Brought to ER by EMS who provided history. All vital signs within normal limits except blood pressure which was 199/111 at 7:10 AM, at 8:00 BP was 157/65. Physical exam revealed- Mucous: Extremity Left Upper Extremity, (LUKE), with flexion deformity elbow, Contracture left fingers, multiple areas of chamois left elbow/forearm/hand with soft tissue swelling, (sts), neurovascular intact. No pelvic tenderness to palpitation, (ttp), or instability. Hips partially flexed and knees flexed. Unable to fully extend. No leg length discrepancy noted. NF intact lower extremities. Large skin tear distal upper arm and partially avulsed, (torn flap of skin). Left lower extremity, (LLE), with anterior skin tear with partially avulsed skin. 5 x 5 cm skin tear with avulsed skin right lateral neck with surrounding ecchymosis, no hematoma appreciated. Neurological: Oriented x1, repeated What are you doing to me? Speech is clear and fluent. Does not initiate conversation. Does not answer questions. Able to move extremities although has limit contractions. Psychiatric: Patient is uncomfortable and aggravated with any questions or examinations. She was upset while cleaning wounds and changing positions. 3/17/23 X-ray, (XR), elbow Left, (LT), Exam XR hand LT, XR elbow LT, XR humerus LT Min, XR forearm LT, CT Head without Contrast and XR Chest documents some arthritic, ground glass opacity in the right upper lobe, and degenerative disease but there were no fractures or intracranial hemorrhage, midline shift or mass present. There was fecal impaction. Summary: Discussed findings with POA, her daughter. She declines cervical collar and spine surgery follow-up for her mother. She states that her mother would not tolerate it and it would make her uncomfortable. She instead wants comfort care and would contact hospice. R2 was returned to nursing home. V18 (Certified Nursing Assistant/CNA), stated she was reaching for a diaper when R2 fell out of bed. It was just a fluke, because R2 normally does not move without assistance or physical guidance. R2 is a 2-person assist, but to change her in bed can be accomplished by 1 person. The Facility policy Fall Management dated July 2017 documents it is the facility's policy to assess and manage resident falls through prevention, investigation, and implementation and evaluation of interventions.

Based on interview and record review, the facility failed to assess, monitor, and provide treatment to prevent the development of pressure ulcers for 1 of 4 residents (R2) reviewed for pressure ulcers in the sample of 12. This failure resulted in R2 developing a Stage IV pressure ulcer and being admitted to the hospital with a diagnosis of Osteomyelitis. The Immediate Jeopardy began on 12/14/22 when due to the facility's failure to assess and monitor and provide progressive treatment, R2 developed excoriated buttocks. R2's excoriation worsened without progressive treatment and R2 developed osteomyelitis, and an unstageable pressure ulcer which required hospitalization and surgical debridement. V1 (Administrator), V2 (Director of Nursing/DON) and V3 (Assistant Director of Nursing/ADON) were notified of the Immediate Jeopardy on 1/17/23 at 3:20 PM. The Immediate Jeopardy was removed on 01/18/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R2's Face Sheet, undated, documents R2 was admitted to the facility on [DATE] and had diagnoses of chronic kidney disease, stage 3, Obstructive and reflux Uropathy, Retention of urine, Type II diabetes Mellitus with diabetic Chronic Kidney disease, Pressure Ulcer of left buttock, stage 3, and need for assistance with personal care. R2's Minimum Data Set (MDS), dated [DATE], documents R2 is cognitively intact and requires extensive assistance, 2 plus person physical assist with bed mobility. It also documents R2 is total dependence, 2 plus person physical assist with toilet use and bathing. R2's MDS documents R2 has an indwelling catheter and is always incontinent of bowel. It documents R2 is at risk for developing pressure ulcers/injuries. It further documents R2 has no skin issues. R2's Care Plan, undated, documents Problem start date: 06/01/22, R2 is at risk for pressure ulcers/skin breakdown r/t (related to) incontinence. On 12/30/22, R2's Care Plan was updated and documents 12/14/22, Excoriation to bilateral buttocks noted, and Triad cream as ordered for protection. Do weekly skin checks, notify family and MD (Medical Doctor) of any new skin issues. On 01/03/23, R2's Care Plan was updated and documents R2 has an unstageable pressure ulcer to his coccyx. R2's Physician's Orders, dated 06/04/22, documents apply Triad Cream to buttocks every shift and PRN (as needed). R2's Progress notes, dated 07/29/2022 at 4:50 PM, documents Resident seen by V19 (Wound Care Physician), the new wound Dr (doctor), for treatment to the coccyx. The order is for Silvadene, antifungal and Maalox every shift. R2's Initial Wound Evaluation & Management Summary, dated 07/30/22, documents Stage 3 Pressure Wound of the left buttock. R2's Physician's Orders, start date of 08/01/2022, documents Cleanse with NS (normal saline), apply Silvadene, calcium alginate, collagen powder and a dry dressing to left buttocks once daily for 30 days. R2's Wound Evaluation & Management Summaries, dated 08/19/22 and 8/26/22, documents R2 had a Stage 3 Pressure Wound of the left buttock, which was improving and healed. R2's Electronic Medical Record, had no documentation R2 had any pressure ulcers /injuries from 9/12/22 through 12/8/22. Skin Observation Information in R2's Electronic Medical record, dated 12/08/22 at 12:16 AM, documents excoriated buttocks. There was no documentation in R2's medical record that V8 (Medical Doctor/MD), or V12 (Nurse Practitioner/NP), were notified of R2's excoriated buttocks. R2's Progress Notes, dated 12/14/22 at 12:47 AM, written by V21 (Licensed Practical Nurse/LPN), documents Night nurse went into resident's room to look at buttocks due to concern noted by hall aide. Nurse examined resident's skin and saw there were 2 prominent areas on both L (Left) & R (Right) buttock that were excoriated. Redness also covered both of resident's buttocks. (Brand type) skin protectant/barrier cream, applied and note left for wound nurse. Will continue to update & monitor. On 01/10/23 at 1:58 PM, V21 (LPN) stated she had worked at the facility only one time. She said she remembers R2. V21 said she went in to look at his bottom and noted the top layer to be excoriated. She said she did not see any open areas. V21 stated she put the (Brand type) skin protectant/barrier cream, on it to protect it more, and then asked him (R2) if he wanted anything on it to cover it. V21 said R2 said no, he would just have the wound nurse look at it tomorrow (12/15/22). V21 stated she wrote a note on a piece of paper and enclosed it, labeled it as per wound nurse, and the other nurse told her what door to hang it on. V21 stated she also passed it on in report about R2's buttocks being excoriated. R2's Skin Observation Information in R2's Electronic Medical record, dated 12/14/22 at 10:12 PM, documents R2 had an excoriated buttock. R2's Electronic Medical Record, documents Confidentiality Note, dated 12/15/22 at 7:55 PM, Attn (Attention) V8 (Medical Doctor), Resident (R2), 4 new open wounds on resident L (Left) R (Right) buttock, 1 coccyx, 1 under right testicle. Applying Triad. Please advise. There was no documentation describing the size or appearance of any of these new pressure ulcers. R2's Fax Response from V12 (NP), dated 12/16/22 at 8:47 AM, documents Continue with barrier cream to area BID (twice a day) and PRN (as needed) for soiling. Monitor for improvement, if no improvement or any worsening, update provider. There was no documentation a physician's order was written for the barrier cream, which V12 ordered on 12/16/22. R2's Skin Observation Information in R2's Electronic Medical record, dated 12/21/22 at 2:51 AM, documents (bilateral) buttocks excoriated. There is no documentation of any pressure ulcer to R2's right testicle or any description of R2's skin condition. R2's Skin the Vital Organ Assessment and Documentation Tool, dated 12/27/22, written by V9 (Certified Nurse's Aide/CNA), documents Open Area. The adjacent body figure has a circle placed around the buttocks. This documentation did not describe the open areas or condition regarding R2's skin or R2's scrotum. On 01/10/23 at 1:15 PM, V9 (CNA) stated she did give R2 a shower on 12/27/22. When question about the shower sheet having documentation stating there was an open area on R2, V9 stated there must have been an open area for her to circle that. She said the whole area was excoriated and he had an open area on his buttocks. V9 said she put on the sheet no new wounds because it was a wound they already knew about. She said she doesn't think she informed the nurse because it was an area they already knew about. V9 stated if it had been something new, she would have put it on the sheet. R2's Skin Observation Information in R2's Electronic Medical record, dated 12/28/22 at 9:20 AM, documents coccyx excoriated. The Observation Information documented that wound physician would be consulted and the area measured 18.4 centimeters (cm) by (x) 15 cm. This Observation did not include a description of the areas including odor or drainage. There was