Every finding on record at Batavia Rehabilitation and Health Care Center

Based on interview and record review, the facility failed to ensure falls with injury was reported to the State Agency and failed to ensure information in the final reportable submitted to the State Agency was accurate. These failures affected 2 (R7 and R13) out of 2 residents reviewed for submission of a reportable in the total sample of 39 residents. Findings include: 1.R7's (08/25/2026) Final reportable documented, in part Staff interview did note an incident on 8/14 where resident was noted next to bed on fall matt. Resident was assessed at the time and no changes noted. On August 26, 2026, at 10:39am, V1 (Administrator) reviewed the final reportable and read Staff interviews did note an incident on 8/14 where resident was noted next to bed on fall matt. Resident was assessed at the time and no changes noted. V1 stated no one witnessed the fall incident but R7 was assessed on 08/14/2026. Inquiring if there's any documentation that would support this statement. V1 stated he reviewed his medical record and there was no documentation that he was assessed and as the old cliché goes, if not documented, it never happened. V1 stated the expectation with submission of reportable to IDPH was it should be as accurate as it could be. V1 stated he could not provide documentation that R7 was assessed on that day. On August 25, 2026, at 2:50pm, V2 (Director of Nursing) read the witness statement dated 08/22/2026 and stated during shift change, (V4 – Certified Nursing Assistant) notified (V9 – Registered Nurse) that R7 was on the floor mat. V4 and V9 went to the room and R7 was on the floor mat, mostly on the hard floor. V2 stated it was a fall, and it should have been reported to her, to the family, doctor, hospice nurse; and the nurse should do risk management for fall and to document the fall. V2 stated V9 was expected to do all that if she was on duty. V2 stated the purpose of documenting the fall in case there was an injury, everyone was notified, and the nursing staff were aware to monitor the resident. Something to reference to if later on the resident was noted with skin alteration of change in condition. V2 stated nobody documented the fall incident on 8/14/2026. Nobody documented a post fall note which should be done every shift for 72 hours. On August 25, 2026, at 2:57pm, V2 (Director of Nursing) stated R7 had a fall on August 14, 2026, and another fall on July 01, 2026, and there should be 2 Falls risk management documents but only was one documented, which was the fall on July 01, 2026. On August 26, 2026, at 10:59am, V2 (Director of Nursing) read R7's final reportable that was submitted by V1 on August 25, 2026, which showed Resident was assessed and no changes noted. V2 stated Who assessed R7? Nothing was documented about his fall. V2 stated (V1) needed to amend the final reportable because the statement in the final reportable that (R7) was assessed was not an accurate statement. V2 stated she did not know if there was a policy about submitting reportable with accurate information; but on her professional opinion, the facility was expected to submit the final reportable with accurate information. R7's progress notes, dated August 12 through 22, 2026 were reviewed. There was no documentation of R7's fall incident on August 14, 2026; no documentation written on 08/14/2026 from any department. The email correspondence with V2, dated August 26, 2026, documented, in part IDPH reportable documentation should consist of an initial report with a final report submitted within five days after the facility investigation has come to completion. All reportable documentation should include accurate information. 2. R13's face sheet, dated August 25, 2026, showed R13's diagnoses included dementia with other behavioral disturbance, unsteadiness on feet, restlessness and agitation, and anxiety disorder. R13's MDS (Minimum Data Set), dated August 10, 2026, shows R13's cognition was severely impaired. Review of R13's care plan showed R13 had impaired cognitive function and thought processes related to dementia, was at risk for elopement and disruptive behaviors, memory loss, and other significant judgement concerns, and R13 had a communication problem related to a language barrier. Review of R13's progress notes showed R13 experienced a fall on March 10, 2026, and no injuries were identified. Progress notes dated March 10, 2026, to March 11, 2026, show R13 was monitored by nursing staff and R13 did not complain of pain/discomfort and no injuries were identified from the fall. R13's progress note, dated March 12, 2026, showed, While getting up this resident from bed by CNA resident started to be agitate and aggressive. Resident bit her lip and noted with fresh blood from lower lip. Lower lip with open wound measuring 1 cm in size. Resident didn't' fall per CNA statement. Resident alert/confused. No facial grimacing noted. Ice pack applied to affected site. R13's progress note, dated March 12, 2026, showed, After behavior issue incident, observed that resident's right wrist slightly swollen with pain when touched. Facial