no documentation regarding any opened pressure ulcer to R2's scrotum. On 01/11/23 at 8:34 AM. V2 (Director of Nursing/DON), stated she would expect the nurses to just document the assessment, and if they see any changes in the resident, to get an order if they didn't already have an order in place. She said if the nurses were to see the wound wasn't improving or was worsening, she would expect the nurses to call the doctor to see if they wanted to change the order and get an order for them to be seen by the wound specialist. V2 said she reads the nurses notes every day, and if she sees something that is off, she will go down and look at that resident, then if she thinks they need it, she will have them on the list to be seen by the wound specialist. V2 stated what had changed from 12/08/22 to 12/28/22 was she believes on the left side of his buttocks he had what looked like an open area and yellow slough on it. She said the order he had in place was triad cream, PRN, and barrier cream. V2 said for a treatment for an open wound, she would have them seen by the wound doctor the next day, and he would give them an order. She said usually Silvadene Cream. V2 said she would expect the CNAs to report any skin issues to the nurses. R2's Skin the Vital Organ Assessment and Documentation Tool, dated 12/28/22, documents red, open. The adjacent body figure on the assessment has a circle placed around the buttocks and documents red, open. This documentation did not describe the open area or condition regarding R2's skin and scrotum. R2's Progress Notes, dated 12/29/22 at 9:45 AM, written by V15, (Licensed Practical Nurse/LPN), documents CNA reported res (resident) has large open area to coccyx. Upon assessment, unstageable pressure ulcer noted to coccyx. Whole area measures 14.5cm (centimeter) x 11.2cm x 0.1cm. Center covered with yellow/tan slough and measures 3.5cm x 5.7cm x UTD (Unstageable). Scant amount of serous drainage from area. Cleansed with NS (Normal Saline). Unable to apply dressing r/t (related to) location and proximity to anus. Silvadene and collagen powder mixed and applied to open area. DON (Director of Nursing) aware and reports res (resident) is to be seen by (Wound consultant company) specialist tomorrow. Fax sent to V8's (Medical doctor) office re (regarding): area and (Wound Consultant Company) referral. R2's Physician's Orders, dated 12/29/22, documents Barrier Cream to buttocks BID (twice a day) for soiling. R2's Progress Notes, dated 12/29/2022 at 2:24 PM, document POA (Power of Attorney), V6, here and looked at res wound. Indwelling catheter draining cloudy amber urine. Output of 900cc (cubic centimeters) at this time. (Indwelling) Catheter care provided. Noted posterior penile shaft is split from chronic catheter. POA requested res be sent to Local Hospital ED (Emergency Department) for eval/tx (evaluation/treatment). On 01/09/23 at 12:27 PM, V15 (LPN) said it started with R2 not being out of bed for breakfast. She stated she asked the CNA (V16) why R2 was still in bed. V15 said V16 told her R2 was only to be up out of bed for one meal because he had a wound on his bottom, and he chose lunch. V15 stated she asked V16 if they were doing any kind of treatment for him because she didn't have a treatment ordered. She said V16 told her they were putting barrier cream on his bottom. V15 stated she wanted to look at R2's bottom, so she asked V16 to help her. V15 stated she went and got R2's medications ready and came back to R2's room. V16 was busy with someone else at this time so V15 said she gave R2 his medications, and after that, she helped R2 to turn on his side. V16 stated R2 was soiled, so she went and got V16 to help, and they cleaned R2 up. V15 stated I was so angry at what I saw. V15 stated the wound had an appearance of a butterfly shape and deep purple in color. She said the CNA told her it had been red for a couple of weeks before this. V15 stated the center was yellow/tan in color with what appeared to slough/eschar. V15 stated there was open tissue around it, and it went down further on his right side, down towards his scrotum. V15 stated V16 said she worked on Sunday (12/25/22) and that was what R2's bottom looked like on Sunday. On 01/03/23 at 10:31 AM, V6 (R2's POA) stated when R2 was admitted to the facility he did not have any pressure ulcers. She said R2 has been at the facility for a while (over a year). V6 said the facility called her about 2 to 3 weeks ago and told her R2 had 2 red areas noted to his bottom. V6 stated the nurse told her they were going to put some cream on the areas and keep him in bed longer and on his sides to keep him off his bottom a little more. V6 said last Wednesday, 12/28/22, R2 called her and said his butt hurt really bad. V6 stated she told R2 she would be up to see him the next day (which was Thursday 12/29/22) and she would look at it. She stated the nurse (V15) told her when she got to the facility R2's bottom was really bad. She said when she saw it, she couldn't believe it. V6 said no one at the facility had called her to inform her that the areas to R2's bottom had gotten worse. V6 said she talked with the DON (V2) and the DON told her (V6) that she worked the on the floor the previous Saturday to help out and she had seen R2's bottom. V6 said V2 stated she was going to have R2 seen by wound care the following day (which was Friday). V6 stated she told V2 that it would almost be a week since this was noticed, and he should have had something done sooner. V6 said that was when she told the facility she wanted R2 to be sent out to the hospital to be evaluated and treated. V6 said that R2 was admitted to the hospital, and he has an admitting diagnosis of Osteomyelitis. The Facility's Wound Summary Report dated 12/24/22 at 3:32 PM, documents R2 has excoriation to his sacrum (bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis), with the current size of 14.5cm x 11.2cm and with the healing status of declining. The Facility's Wound Summary Report, dated 12/29/22 at 9:01 AM, documents that R2 has an unspecified ulcer to his sacrum with a current size of 14.4cm x 11.2cm and a healing status of declining. R2's Hospital Emergency Department records, dated 12/29/22 at 4:23 PM, documents Musculoskeletal: Comments: Large area of red excoriated skin throughout perineum, buttocks and lower scrotum- very weepy with clear drainage- appears bad candida rash that the skin appears wet and saturated and sloughing off- at lower sacrum/coccyx there is a 4cm circular ulcer with purulent drainage. R2's Hospital Emergency Department records, dated 12/29/22 at 19:38 (7:38 PM), documents CT scan (Computed Tomography Scan) with contrast, Clinical impression: Acute Osteomyelitis (inflammation or swelling in the bone) of coccyx, sacral decubitus ulcer, stage IV (4), and candida skin infection. Npiap.com (National Pressure Injury Advisory Panel) documents a stage 4 Pressure Injury as full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. R2's Hospital Emergency Department records, dated 12/29/22 at 11:17 PM, documents Assessment/Plan: Principle Problem: Acute Osteomyelitis of coccyx Acutely infected chronic sacral decubitus ulcer Plan: -general surgery consult - hold Eliquis as per surgeon for likely OR (Operating Room) in the upcoming days - IV (Intravenous) ABX (Antibiotics) - DVT (Deep Vein Thrombosis) prophylaxis Lovenox for now then switch back to Eliquis when okay with surgeon. Estimated LOS (length of stay) > (greater than) 2 midnights. MDM (medical decision making) complexity: High. On 01/04/23 at 10:32 AM, V5 (Emergency Department Registered Nurse/ED RN), stated R2 presented to their facility with wound infection and red area to buttocks. V5 said upon her assessment it was noted R2 had a significant area to his sacral area with green/yellow drainage noted. She said they did tests, and it showed the area to have Osteomyelitis. V5 stated R2 also had a pressure ulcer to his scrotal area. V5 stated, to her knowledge R2 did not have an order in place for the area to his bottom. V5 said R2 was admitted to the hospital with a diagnosis of Osteomyelitis. On 01/05/23 at 12:40 PM, R2 stated he was not turned and repositioned every 2 hours while he was in bed, and he wasn't repositioned while he was up in his wheelchair. R2 said he would have let the staff turn and reposition him in bed and his chair at any time, and he stated he never refused to let them turn or reposition him. R2 stated he did not have any skin issues when he first arrived at the facility. R2 stated he started having issues about 6 months ago, and he let them know when he first started having the issues. R2 stated the facility didn't look at his bottom every day. He said they would put the cream on his bottom every time he went to the bathroom (was dirty), but they didn't do anything else for it. R2 stated he didn't know if the CNA's told the nurses about his bottom being sore. On 01/04/23 at 1:40 PM, V7 (Registered Nurse/RN) stated she took care of R2 a couple of times since she started working at the facility. She said the first time she saw R2's buttocks, they were red and excoriated, and she felt like part of the wound was a little darker. V7 said they were applying cream to R2's buttocks at that time. On 01/04/23 at 2:10 PM, V9 (Certified Nursing Assistant/CNA) said the last time she seen R2's buttocks they were red and looked like some of the skin was peeling off. V9 said they were putting cream on his bottom. On 01/09/23 at 10:30 AM, V9 (CNA) stated she doesn't remember R2 having any open areas on his bottom, but she does remember a little bleeding when they had to clean him up. V9 stated she remembers R2 was sitting in his wheelchair, and she was pushing him out to the dining room, and R2 complained his bottom hurt. V9 stated she doesn't remember what day this was on, but it was recent. She said she doesn't think she reported it to the nurse because the nurses already knew about R2's bottom being sore. On 01/12/23 at 12:55 PM, V23 (Certified Nursing Assistant/CNA) said it was a time between 12/05/22 to 12/16/22 when R2's bottom opened up. She said she was the one that found it and she reported it to V13 (LPN). V23 stated when it first opened, it just looked like the first layer of skin had come off. She said V13 reported it to the doctor, and then she went on vacation and no one else did anything. She said it got worse about a week before he got sent out. She stated she had worked Christmas day, and when questioned if his bottom looked the same as the day he was sent to the hospital, V23, stated, I believe so, yes. On 01/05/23 at 11:03 AM, V12 (Nurse Practitioner/NP), stated she received a fax on 12/15/22 in the evening or the early morning of 12/16/22 from the facility stating R2 had an open area on his scrotum, and excoriation and open area to his buttocks. V12 said the fax documented the nurse had applied cream to R2's buttocks. V12 said she sent an order back to the facility, stating continue with barrier cream to area BID and PRN for soiling. Monitor for improvement, if no improvement or any worsening, update provider. V12 stated that she was never notified of any changes in R2's condition. She said she even came and saw R2 on 12/19/22 and no one mentioned anything to her about R2's condition. V12 stated if someone would have notified her of R2's buttocks had gotten worse, she would have ordered a consult with wound care. When V12 was questioned, could the outcome for R2 been different if she (V12) had been notified in R2's change of condition? V12, stated, Potentially. On 01/12/23 at 2:55 PM, V19 (Wound Care Doctor) stated his methodology when it comes to assessing skin/wound issues of any kind would be where is the wound located, how long has the wound been there, the story behind the wound (he stated it will differ from patient to patient), he stated a good history will help the treatment plan, size of the wound, any odor, and is there any drainage. V19 stated if someone is excoriated, it doesn't change to a pressure ulcer overnight. V19 said if it is from moisture, it will usually have multiple spots, will be bright red, will sometimes bleed, and it will take a while for it to break down to a mild ulcer. V19 said they will use barrier cream, repositioning, and nutrition. V19 stated R2's condition could have potentially had a different outcome if the facility would have contacted him (V19), and it (wound) had been treated sooner. V19 stated he had treated him (R2) once and healed him. The Facility's Wound Management Program, revised date 02/26/2021, documents Policy it is the policy of (Corporation) to manage resident skin integrity through prevention, assessment, and implementation and evaluation of interventions. Procedure 1. The facility is provided with Wound care Protocols. There are to be utilized to assist in the care and treatment of wounds. It further documents Physician orders should be obtained and followed for each resident. The policy further documents 3. Residents identified at risk on the Braden scale will have this addressed on their care plan and will have interventions put in place for preventative measure. Identifier will be assigned to resident room nameplate for risk assessment score. High risk or with a wound identified will have skin checks daily. It also documents c. If any new areas are identified, write a nurse's note describing the area found and the protocol followed to treat it, Skin Tear Protocol (NUR1225) or New Skin Condition Protocol (NUR1230). Assessments for EHR (Electronic Health Record) are assigned. It further documents f. The nurse will measure the area; call physician to obtain appropriate treatment order, call the guardian/family member to inform him/her, document the area on the T.A.R. (treatment administration record), and initiate the treatment. It also documents 15. Physician and guardian/family member are called after the weekly Wound Committee meeting with an update of the current wound condition. These calls are documented in the nursing notes. The Immediate Jeopardy that began on 12/14/22 was removed on 01/18/23 when the facility took the following actions to remove the immediacy: 1. Immediate Corrective Action for those affected by the deficient practice: A. All residents with a Pressure Ulcer(s) have been assessed by the Wound Physician, V19, on 1/13/2023 and again by the Director of Nurses, V2, on 1/17/2023. B. Progressive interventions are in place and Care Plans have been Updated by the Care Plan/MDS Nurse, V26, on 1/17/2023. C. All residents at high risk for Pressure Ulcers have been assessed by V2 (DON) and V3 (ADON) on 1/17/2023 and progressive interventions are confirmed to be in-place and Care Plans updated by the Care Plan Nurse, V26, on 1/17/2023. D. Wound Management Policy has been reviewed by V1 (Administrator) and V2 (DON) on 1/17/2023. This includes a Policy for what the CNA's responsibility toward wound care entails, which includes looking at skin during routine care and reporting any abnormalities to their nurse. E. Nurses have been educated on the Wound Management Policy by V3 (ADON) starting on 1/17/2023 and completed on 1/18/2023. CNA's have been educated on the Wound Management Program starting on 1/18/2023. Nurses and CNAs that were not educated on 1/17/2023 or 1/18/2023, will be educated prior to beginning their next working shift. 2. Process/Steps to Identify Others having the potential to be impacted by the same deficient practice: A. All residents at High Risk of Pressure Ulcers have been assessed by V3 (ADON) on 1/17/2023 and interventions are confirmed to be in place. B. All residents' skin were assessed by Administrative Nursing and new Braden assessments were completed on every resident on 1/18/2023. C. Care Plans for all residents for High Risk of Pressure Ulcers have had their Care Plans reviewed/Updated by V26 (Care Plan/MDS Nurse) on 1/17/2023. 3. Measures Put into Place/Systemic Changes to Ensure the Deficient Practice Does Not Recur: A. All residents will be assessed for Pressure Ulcer risk on admission and/or readmission, quarterly and with any significant changes using the Braden Scale by the Nurse and resident Care Plans will be updated appropriately as needed. This will be completed on an on-going basis. B. Residents deemed High Risk for Pressure Ulcers, or who are admitted with a Pressure Ulcer will have interventions initiated and appropriate Care Plans in place. V2 (DON)/or designee will ensure that the Braden scale is completed upon admission and/or readmission, quarterly and with any significant change. The DON and/or designee will review the care plan to ensure that the care plan has been updated and appropriate interventions are in place. V2 (DON) and/or designee will complete the Braden Audit and Care Plan Audit to show that this has been completed. 4. Plan to Monitor Performance to Ensure Solutions are Sustained: A. Skin checks are scheduled in the electronic medical record. V2 (DON) and/or designee will run the schedule compliance report out of the electronic medical record on a weekly basis to ensure that all residents received a skin check. Any abnormalities noted will be addressed immediately, interventions put into place, and care plans updated appropriately by V2 and/or designee. Findings will be documented on the skin compliance audit report and reviewed weekly in the IDT meeting with the QA Team which includes Administrator, Director of Nursing, Assistant Director of Nursing, MDS/Care Plan Nurse, Social Service Director, Therapy Director and Dietary Manager. B. V2 and/or designee will perform skin checks on three residents weekly x 8 weeks to ensure accuracy of completed skin checks. Findings will be reported IDT meeting weekly. C. V2 and/or designee will complete rounds with the wound care physician weekly to observe residents with pressure injuries on an ongoing basis. DON and/or designee will review wound care report weekly to ensure appropriate treatment and interventions are in place for all residents that have a pressure injury. On 1/19/23, the surveyors confirmed the facility removed the Immediacy by observing R1's, R3's, and R7's pressure ulcer treatments. The surveyors reviewed R1's, R3's, R6's, R7's, R8's, R9's, R10's, R11's, and R12's Braden Scale, Care Plan, Skin Assessments, Progress Notes, and Physician's Orders, with no issues or concerns noted. V10 (Certified Nursing Assistant/CNA), V13 (Licensed Practical Nurse/LPN), V24 (CNA), V26 (Minimum Data Set/MDS Coordinator), V27 (Agency LPN), V28 (CNA), V31 (Agency LPN), V32 (Agency CNA), V33 (CNA), and V34 (Agency CNA) were all interviewed regarding Wound Management Policy, expectations, and responsibilities.