grimacing noted. [Physician] was notified with order STAT portable to right wrist - 2 views due to swollen and pain. R13's X-Ray report, dated March 16, 2026, shows R13 was diagnosed with a dislocation of her right ulna relative to the carpal bones. On August 25, 2026, at 11:15 AM, V2 (Director of Nursing) stated V1 conducted the investigation regarding R13's dislocated wrist but V1 could not locate the investigation file. V2 stated V1 was the facility abuse coordinator and R13's injury was investigated as an injury of unknown origin and abuse. V2 stated she had the final investigation report in her computer, but she did not submit the final investigation to Illinois Department of Public Health. V2 provided a copy of the final investigation report, dated March 20, 2026, showed R13 was sent to the hospital emergency room for pain and swelling of her right wrist. The report shows R13 was diagnosed with a dislocation of her ulna relative to the carpal bones. The report shows an investigation was conducted but failed to show that the police or Illinois Department of Public Health were notified of the incident or investigation. On August 25, 2026, at 10:19 AM, V1 (Administrator) stated V2 (Director of Nursing) did a reportable regarding R13's dislocated wrist but he was unable to locate the investigation or evidence the report provided to Illinois Department of Public Health. Review of Illinois Department of Public Health incident reports fail to show the incident/investigation was reported to the Department of Public Health. Facility Abuse, Prevention, and Prohibition Policy, dated November 2025, showed nursing staff were responsible for reporting the appearance of injuries of unknown origin and upon report of such abnormalities of suspicious injuries the Director of Nursing/Designee was responsible for evaluation and assessment. The document showed, If the sources of the injuries are unknown, an Occurrence Report must be completed, and an investigation initiated. Law enforcement and your state agency must be notified within two hours of the discovery of the injury and an investigation initiated immediately.

Based on interview and record review, the facility failed to ensure a fall incident and post fall assessment was documented in the resident's medical record. This failure affected 1 of 3 residents (R7) reviewed for falls in the total sample of 39.Findings include:R7's investigation of a fall provided by V1 (Administrator) on August 24, 2026, documented, in part August 22, 2026, had been trying to get hold of (V9- Registered Nurse) for several days. V1 discovered V9 was traveling. When V1 interviewed V9 it was reported that on Friday the 14th, (V8 - Licensed Practice Nurse) was coming on duty to relieve (V9). V4 (Certified Nursing Assistant) heard a thump around 3:00pm. V4 found R7 on the floor near the door near the safety floor mat, but R7 was mostly on the hard floor. When V9 mentioned the incident the first time, V9 inferred that it was long time ago, but when (V1) inquired further (V1) understood it happened on Friday the 14th of August.R7's progress notes dated August 12-22, 2026, were reviewed with no documentation of R7's fall incident on August 14, 2026; there was no documentation written on August 14, 2026, from any department.The email correspondence dated August 25, 2026, with V2 (Director of Nursing) only include one Risk management for fall dated July 01, 2026. No other risk management document for fall was provided.The Daily Staffing assignment dated August 14, 2026, documented that V4 (Certified Nursing Assistant) was assigned to R7 during the 6am - 2pm and 2pm - 10pm shifts, V8 (Licensed Practice Nurse) was assigned to R7 during the 2pm -10pm shift, and V9 (Registered Nurse) was assigned to R7 during the 6am - 2pm shift.On August 26, 2026, at 10:10am, V4 stated on 08/14/2026 at 1pm, she came to R7's room to change his incontinence brief. V4 stated she left R7 in bed. V4 explained around 3pm she was on her way to the restroom located across his R7's room when she heard an unusual sound coming from his R7 room. V4 stated she went to his room, and V4 saw R7 on the floor mat; the floor mat was about 4inches thick. V4 stated she asked R7 what he was trying to do and R7 stated he wanted to go to the bathroom. V4 stated she hollered and V9 (Registered Nurse) came in. V4 stated when she came in, she did not know what V9 did because she left the room to use the restroom. V4 stated that was considered a fall, and she reported to her (V9) that he fell. V4 stated she did not know what was expected of the nurse if there was a fall incident, but she was sure she, as a CNA, had to report to the nurse a fall incident in which she did.On August 25, 2026, at 12:37pm, V9 stated she already gave a report to V8 (Licensed Practice Nurse) when somebody told her that R7 was on the floor mat. This surveyor inquired if she completed a risk management document for the incident. V9 stated no because she already gave report to V8, and she was already leaving, and the other nurse, V8 should follow the documentation on the fall. On August 26, 2026, at 11:34pm, V8 (Licensed Practice Nurse) stated she was not aware of any incident R7 had on August 14, 2026, and nobody reported to her that R7 had a fall incident. V8 stated V9 did not endorse that R7 had a fall on that day. On August 25, 2026, at 2:50pm, V2 (Director of Nursing) read the witness statement dated August 22, 2026, and V2 stated during shift change, (V4 - Certified Nursing Assistant) notified (V9 - Registered Nurse) that R7 was on the floor mat. They (V4 and V9) went to the room, and R7 was on the floor mat, mostly on the hard floor. V2 stated it was a fall, and it should have been reported to her, to the family, doctor, and hospice nurse; and the nurse should do risk management for fall and document the fall. V9 was expected to do all that if she was on duty. V2 stated the purpose of documenting the fall in case there was an injury, everyone was notified, and the nursing staff were aware to monitor the resident. V2 explained the documentation of the fall incident would be something to reference if later the resident was noted with skin alteration or change in condition. V2 stated nobody documented the fall incident on August 14, 2026. Nobody documented a post fall note which should be done every shift for 72 hours.On August 25, 2026, at 2:57pm, V2 (Director of Nursing) stated there was a fall on August 14, 2026, and a fall on July 01, 2026, there should be 2 fall risk management documents but only one was documented, which was the fall on July 01, 2026. The facility provided their Skilled Nursing Post-Fall Quick Reference Guide for Licensed Nurse dated May 2025, documented, in part Assess resident head to toe. Check for ROM (Range of Motion). Perform skin assessment. Safely transfer the resident back into their chair, wheelchair, bed, etc. Investigate the fall by recreating what happened and determine root cause by using Fall Huddle Tool and Risk Management as a guide. After you determine the root cause, implement a new intervention to prevent the resident from falling again. Call your nurse manager to discuss. Call the resident representative and the provider. Make them aware of the details surrounding the fall and what the new intervention will be to prevent another fall from occurring. Use telehealth if available and applicable. Document a progress note with details surrounding the fall. Include resident representative notification and provider notification. If the resident received an injury from the fall, document this by completing a SBAR. Make sure a treatment order is obtained and documented on in the EHR. Document an occurrence report in full. Utilize Risk Management in PCC for the occurrence report if PCC is used. Complete a new fall risk assessment in the resident's electronic health record. Update the care plan through the fall risk assessment. Communicate the resident's fall by utilizing the communication board in shift-to-shift report. Document q (every) shift for the next 72 hours.

Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse by an employee. This applies to 1 of 3 (R1) residents reviewed for physical abuse. This past noncompliance occurred from 8/24/2025 to 9/10/2025. Findings include: R1's EMR (Electronic Medical Record/EMR) showed she was admitted to the facility on [DATE] with multiple diagnoses, including dementia with mood disturbances of restlessness and agitation. R1's Abuse Risk assessment dated [DATE] said she was at risk for abuse due to her mental, emotional, physical, and behavioral changes related to her dementia. R1's care plan said she required staff to give her time and redirection to minimize her behaviors. R1's MDS (Minimum Data Set) dated 11/12/2025 said she was severely cognitively impaired. On 12/08/2025 at 9:15 AM, R1 was calmly sitting in the common area. R1 was severely cognitively impaired and unable to be interviewed regarding her reported abuse incident on 8/24/2025. At 10 AM, V8 (Certified Nurse Assistant/CNA) said she routinely cared for R1 and, at times, R1 would display behaviors of agitation related to her dementia and required redirection to reduce her anxiety. V8 said after R1's reported abuse incident involving V3 (CNA), the facility conducted mandatory education on dementia care and abuse prevention. On 12/08/2025 at 12 PM, V3 was contacted for an interview regarding R1's physical abuse incident on 8/24/2025 but was unavailable. On 12/08/2025 at 12:25 PM, V4 (Agency RN) was also contacted for an interview regarding R1's physical abuse incident on 8/24/2025 but was unavailable. V4's witness statement dated 8/24/2025 said that approximately at 3 PM, he observed V3 pulling R1's hair and pushing her to sit back down into her chair. V4's statement further said V3 denied the incident. Then he contacted all the responsible parties to report the incident. V4 also performed a skin check on R1 after the incident, and no injury was noted, and R1 did not display any signs of distress. The Final Reportable from R1's 8/24/2025 incident showed Abuse substantiated based off witness statement. CNA employment terminated. Resident has no noted ill effects from incident, no injury noted and no change in behavior/demeanor. On 12/08/2025 at 12:30 PM, V2 (Director of