Based on observation, interview and record review, the facility failed to offer, serve, or send a lunch to a resident prior to leaving the facility for dialysis for 1 of 3 residents (R2) reviewed for nutrition in the sample of 10. Findings include: R2's current Face Sheet documents R2 has a diagnosis of Dependence on renal dialysis, Dementia, Vitamin D deficiency, and Metabolic Encephalopathy (A broad category that describes abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function) and Protein-Calorie Malnutrition. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is moderately cognitively impaired and is independent with eating with set up help only required. R2's Intake Records for Sunday, 11/20/22, Tuesday 11/22/2022, and Monday, 11/28/2022 document None or Not taken for the lunch intake. R2's Care Plan, dated 11/28/2022 and edited on 11/29/2022, documents, I am at risk for complications due to end-stage renal disease and hemodialysis. On dialysis days, I do not always eat lunch because I eat a later breakfast. R2's Care Plan does not address R2's nutritional status. On 11/28/2022 from 9:36 AM until 11:25 AM, R2 was observed in his wheelchair in sitting area/dining room of the facility. During this time, R2 was not offered anything to eat. R2 was observed leaving the facility at 11:25 AM for dialysis. On 11/28/2022 at 11:23 AM, V6 (MDS/Care Plan Nurse) stated, (R2's) dialysis days are usually Monday, Wednesday and Friday but last week was different because of the Holiday. He had it Sunday (11/20/2022), Tuesday (11/22/2022) and Friday. On 11/28/2022 at 1:00 PM, V11 (Dietary Aid) stated, I'm not sure what (R2) had for lunch. I will ask (V9) because she served lunch today. At this time, V9 (Dietary Aid) stated, Did he get lunch? I don't think he did. Usually, we save him a tray. I will make him a grilled cheese when he gets back, but he usually doesn't want to eat after dialysis. On 11/28/2022 at 2:00 PM, V13 (Certified Nursing Assistant/CNA), stated R2 gets back from dialysis around 3:30 or 4:00 PM. On 11/29/2022 at 10:24 AM, V1 (Administrator) stated, R2 eats a late breakfast. We used to pack a lunch for him, but he says the dialysis makes him nauseated even though we offered options for lunch. He eats well at breakfast and then eats dinner. We offer him something as soon as he gets back but he doesn't feel like eating. On 11/29/2022 at 10:59 AM, V2 (Director of Nursing/DON) stated, R2 eats a late breakfast. We used to send sack lunches with him, but he never ate them. It just got to where he just didn't take it. Now they offer him something when he gets back. R2 just wants 2 peanut butter and jelly sandwiches and he eats them when he gets back. On 11/29/2022 at 12:20 PM, R2 was observed in the dining room, eating the lunch that was served. On 11/29/2022 at 2:35 PM, V1 (Administrator) stated that he would expect the staff to give the meal early or save the meal for when the resident got back from an appointment.

Based on observation, interview, and record review the facility failed to store and label food in a manner that keeps it free from contaminants. This has the potential to affect all 57 residents living in the facility. Findings include: On 07/12/22 at 8:08 AM on the initial tour and follow-up tour on 07/13/22 at 7:45 AM of kitchen, the following dry foods were found opened, not dated and no expiration date: - 50-pound bag of rolled oats was opened and left open with no date of opening. - 60-ounce bag of croutons open, with no date of opening. Bag was closed with a rubber band - 60-ounce bag of baking coconut, open, with no date of opening and taped closed. - 100-ounce bag of spaghetti, open, with no date of opening and closed with a rubber band. - 160-ounce bag of macaroni, open with no opening date and closed with a rubber band. On 07/13/22 at 7:45 AM, the following refrigerated items were found to be unlabeled and undated: Two 1- gallon pitchers with liquid (1 red and 1 brown) were not labeled and without a date. On 7/13/22 at 7:45 AM, V18 (Dietary Manager) states This must have occurred because my worker was out sick. I have trained staff to make sure they follow the policy and procedures, and my directions are followed. I normally double check to make sure things are labeled and sealed. On 7/13/22 at 8:00 AM, V1 (Administrator) states, I rely on my staff to make sure we are following our policy and procedures. V18 is pretty thorough so I am sure it was something that was overlooked. On 7/13/22 at 12:30 PM, both V12 (Cook) and V13 (Dietary Aide) both state they have been trained on when and how to label, date and close bulk dry goods. The policy on Food and Storage dated 2019 and revised March 2022 documents: Plastic containers with tight-fitting covers must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods. All containers must be legible and accurately labeled and dated. The Facility's Resident Census and Census and Conditions of Residents form, CMS 672, dated 07/12/22 documents the facility had a census of 57 residents.

Based on observation, interview and record review, the facility failed to identify and assess pressure ulcers for one of five residents (R44) reviewed for pressure ulcers in the sample of 33. Findings Include: R44's Skin Integrity Care Plan date initiated is 12/25/20 documents I will have no skin issues/break down through next review period. The Care Plan also documents Do a weekly skin check and notify my family and Physician of any new areas. Peri care after each incontinence episode. R44's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Cover it with a dry dressing. R44's June POS dated 6/29/22 to 7/7/22 documents cleanse scrotal area with normal saline and apply collagen powder, cover with dry dressing daily until healed. R44's Local Wound consultant Form dated 7/6/22 also documents R44's Non pressure ulcer to scrotum with fat layer exposed is resolved. R44's Local Wound consultant Form documents R44's right buttock pressure ulcer is resolved and discontinue treatment. R44's POS dated 7/7/22 with an open-ended end date documents apply barrier cream to the scrotum twice daily and whenever necessary. (The previous treatment was discontinued when the scrotum was resolved on 7/6/22.) R44's Local Wound Consultant Form dated 7/12/22 documents that the Wound Consultant did not see R44's scrotum and right buttock for this visit. On 7/14/22 at 11:30 AM, V6 (Licensed Practical Nurse/LPN) entered the room to perform treatments on R44's left heel, right buttock. R44 has two dime size open areas to his scrotum. He also has a nickel size area open on his right buttock. There was no documentation in R44's medical record when these areas developed and if a new treatment was ordered for these pressure ulcers. R44's Treatment Administration Record for the month of July 2022 documents that skin checks are to be done daily with CROPS which stands for C-clear, R-redness, O-open, P-pressure, and S-skin tear. The daily skin check was completed but did not document the new open areas to the buttocks and scrotum. On 7/15/22 at 12:09 PM, V3 (Assistant Director of Nursing/ADON) (The Local Wound Consultant) did not look at it because it was healed the week before, and no one told us that the pressure ulcer had reopened. The facility's Wound Care Program Policy dated 7/2014 documents in developing a comprehensive treatment plan for wounds, the clinician should assess not just the wound, but the whole person. The factors affecting the ability of the wound to close and ultimately heal need to be included in the overall treatment. Expect a clean ulcer with adequate interventions and blood supply to show evidence of healing within two weeks. Failure to do so should prompt a reevaluation of the plan of care, and evaluation of adherence to the plan and a possible modification of the plan. Assessment of the wound is necessary prior to developing a plan of care Parameters Include: etiology, pathogen confirmation, wound bed, location.