Nursing/DON) said V1 (Administrator) was the facility's abuse coordinator and was immediately notified of R1's incident on 8/24/2025. V2 said the facility implemented their abuse policy and concluded the allegation of physical abuse from V3 (CNA) towards R1 was substantiated based on V4's eye-witness statement. V2 said all residents had the right to be free from abuse. V1 also reported V3 was unavailable for an interview after she was terminated on 8/24/2025. The facility's Abuse policy dated 03/2025 said all residents had the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone. The facility's abuse prohibition program includes the following components: Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/Response. Residents will be monitored for behavior changes, and intervention strategies will be implemented to prevent the occurrence of abuse. Prior to the survey date of 12/08/25, the facility had taken the following actions to correct the noncompliance:On 8/24/2025, V3 (CNA) was removed from the facility immediately and officially terminated from the facility.On 9/02/2025, a facility-wide staff in-service titled Prevention and Prohibition on Dementia Care Education was completed.On 9/10/2025, a facility-wide staff in-service regarding the facility's Abuse Prevention policy was completed, which included a post-quiz on the topic and was completed for all staff. The Administrator/Abuse Coordinator continues to review all resident grievances and abuse allegations. The facility has not identified any abuse allegations after the incident on 8/24/2025.On 9/10/2025, the facility performed a QA (Quality Assurance) meeting with the facility's Medical Director, Administrator, and Director of Nursing to review the facility's plan of correction and monitoring plan.

Based on interview and record review, the facility failed to provide 8 hours of RN (Registered Nurse) coverage on 20 days during the past 6 months. This applies to all 37 residents who reside in the facility. The findings include: The PBJ (Payroll Based Journal) report for quarter 4 2024, showed dates in December when there was no RN on duty. V2 (Director of Nursing) provided documentation to show she was the RN on some of those December dates. Review of the staffing schedule with V2 showed that December 7, 8, 22, 25, and 29, 2024 did not have any hours of RN coverage working in the facility. V2 stated on June 3, 2025, at 11:12 AM, that the facility does use agency staff. V2 stated she had to work out a system with payroll to report V2 hours as RN coverage for PBJ. V2 stated she works Monday through Friday and provides the RN coverage on those days. Review of January, February, March, April, and May 2025, staffing schedules with V2, showed there was no RN coverage for 8 hours, and V2 did not work on the following days: January 1, 4, 5, 18 and 19, 2025, February 13, 2025, March 1, 16, 24, 25, 29, 30, 31, 2025, April 26, 2025, and May 26, 2025. V6 (LPN Licensed Practical Nurse/ MDS nurse) stated on June 2, 2025, at 2:28 PM there were only LPNs that worked on some days because we did not have RNs who could work. On June 2, 2025, at 2:10 PM, V1 (Administrator) stated the facility had five stars but last year the facility began reducing nurse staffing which caused occasional shortages in RNs. V1 stated if an RN had last minute call off and the facility was unable to find an RN to fill in and cover the call off that would also cause an RN shortage. DON is an RN and works full time.

Based on interview and record review, the facility failed to develop and present a facility QAPI (Quality assurance Performance Improvement) plan. This applies to all 37 residents residing in the facility. The findings include: Long Term Care Facility Application for Medicare and Medicaid, dated June 2, 2025, shows the facility census was 37. On June 3, 2025, V1 (Administrator) provided a document QAPI Policy, dated January 2024, and stated the document was the facility's QAPI plan. The document shows, The QAPI Program takes a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality while involving all caregivers in practical and creative problem solving. The community QAPI Program achieves the following: monitor quality/performance, find opportunities for improvement, improve performance, achieve resident/family desired outcomes, meet regulatory requirements, understand the CMS (Centers for Medicare & Medicaid Services) survey process and regulations, provide a QAPI path to correcting issues. The QAPI Program consists of monthly/quarterly meetings, daily quality assurance activities, 'QAPI tasks' and Performance Improvement Plans. The document fails to show how the committee will identify and correct quality deficiencies, failed to reflect specific aspects unique to the facility population and programs, track and measure performance, how goals and thresholds for performance would be established, systems of analyzing root causes of quality concerns, and monitoring/evaluating the effectiveness of corrective actions. On June 3, 2025, at 10:34 AM, V1 (Administrator) stated he confirmed with corporate that the QAPI Policy he provided was the facility QAPI plan.