Based on observation, interview and record review, the facility failed to provide supervision and implement effective interventions to prevent accidents/falls for 2 of 2 residents (R21, R257) reviewed for supervision to prevent accidents/falls in the sample of 33. Findings include: 1. R21's Care Plan dated 4/27/2022 (initiated 8/21/2021) documents At risk for skin breakdown. I have thin skin and am prone to skin tears. I wear derma-sleeves to my bilateral lower extremities R/T (related to) frequent reoccurrence of skin tears to my lower legs. Goal: My skin tear will be closed without infection by next review. Interventions/tasks: Administer treatment as ordered. See current physician order sheet or treatment book. Apply derma-sleeves to my lower extremities prior to getting out of bed and remove at bedtime. Encourage me to be out of bed as tolerated. Keep skin tear site clean and dry. Monitor dressing(s) if applicable and let the nurse know if it is saturated or falling off. Monitor fingernails weekly for length and jagged edges. Monitor for discoloration, bruises, swelling, new skin tears, and redness. If noted, report to nurse/MD (physician.) Notify physician if any s/sx (signs and symptoms) of infection occur. Please pay special attention when moving me. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Turn and reposition every 2 hours and PRN (as needed). R21's Skin/Wound Note, dated 5/8/2022 at 6:27 AM documents CNA (Certified Nurse's Assistant) was getting resident out of bed and into wheelchair and hit resident's right leg on the wheelchair causing a 3 cm (centimeter) long skin tear. Skin well approximated. Area cleansed with NS (normal saline.) 3 steri strips and dry dressing applied. Resident denies pain. MD (physician) updated. R21's Physician's Order Sheet, dated 5/8/2022 documents right shin: monitor steri-strips to skin tear and change dressing daily and PRN until healed. On 7/14/2022 at 12:45 PM V7 (Certified Nursing Assistant/ CNA) and V8 (Certified Nursing Assistant/ CNA) transferred R21 from wheelchair to bed using a full body lift. V7 stated R21 used to be a 1 or 2 staff assist stand and pivot transfer but she is weaker now, so they use the lift. While R21 lay in bed, no derma sleeves were on her bilateral lower extremities. On 7/14/2022 at 1:40 PM, V7 stated R21 used to wear derma sleeves on her arms and legs, but she doesn't wear them anymore. On 7/14/2022 at 12:55 PM, V3 (Assistant Director of Nurses/ADON) stated when the incident is witnessed the facility does not document an investigation because they know how it occurred. V3 didn't know who transferred R21 to bed that day. She stated R21 was a 1 or 2 staff stand and pivot transfer in May 2022, it depended on how R21 was feeling that day to see how many staff needed to assist the transfer. On 7/14/2022 at 1:30 PM, V2 (Director of Nursing/DON) stated she expects staff to follow physician's orders and if the resident had a physician's order for derma sleeves to her bilateral lower extremities she should have them on. 2. R257's undated Face Sheet documents he was admitted to the facility on [DATE]. R257's Fall Risk Assessment, dated 7/8/2022 documents he was a high fall risk. R257's Progress Note dated 7/8/2022 at 9:00 PM documents resident arrived to facility via ambulance with two attendants and multiple family members accompanying. Resident transferred to bed with assistance of ambulance attendants. Resident admitted with hx (history): [CONDITION(S)] (stroke), [CONDITION(S)] (lung disorder) prostate CA (cancer), [CONDITION(S)] and [CONDITION(S)]. Resident incontinent of bowel and bladder. Alert and oriented x 0. Blind in both eyes r/t recent [CONDITION(S)]. Allergic to [MEDICATION(S)]. Max (maximum) assist. Resident on 2L (liters) oxygen per NC (nasal cannula.) Respirations even and non-labored. Bowel sounds active and present x 4. R257's Progress Note dated 7/09/2022 at 5:27 PM documents At 4:24 writer observed res (resident) slide out of bed and onto his knees. Torso/head remaining on bed. Incontinent of bladder and linens soiled. Res unable to explain what he was doing. Appears he was attempting to gather soiled linens as he was balling them in his hands. No injuries noted to bil (bilateral) knees. Gripper socks on and bed in lowest position at time of fall. MD (doctor) notified of fall. Family, informed of fall with no injury. No questions voiced at this time. R257's Progress Note dated 7/10/2022 at 12:22 AM documents CNA found resident on floor of room. CNA notified nurse. No apparent injuries upon assessment. POA (Power of Attorney) and physician to be notified. R257's Progress Note dated 7/10/2022 at 11:09 AM documents At approximately 7:00 AM resident attempting to climb out of chair and has previously fallen twice. R257's Progress Note dated 7/10/2022 at 7:40 PM documents CNA called nurse to room at this time and resident was lying on floor. Family had recently been here and he was sleeping in (brand name) chair. Once family left resident tried transferring self out of chair and was found on the floor by his bed. No injuries noted. Combative with staff as we were trying to get resident assessed and back in chair. Appears to be baseline. Vitals obtained at this time. MD faxed. POA called and aware of fall. R257's Progress Note dated 7/10/2022 at 10:45 PM documents CNA called nurse to room and resident was lying on floor in urine. No injuries noted. Vitals assessed and neuros. WNL (within normal limits). R257's Progress Note dated 7/10/2022 at 11:46 PM documents due to combativeness and reoccurring falls discussed with POA sending resident to hospital for evaluation and treatment. R257's Electronic Medical Record (EMR) no documentation of when he was readmitted to the facility from the hospital. R257's Progress Note dated 7/11/2022 at 6:10 PM documents resident had witnessed fall. This nurse witnessed resident attempting to get of w/c (wheelchair) and slid and fell to the floor. Resident did not hit his head. Resident assessed, [NAME]. Vital signs WNL. Resident's family called to inform of event. R257's Undated Baseline Care Plan documents he was a high fall risk, no progressive interventions after the falls were documented. On 7/15/2022 at 8:45 AM, V2 (Director of Nursing/DON) stated she expects staff to document a progressive intervention after every fall. There were progressive interventions in place after the resident fell but they weren't documented on his care plan. The facility's Fall Management Policy, revised July 2017 documents residents identified as high fall risk will have fall prevention addressed on the plan of care.

Based on interview, record review, and observation the facility failed to provide catheter care without breaches in infection control, and or reassess catheter after self-removal for two of three residents (R44, R30) reviewed for catheter care in the sample of 33. Findings Include: 1. R44's Minimum Data Set (MDS) dated [DATE] documents R44 has a catheter and is always incontinent of bowel. R44's Catheter Care Plan initiated on 9/24/2020 documents R44 has a suprapubic catheter and will show no signs and symptoms of a urinary tract infection. The Catheter Care Plan also documents cleanse the suprapubic catheter every day, and apply triad paste. Cover the catheter with a dry dressing. On 7/14/22 at 11:00 AM, V7 (Certified Nursing Assistant/CNA) removed the old dressing off of R44's left buttock, because he was incontinent of bowel. but she did not wash her hands or change her gloves. She wiped feces off of the resident with a washcloth that she wet in a basin of water and no rinse peri wash. V7 then went into the wash basin with the same gloves two more times to wet wash cloths, to cleanse the rectal area of feces. She then went in with same gloves, in the wash basin and performed catheter care. She removed the old dressing off of the catheter area with the same gloves and cleansed around the catheter insertion site and down the catheter with the same gloves. V7 did not cleanse her hands when going from soiled to clean while performing catheter care. On 7/14/22 at 11:30 AM, V6 (Licensed Practical Nurse/LPN) went in and applied Triad Cream and placed a dry dressing on R44's suprapubic catheter site. The Catheter bag was on the floor, and she was standing on it. On 7/15/22 at 9:15 AM, V3 (Assistant Director of Nursing/ADON) stated during catheter care. I would expect the (CNA) to introduce herself to the resident wash her hands, gather the water and wash cloths. Use more than one wash cloth, and wash hand and change gloves, when going from dirty to clean. The facility Care Plan dated 7/2017 documents use standard precautions when handling and manipulating the drainage system. Maintain clean technique when handling or manipulating the catheter, tubing or drainage bag. 2. R30's Admission MDS, dated [DATE] documents he is moderately cognitively impaired, requires extensive assistance of one-person physical assist for toilet use and personal hygiene and an indwelling catheter. R30's Care Plan, dated 2/11/2022, had no documentation regarding R30's indwelling catheter. R30's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R30's Nursing Note, dated 3/30/2022 at 4:34 PM documents CNA (certified nurse assistant) reported res sitting in w/c (wheelchair) in room bleeding from unknown source. Entered room to observe res sitting in w/c near bed 2. Wearing t-shirt, gait belt and non-skid socks. Pants sitting on floor under front wheel of w/c. Nasal cannula in place, but not connected to concentrator. Foley drainage (catheter) bag hanging on side of bed closest to door and catheter lying across bed. Balloon intact. Large amount of blood smeared on floor and both beds. Large clots noted on floor under seat of w/c and blood dripping from urethral meatus (tip of penis). Res unable to report what happened. Writer and CNA assisted res from w/c to bed with use of gait belt and w/w (wheeled walker.) Physical assessment completed with only one source of blood identified. Perineal care provided. Small amount of bleeding continues from site. R30's Communication with Physician Situation Note, dated 3/30/2022 at 4:45 PM the Nurse Practitioner (NP) informed of displacement of foley catheter with bleeding from urethral meatus r/t (related to) trauma. Background: Currently on [MEDICATION(S)] therapy. Assessment (RN)/Appearance (LPN): Recommendations: Instructed to monitor bleeding. When it ceases, attempt to re-insert catheter. If met with resistance, unable to place catheter, it doesn't drain or he doesn't stop bleeding in 5-10 min (minutes) send res (resident) to ER (emergency room ) for eval (evaluation)/tx (treatment.) If catheter re-inserted, monitor output and send to ER if bleeding continues. R30's Electronic Medical Record, dated 3/30/2022 between 4:45 PM and 6:59 PM documents no assessment of the resident. R30's Nursing Note, dated 3/30/2022 7:00 PM writer called to resident's room by aide and noted bright red blood dripping on bathroom floor and large amount noted to front of gown. resident up with walker and gait belt with stand by assist. Denies any dizziness, lightheadedness or pain. small amount of bright red blood/urine noted in cath (catheter) bag. vs (vital signs) 141/66-84-18-93% on O2 (oxygen) at 2L (liters.) R30's Communication with Physician Situation Note, dated 3/30/2022 7:05 PM large amount of bright blood noted around urethral meatus and in cath bag. Background: no information documented. Assessment (RN)/Appearance (LPN): no information documented. Recommendations: NP updated by ADON of impending transfer per previous order. R30's Communication with Family NOK (next of kin)/POA (power of attorney) Note, dated 3/30/2022 7:20 PM documents POA updated on continued bleeding and impending transfer for further eval. POA upset at resident's current condition and feels staff should have been monitoring more closely. this writer voiced understanding and stated ADON would be made aware of concerns. R30's Nursing Note, dated 3/30/2022 10:55 PM notified of need for pick up at 7:40 PM. Arrived with 2 EMTs (Emergency Medical Technicians) at 8:00 PM. Report called to hospital ER at 8:02 PM. On 7/14/2022 at 9:15 AM, the Director of Nursing (DON) stated the resident is alert and could say what happened so no investigation was completed. 7/14/2022 at 10:11 AM, V4 (Licensed Practical Nurse/ LPN) stated she was assigned to the resident on 3/30/2022 and recalled the incident. Staff notified her the resident was bleeding. She walked in the resident's room and there was a bloody mess. The resident was sitting in his wheelchair and there was blood dripping from his penis. The catheter bag was laying across the bed, the catheter balloon was intact. The resident was not able to state what occurred. There was a large puddle of blood with clots under the resident's wheelchair. V4 didn't put the catheter back in and could not recall if she monitored him after she left his room at that time. On 7/14/2022 at 10:30 AM, V3 (ADON) stated V4 (LPN) notified her that R30 pulled out his catheter. When she entered R30's room she observed blood on the floor, his bed sheet and on his curtain. R30's catheter was hanging on the side of the bed and it was pulled out. Blood was dripping from his penis and his penis was split open. She called the Nurse Practitioner (NP) and she instructed staff to monitor the resident for bleeding and if he's still bleeding to send him to the emergency room (ER.) She didn't know if the nurse put the catheter back in or not. On 7/14/2022 at 11:14 AM, V2 (Director of Nursing/DON) stated she expected staff to document if they reinserted the resident's catheter after it was pulled out but if nothing was occurring during that time, she didn't expect staff to document if they were monitoring the resident for bleeding or not. The facility's Catheter Care, Urinary policy, revised 7/2017 documents the purpose of this procedure is to prevent catheter-associated urinary tract infections. Complications: observe the resident for complications associated with urinary catheters check the urine for unusual appearance (color, blood etc.) Notify physician or supervisor in the event of bleeding, or if the catheter is accidently removed. Documentation: the following information should be recorded in the resident's medical record: any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting or pain. Any problems or complaints made by the resident related to procedure. Reporting: report other information in accordance with facility policy and professional standards and practice. The facility's Change in Condition policy, revised 2/2021 documents policy: it is the policy of the facility that resident change in condition will be assessed promptly and follow up activity will occur as appropriate and in a timely manner. Definition: change in condition is defined as an improvement or decline in the resident's physical, mental or psychosocial status that effects less than two areas of activities of daily living. Significant change is defined as an improvement or decline in the resident's physical, mental or psychosocial status that effects two or more areas of activities of daily living. Procedure: the staff person who first notices the change reports resident change in condition immediately to the licensed nurse. The licensed nurse assesses the resident including vital signs and notes signs and symptoms, regarding physical and mental changes in condition. The results of the assessment, including vital signs, symptoms and any physical and/or mental changes in condition are documented in the resident's medical report. The resident's primary physician or designated alternate will be notified immediately of any change in resident's physical or medical, this includes: accident involving the resident, deterioration in health, mental or psychosocial status. Need to alter (need to discontinue an existing form of treatment due to adverse consequences or to commence new form of treatment.) Notification of physician and/or responsible parties shall be documented in the clinical record as well as on the 24-hour report form. Status changes, which are not significant enough to be reported, must also be documented in the medical record. Significant change in condition requires a comprehensive resident reassessment (MDS) with associated documentation in the clinical record and care plan. The assessment must address all aspects of the resident's condition affected by the change. Acute conditions or clinical complications can trigger a reassessment. All changes in condition must be completely and objectively documented in the clinical record. Appropriate follow through from shift to shift is imperative for all resident with any change in condition. The nursing staff must utilize the tools provided for formal communication from shift to shift.

Based on interview and record review, the facility failed to perform dressing changes to the [CONDITION(S)] access site for 1 of 2 residents (R2) reviewed for [CONDITION(S)] in the sample of 3. Findings include: R2's Face Sheet, undated, documents R2 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Minimum Data Set (MDS), dated [DATE], documents R2 has severe cognitive impairment. R2's Care Plan, dated 10/7/19, documents R2 requires hemodialysis related to renal failure with an intervention to check and change the dressing to the access site daily. R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Treatment Administration Records (TAR), fails to document that the [CONDITION(S)] dressing was removed for the entire month of April 2022, 5 times in May 2022 and 1 time in the month of June 2022. R2's [CONDITION(S)] Communication Form, dated 6/8/22, documents Coban was still on from Monday, it could clot the access, please remove bandages after [CONDITION(S)]. On 7/1/22 at 10:25AM, V8, [CONDITION(S)] Registered Nurse (RN), stated they have a problem with R2's dressings. V8 stated after his [CONDITION(S)] treatment, they hold pressure for 20 minutes over the access site, once the bleeding stops, they will leave a gauze dressing in place and then the facility is to remove it within 6-8 hours after they return. V8 stated they send a [CONDITION(S)] communication form with him after each treatment and write on there to remove the dressing in the morning. V8 stated R2 comes back to the [CONDITION(S)] center with the same dressing on. V8 stated when they leave that dressing on and don't change it, it can cause damage to the site. V8 stated the facility has an order to remove the dressing the mornings after [CONDITION(S)] on Tuesdays, Thursdays and Saturdays. V8 stated when he came back to the [CONDITION(S)] center on Monday 6/27/22, the dressing that was put on by the [CONDITION(S)] center on Friday 6/24/22 was still in place and had not been changed. V8 stated R2 had scabs over the new site, so they sent him to the emergency room . On 7/1/22 at 9:40 AM, V2, Director of Nurses (DON), stated she would expect the nurses on a [CONDITION(S)] resident to check the fistula site for thrill, bruit before and after [CONDITION(S)] and monitor the site for any infection, bleeding or swelling to the site. On 7/1/22 at 2:00 PM, V2 stated she would expect the nurses to perform dressing changes to the site as ordered. The Hemodialysis Access Care Policy and Procedure, dated 7/2017, documents Care involves the primary goals of preventing infection and maintaining patency of the catheter (preventing clots).

Based on observation, record review and interview, the facility failed to provide a safe transfer to prevent a fall for 2 of 8 residents (R1 and R3) reviewed for falls in the sample of 8. This failure resulted in R1 sustaining a fracture of the left femur and hospitalization . Findings include: 1. The ECR (electronic clinical record) for R1 documents diagnoses, in part, as Osteoarthritis, Pain in Left and Right Hip, Difficulty Walking, Unsteady on Feet, Angina Pectoris, Atrial fibrillation, Chronic Obstructive Pulmonary Disease, Dementia, and Chronic Kidney Disease. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is moderately impaired with cognition, transfers and ambulates with an extensive assistance of 2 staff and has impaired range of motion in the lower extremities. The MDS documents R1 has unsteady sitting and standing balance. R1's Morse Fall Scale, dated 9/11/2016, documents R1 is a high risk for falls. The Fall Investigation, dated 12/12/2106 at 10:00 PM documents, in part, CNA (Certified Nurse's Aide) was assisting (R1) to bed from the commode that was right next to the bed, when the bed began to move backwards. CNA (E4) began to lower (R1) to the floor when she heard a POP from the resident's body. Upon entering the room, nurse noted (R1) to be laying on the floor with back leaning against the bed, with the LLE (left lower extremity) externally rotated. (R1) complained of pain to the area. (R1) was not moved at this time. (Z1), Physician notified and orders given to send (R1) to the (local hospital) ER (emergency room ) for evaluation and treatment. 