Based on interview and record review, the facility failed to have a water management plan for Legionella which included ways to intervene when control limits are not met and to document control measures for the prevention of Legionella growth. The facility also failed to follow their Infection Prevention and Control Program for surveillance of infections. This applies to all 37 residents residing in the facility. The findings include: The facility's Long-term Care Application for Medicare and Medicaid dated June 2, 2025, showed the facility's census was 37 residents. 1. On June 4, 2025, at 2:19 PM, V10 (Maintenance Director) said for the facility's water management plan for Legionella, V10 empties the hot water heaters about once a month but does not empty the kitchen's hot water heater because there is a water softener. V10 said the only thing he does with the shower heads is replace them when they break which is about three times a year. On June 4, 2025, at 2:26 PM, V1 (Administrator) said V10 should be following the facility's water management plan for Legionella. V1 said he completed a Legionella environmental assessment form for the facility last year but did not do anything with assessment when it was completed. The facility's water management plan for Legionella dated December 13, 2019, showed Control Measures: Water Heaters are maintained at appropriate temperatures 60 degrees Celsius and above; Annual cleaning of water heaters and thermostatic mixing valves; Quarterly dissemble shower heads to be cleaned and disinfected; Quarterly clean and/or replace faucet aerators; Weekly randomly check hot and cold water temperatures, (let run for one minute before); Weekly flush toilets, taps, and shower heads not in use; Continuous Positive Airway Pressure machines use distilled water and are changed daily; Humidifiers for oxygen concentrators use humidified water and are changed every three days . The facility does not have documentation to show the control measures were being monitored. The facility's water management plan for Legionella does not include interventions if control measures cannot be met. On June 3, 2025, at 3:40 PM, V1 said he provided the facility's new water management plan for Legionella. V1 provided a one-page facility document titled Water Management Program, Facility Legionella Base Line/Annual Testing dated May 23, 2019. The document showed Instruction: Each Senior Health Care Facility will purchase through [medical equipment company] the following kit: .Kit will be ordered, and four base line tests will be administered at each facility (one test for reserve). Listed below are the locations for testing to be recorded for base line . Once the test kits arrive, ensure all Water Management Program check list and logs have been active and proceed with the testing. Utilize the Legionella test log to record the initial base line results for validation. If failed test identify area test is pulled from and start with immediate actions to secure and flush system, inspect for any impedance to the system, check system integrity for leaks or deterioration, compare to other test locations and validate if any other tests have similar results . On June 4, 2025, at 2:26 PM, V1 confirmed the document was instructions for performing Legionella testing in the facility. 2. On June 3, 2025, at 1:54 PM, V2 (DON/Director of Nursing) said she has been the facility's Infection Preventionist since 2020. V2 said she used to perform McGeer's Criteria for infections but stopped some time last year. V2 said she does not use a standardized tool for data collection of resident infections to identify if a resident has an infection. V2 said the facility had a COVID-19 outbreak in April 2025, and 10 residents tested positive for COVID-19. The facility's April 2025 Resident Infection Control and Antimicrobial Log does not show the residents who were positive with COVID-19 infection. The facility's policy titled Infection Prevention and Control Program Manual- Surveillance dated 2019, showed Infection Surveillance- Overview: Purpose: Infection prevention begins with routine and ongoing surveillance to identify possible communicable diseases or infections before they can spread to other persons in the facility or have the potential to cause an outbreak. The facility closely monitors all residents who exhibit signs/symptoms of infection through ongoing surveillance and has a systemic method for collecting, consolidating, analyzing, and interpretation of data concerning the frequency and cause of a given disease or event, followed by dissemination of that information to those who can improve the outcomes. The intent of surveillance is to identify possible communicable diseases or infections before they can spread to other persons in the facility. In addition, surveillance is crucial in the identification of possible clusters, changes in prevalent organisms, or increases in the rate of infection promptly. The results should be used to plan infection control activities, direct in-service education, and identify individual resident problems in need of intervention.