'I was going to bed, and I just started going down.' Predisposing Environmental Factors-Furniture. Predisposing Situation Factors-Improper Footwear. Bed wheel locks were not completely locked, causing the bed to move, resulting in (R1) being lowered to the floor. (R1) was ultimately admitted with a left femur fracture. Investigation revealed the CNA, (E4) involved in the transfer was not using a gait belt. Also per Care Plan, (R1) is to be transferred with 2 assist due to fluctuations in strength and history of knees giving out when standing. (R1) was being transferred with assist of 1 at time of incident. Disciplinary action was taken by DON, (Director of Nursing) towards CNA involved. She was suspended X 3 days. Also DON (E2) conducted inservices with all CNA's on gait belt policy. On 1/05/2017 at 3:07 PM, E4 reported on 12/12/2016 around 9:55 PM, she and E5, CNA, had put R1 on the bedside commode. E4 stated, in part, (E5) left to put someone else to bed. I stood (R1) up from the commode. I was facing (R1). I hugged her and picked her up to turn her back toward the bed. When she (R1) went to sit down, the bed scooted back. I went to put her back on the commode, and before I could turn her, I heard a POP. Her body started giving out. She's short and wide. I lowered her to the floor. There was no help coming from her anymore. When I sat her down on her bottom, her legs were straight out in front of her. I asked her if she was OK, and she said she was fine. I left, walked out the door and called (E5). (E5) came out and got the nurse, (E6), Licensed Practical Nurse (LPN). When I went back in, I noticed her leg was crooked. (E5) and (E6) came in. E4 reported she did not place a gait belt on R1 prior to the transfer. On 1/05/2017 at 3:25 PM, E5 reported that on 12/12/2016 she and E4 had placed R1 on the commode without using a gaitbelt. E5 reported she left to answer a call light and when she was done, E4 told her to get the nurse because R1 was on the floor. E5 reported she went and got E6, and both entered R1's room. E5 reported R1 was alert and awake, with the left leg turned inward. E5 stated R1 reported she was alright and E6 left to notify E7, LPN, an ambulance and a doctor. E5 reported R1 usually can be a one assist, but her Care Plan says 2 assist. E5 confirmed a gait belt should have been used for R1 for the transfer. On 1/05/2017 at 3:58 PM, E6 reported on 12/12/2016, E4 came and got her and reported R1 had fallen. E6 stated, in part, I knew she (R1) had previous knee problems, and was a 2 assist with a gait belt. (R1) was alert and awake, lucid. Then I scanned down and noticed a major left external rotation and complaints of left leg pain. I said I wasn't moving her, and I called (Z1). I called 911 and the ambulance arrived. Her vital signs were normal. When the EMT's (emergency medical technicians) took her vital signs, her blood pressure was lower. E6 reported R1 left by ambulance and never returned to the facility. On 1/05/2017, at 12:40 PM E1, Administrator, reported R1 was sent to the local hospital on [DATE] and was discharged from the facility. E1 reported R1 received hospice services at the local hospital for the [DIAGNOSES REDACTED]. On 1/05/2017 at 3:50 PM, E2, Director of Nursing (DON) stated, All residents need use of a gait belt unless they are transferred with a mechanical lift. (E4) was suspended for 3 days. R1's Care Plan, updated 11/01/2016, documents, in part, I have an ADL (activities of daily living) self-care performance deficit related to limited mobility and pain related to Osteoarthritis. TOILET USE: I need assist of 2 caregivers. TRANSFER: I need assist of 2 caregivers. 9/23/2016 Skilled PT (physical therapy) to evaluate and treat related to recent falls and pain to my right leg and lower back. Provide me with a wheeled walker. Place a gait belt around my waist. The History and Physical (H&P) from Z1 at the local hospital, dated 12/12/2016, documents R1 was alert, and verbalized the accident. The H&P documents R1 was stable, and her family requested she be referred to an orthopedic surgeon at an out of state hospital. The Hospital record documents R1's family refused the surgery due to the risks. R1 was certified and placed on hospice on 12/16/2016 per the family's request for the [DIAGNOSES REDACTED]. The facility's policy and procedure, dated 4/01/2008, and entitled, 'Low Risk for Falls Protocol' documents in part, Procedure: Wheel locks on bed are locked. Resident will be offered the use of a transfer assist device for the bed as appropriate. The facility's policy and procedure, dated 3/1996, and entitled, 'Gait Belt/Transfer Belt' documents, in part, A gait belt/transfer belt will be utilized by facility staff when deemed appropriate by Physical Therapy and/or Nursing. Purpose; To promote safety in transferring and ambulating residents. CNA's will routinely wear gait/transfer belts on their person until needed during resident care. The Licensed Nurse/CNA, when transferring or ambulating the resident, grasps the secured gait/transfer belt to provide stability and balance during movement. Once resident has been moved and safely repositioned, the gait/transfer belt is removed from the resident and the CNA keeps it on his/her person until next resident use. 2. R3's ECR documents diagnoses, in part, as [DIAGNOSES REDACTED], Hemiparesis, Osteoarthritis, Convulsions, and Dementia. R3's MDS, dated [DATE], documents R3 is severely impaired with cognition and requires the extensive assistance of 2 staff for transfers, with poor sitting and standing balance. R3's Care Plan, revised on 8/03/2016, documents R3 is a high risk for falls. R3's Care Plan documents, in part, I am at high risk for falls. I use a wheelchair for my main mode of mobility. I need 2 assist with transfers. On 1/05/2017 at 1:00 PM and 2:55 PM, R3 was propelling herself in a wheelchair using her feet. R3 was very confused, but talkative and alert. There were anti-tippers on the back of the wheelchair. R3 was sitting on a slick vinyl, gel pressure relieving cushion in the wheelchair. The Fall Investigation for R3, dated 11/06/2016 at 2:13 PM, documents, in part, Resident (R3) was taken to bathroom and cleaned up due to having BM (bowel movement). (R3) transferred to wheelchair and due to buttocks still being wet from cleaning, she slid off wheelchair and fell to the floor. Resident buttock wet and bare when placed in wheelchair. Injury type-abrasion to right trochanter (hip). Nurse on duty educated CNA, (E12) on ensuring seat and buttock is dry prior to transferring resident into location. The Investigation documented one CNA transferred R3 at the time of the incident.

Based on observation, record review and interview, the facility failed to implement interventions to prevent the formation of a pressure ulcer and ensure a dressing was in place for one of five residents (R12) reviewed for pressure ulcers in the sample of 15. This failure resulted in R12 developing a facility acquired Stage III pressure ulcer to her sacrum. Findings include: R12's physician's orders [REDACTED]. The Minimum Data Set (MDS), dated [DATE], documents R12 is severely impaired with cognition, requires extensive assistance with bed mobility and is occasionally incontinent of urine. The Braden Scale, dated 2/01/2016 documents R12 is at risk for skin breakdown. The facility's Weekly Skin Report for 5/08 to 5/14/2016 documents, R12 has a facility acquired on 5/13/2016, Stage II to the sacrum measuring, 1.0 centimeter (cm) by (X) 1.5 cm X 0.1 cm. The interventions documented on the report are pressure relieving mattress and wheelchair cushion. Treatments for the ulcer are documented as wound gel and (foam dressing). The facility's Weekly Skin Report, dated from 5/22/2016 to 5/28/2016, documents R12 now has a Stage III pressure ulcer to the sacrum, measuring 0.8 cm X 0.6 cm X 0.3 cm. Interventions are documented as pressure relieving mattress and wheelchair cushion. The intervention is Santyl. A PO for R12, dated 5/23/2016, documents Keep legs elevated when possible. (Special wound consultant) to consult and treat. The Wound Care Report, dated 5/25/2016, from Z2, Wound Consultant documents, in part, well nourished [AGE] year old female, new pressure ulcer, of sacral region, Stage III, 0.8 cm X 0.6 X 0.3 cm X 0.48 cm, minimal necrotic tissue, scant serosanguinous drainage. Complicating factors include fecal and urinary incontinence at times. On 6/09/2016 at 9:40 AM, R12 was sitting in a recliner in the day area, in a reclined position. On 6/09/2016 at 10:12 AM and 10:30 AM, R12 was sitting in the wheelchair. At 10:47 AM, E16 and E18, Certified Nurses Aides (CNA) transferred R12 from the wheelchair to the toilet. R12 had been incontinent of bladder and smelled of urine. A folded incontinent pad was on top of the pressure relieving cushion resting in the wheelchair seat, inhibiting the pressure relieving effect of the cushion. R12 had no dressing to the sacral area. After toileting, R12 was transferred back to the wheelchair and taken into the dining room for lunch at 10:52 AM. On 6/09/2016 at 1:29 PM and 1:40 PM, R12 was in bed turned to the right side with a pillow behind her back. The head of the bed was elevated 30 degrees and her lower extremities were raised with a vinyl covered foam lift cushion. There were no side rails on R12's bed. At 1:41 PM, E19, Licensed Practical Nurse, (LPN) and E4, LPN assisted R12 to turn further to the right side. There was no dressing to R12's sacral area. R12 could not reposition herself. At that time, E19 reported R12 should have had a dressing to her pressure ulcer. E19 stated, I don't know what happened to it. It looks about the same as last week. A small open area was on R12's sacral area. On 6/09/2016 at 1:50 PM, E4 stated, I don't know how (R12) got the wound. On 6/10/2016 at 9:00 AM E2, Director of Nursing (DON) reported R12 likes to lay on her back. R12's Care Plan, dated as revised on 5/24/2016, documents, in part, I have a pressure ulcer on my coccyx related to immobility. Date initiated: 5/23/2016. I need extensive assistance of 2 staff to turn/reposition at least every 2 hours. More often as needed or requested. I require the bed as flat as possible to reduce shear. When I need the head of the bed to be elevated, elevate the foot of the bed as well to prevent me from sliding. Instruct me to shift weight in W/C (wheelchair) every 15 minutes. Place a pressure reducing cushion on the w/c seat. Place a pressure reducing mattress on my bed. Date initiated: 5/23/2016. R12's Care Plan fails to document any refusal or noncompliance with turning or repositioning. R12's Nurses Notes for May and June 2016 has no documentation of refusal to off load pressure to the sacral area when attempted or asked. The facility's Pressure Ulcer policy and procedure, dated 8/1997, documents, in part, A resident who enters the facility with or without (even when the individual's clinical condition demonstrates that they are unavoidable) pressure ulcers will be assessed, and given treatment to prevent the development of ulcers or treated to prevent further development of ulcers. The intent of this policy is to provide assessment and treatment of [REDACTED]. The facility will provide care and services to: Promote the prevention of pressure ulcer development.

Based on observation, record review, and interview, the facility failed to supervise one resident (R14) during toilet use, and failed to follow the air mattress manufacturer's safety recommendations for one resident (R10) of six residents with risks for falls in the sample of sixteen. This failure resulted in R14's fall from the toilet causing a fractured left wrist, multiple facial lacerations, and lacerations to right hand and elbow on 10/1/10. Findings include: 1. R14's record was reviewed as a closed record. The facility's Accident/Incident Report documented R14 had a history of [REDACTED]. R14's Care Plan dated 7/7/10 identified the problem, "Accident/Injury/ADL - I need help with my daily cares. I have fallen in the past. I was recently lowered to the floor by my CNA (certified nursing assistant) in my room." The interventions listed included, "I will need you to assist me with my dressing, grooming, personal hygiene, transfers, and toileting.......I have a hx (history of) falling and was recently lowered to the floor by my CNA in my room.....I have a hx of a left shoulder fracture. I have minimal use of this arm..." The facility's Fall Risk assessment dated [DATE] assessed R14 as HIGH RISK for falls with a score of 13. A score of 10 or above is considered HIGH RISK. On 8/1/10 at 1:15 AM, R14 was found on the floor of her bathroom. The facility's Occurrence Report of that date documented R14 found on the floor. R14 told facility staff she fell g etting off the toilet independently. The facility's Follow Up Report stated (in part), "Resident is currently on a fluid restriction, noncompliant. Resident found multiple times ambulating to the restroom to drink water from the sink....". On 10/1/10 at 3:45 PM, R14's Nursing Notes documented (in part), "CNA summoned nurses to room...Resident noted face down on bathroom floor leaning on R (right) side with R arm under body. Noted small amount of blood on sink and large amount of blood on the floor. Noted head laceration. Resident's shoe off. Head in corner of bathroom.........Noted ST (skin tear) to R. hand measuring 9 cm x 1 1/2 cm (centimeter), and ST to elbow measuring 1.5 cm x 1.2 cm x 5 cm...Lacerations to eye measures 1.3 cm and laceration to forehead measured 3.5 cm x 4.5 cm...Sent to ER to evaluate and treat. Ambulance called". Nursing Notes dated 10/1/10 at 3:15 PM documented R14 was admitted to the hospital with [REDACTED]. The facility's Occurrence Report included a statement by the CNA that R14, "was sitting on the toilet when I went to get a pad for her wheelchair. At that time the resident was still using the restroom (urinating) when I came back for the resident...the resident was screaming and was on the floor....." The Occurrence Report also contained a conclusion note dated 10/8/10 that documented (in part), "Resident has a noted history of self transfers resulting in falls, remains alert and oriented x 3 but chooses not to follow verbal instructions at times." Despite R14's well-documented non-compliance and attempts to self-transfer, R14 was left unattended while seated on the toilet, resulting in hospitalization for a fractured wrist and multiple lacerations. 2. The physician's orders [REDACTED]. The MDS dated [DATE] documents R10 requires extensive assistance with bed mobility, transfers, is nonambulatory, and has limited range of motion with upper and lower extremities. The Fall Risk assessment dated [DATE] documents R10 is assessed as a 7. On 6/15/11 at 9:05 AM, R10 was observed laying on an electric low air loss mattress with built in bolsters on each side. The head of the bed was elevated 45 degrees. R10 had a gastrostomy tube in his abdomen. R10 is nonverbal, and has contractures noted to both hands. R10 could respond by eye movement and smiles. Fall mats were on each side of the bed. R10's bed was in the high position. No side rails were on R10's bed throughout the day of 6/15/11. The corner of the bedside table, near R10 was coated with tape. On 6/15/11 at 10:20 AM, R10's bed was still in the high position. E6, CNA, stated "He (R10) has episodes when he shakes and turns red. His hand and legs shake." R10 was observed to cross his lower legs, but was unable to assist with turning or repositioning. R10 was transferred to a geriatric chair with a mechanical lift. On 6/15/11 at 3:43 PM, R10 was laying in bed on his back leaning to the left with his left arm resting on the left bolster of the bed. The mattress was alternating air throughout the mattress. The head of the bed was elevated. No siderails were on the bed. The bed was in the low position. A physician's orders [REDACTED]." The Resident Occurrence Report dated 5/04/11 documents, "Noted resident lying on floor on right side of bed, head leaned up against nightstand. Neuro checks initiated and within normal limits. Noted pin-point skin tear to right shoulder, abrasion to right knee with bruising and to right elbow. Range of motion within normal limits for resident. Resident awake and smiling at staff. Noted resident on the floor on right side of bed. Trim from nightstand partially torn off. Head of bed was elevated 45 degrees and wedge was in place to back and was positioned on right side." The Report further documents a conclusion as, "Resident has a Huntington"s disease which causes him to have sudden jerky movements. His disease continues to progress but his symptoms are somewhat controlled by medication. Currently uses a (geriatric) chair to assist in sitting posture and utilizes a low air loss mattress with built in bolsters to aid with body alignment. A wedge is placed on backside to provide pressure relief on alternating side due to resident inability to change position. Spoke with hospice RN (Registered Nurse) and resident to now utilize a high/low bed with mats on both sides of bed on the floor." The manufacturer's guidelines for the low air loss mattress, page 3, documents, "(Low air loss) mattresses are not intended to be, and do not function as a patient fall safety device. Siderails must be used with the (low air loss) mattress to prevent falls, unless determined unnecessary based on the facility protocol or the patient's medical needs as determined by the facility, in which case the use of the other suitable patient safety measures are recommended."

Based on interview and record review, the Facility failed provide the assist of 2 staff during a transfer for 1 (R1) of 3 residents reviewed for falls in the sample of 3. This failure resulted in R1 falling during a physical transfer and sustaining an oblique fracture through her distal right fibula. Findings include: Facility Nurses Notes for R1 documents the following: " 4/25/11, 12:30 PM, Summoned to resident's bathroom per daughter. Certified Nurses Aides (CNA's) in bathroom and resident noted on knees on floor. CNA's stated resident got weak during transfer and was lowered to floor. Gait belt on. Assisted to feet and wheelchair with 3 assist and gait belt. Complained of discomfort to knees. 4/25/11, 9:30 PM, CNA reported that resident complaining of pain to bilateral knees. When questioned, R1 says her ankles hurt. 4/26/11, 1:00 AM, Resident complaining of right ankle hurting. Upon assessment, right ankle was noted to be swollen and bruised. Resident stated " I hurt it when I fell " . Ice pack applied to ankle. Physician notified. STAT X-ray ordered. 4/26/11, 6:00 PM, R1's physician here to evaluate and review (R1's) chart. New orders received to transfer to emergency room for evaluation. 10:00 PM, (R1) admitted to hospital with pneumonia " . Facility " Occurrence Report " documents the following " Witness Statement of what happened " written by E4, CNA: " On April 25, 2011, around 12:30 PM, I (E4) was assisting R1 to the toilet. I did this by myself because the other CNA was busy in the dining room. R1 stood really good at first; I had the gait belt on and had her standing. Her pants and (adult incontinent brief) were pulled up. As we were turning towards her chair, she told me her knees were giving out. I then lowered her to the floor, got help and we got R1 up off the floor and laid her down." X-ray "Patient Report", dated 4/26/11, of R1's Right Ankle, shows that "An oblique fracture through the distal fibula is identified. Inferior lateral displacement of the distal fracture fragment is noted. Soft tissue swelling is present". R1's Facility plan of care, dated 4/5/11, documents that she requires the assistance of 2 staff member's with transfers and ambulation. R1's Activity of Daily Living/Falls, documents an intervention of "Two people will need to help me with moving in bed, transferring and ambulating, using a wheeled walker and gait belt " . During an interview with E1, Administrator, on 5/2/11, at 9:45 AM, it was stated that E4 should not have transferred R1 independently and that R1 always requires the assistance of at least two staff members for transfers. E1 said that R1 went to the hospital on [DATE]. When R1 was discharged from the hospital, she was admitted to another Facility. R1 has resided at the Facility since 7/2/10. R1 has diagnoses, in part, of COPD, Osteoarthritis and Atrial Fibrillation. R1's most recent Facility Minimum Data Set (MDS), documents that she requires the assistance of at least one staff member for all activities of living, and is dependent on the assistance of 2 staff members for transfers.