Based on interview and record review, the facility failed to develop an Antibiotic Stewardship Program with a standardized tool and criteria to assess residents for infections. This applies to all 37 residents residing in the facility. The findings include: The facility's Long-term Care Application for Medicare and Medicaid dated June 2, 2025, showed the facility's census was 37 residents. On June 3, 2025, at 1:54 PM, V2 (DON/Director of Nursing) said she has been the facility's Infection Preventionist since 2020. V2 said she used to perform McGeer's Criteria for infections but stopped some time last year. V2 said she does not use a standardized tool for data collection of resident infections to identify if a resident has an infection. V2 said the facility does not have a current Antibiotic Stewardship Program policy. On June 4, 2025, at 10:18 AM, V2 said she had been behind on tracking resident antibiotic use in April 2025 because V2 had to work on the floor as a nurse. V2 said she was unable to keep up with her work. The facility's policy titled Infection Prevention and Control Program dated 2019, showed Mission of Program: The primary mission is to establish an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy: It is the policy that this facility's Infection Prevention and Control Program (IPCP), is based upon information from the Facility Assessment and follows national standards and guidelines to prevent, recognize and control the onset and spread of infection whenever possible. The Infection Prevention and Control Program includes: .3. An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use . Elements of the Program Include: . Antibiotic Stewardship and review including

Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications. This applies to 3 of 5 residents (R13, R18, and R21) reviewed for unnecessary medications in the sample of 14. The findings include: 1. The EMR (Electronic Medical Record) showed R18 was admitted to the facility on [DATE], with multiple diagnoses including neurocognitive disorder with Lewy Bodies, unspecified psychosis not due to a substance or known physiological condition, major depressive disorder, anxiety disorder, paranoid personality disorder, Alzheimer's disease, and unspecified mood disorder. R18's MDS (Minimum Data Set) dated March 31, 2025, showed R18 had severely impaired cognitive skills for daily decision making. R18's Order Summary Report dated June 3, 2025, showed an active medication order dated April 18, 2025, for Haloperidol (antipsychotic medication) Lactate Oral Concentrate 2 mg (milligrams)/ mL (milliliters), give 0.75 mL by mouth every two hours as needed for agitation/restlessness. R18's May 2025 MAR (Medication Administration Record) showed R18 received as needed Haloperidol on May 20 and May 24, 2025. The EMR showed R18 had orders for as needed Haloperidol from November 25, 2025, to June 4, 2025. The facility does not have documentation to show R18 was directly examined by the prescribing practitioner to assess R18's continued need for an as needed antipsychotic medication every 14 days. On June 4, 2025, at 2:42 PM, V2 (DON/Director of Nursing) said as needed antipsychotic medications should only be prescribed for 14 days. V2 said after 14 days, the order should be discontinued, and a new order should be obtained from the physician. V2 said a resident receiving an as needed antipsychotic medication needed to be evaluated by the physician in order for the medication to be reordered. 2. The EMR showed R13 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, major depressive disorder, dementia, unspecified psychosis, and bipolar disorder. R13's MDS dated [DATE], showed R13 had severe cognitive impairment. R13's Order Summary Report dated June 4, 2025, showed an active medication order dated March 31, 2025, for Lorazepam (antianxiety medication) oral tablet 0.5 mg, give one tablet by mouth every eight hours as needed for anxiousness. R13's April 2025 MAR showed R13 received 15 doses of as needed Lorazepam. R13's May 2025 MAR showed R13 received 13 doses of as needed Lorazepam. The facility does not have documentation to show the prescribing practitioner documented the rationale for the extended time and indicate a specific duration for R13's as needed psychotropic medication. On June 4, 2025, at 2:42 PM, V2 said as needed psychotropic medication should only be prescribed for 14 days. V2 said after 14 days, staff should obtain a new order for the as needed psychotropic medication. 48308 3. R21's admission record showed R21 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, unspecified dementia, hypertensive heart disease, alcohol abuse with unspecified alcohol induced disorder, major depressive disorder and anxiety disorder. R21's physician order summary showed R21 had an order for Aripiprazole 1 mg (milligram, antipsychotic medication,) daily. The date of the initial order was not available due to the recent change in the EMR (Electronic Medical Record) system. The Consultant Pharmacist Recommendation to Prescriber dated April 29, 2025, for R21 showed a recommendation for GDR (Gradual Dose Reduction) of Aripiprazole 1 mg to dose every other day for 1 week and then discontinue the medication, due to no behaviors documented in the month of April. On June 4, 2025, at 12:47 PM, V2 (DON) referred to the psychotropic medication log and stated it showed the initial order date for Aripiprazole 1 mg was August 5, 2022. V9 (Social Services Director) and V2 stated R21 was not currently receiving psychiatric services. V2 stated R21's attending physician was prescribing the medication currently. V2 stated she did not give the recommendation form from the pharmacist to the prescriber. R21's behavior monitoring record for the months of April 2025, May 2025 and June 1-4, 2025, showed there were no episodes of behavior documented. On June 4th, 2025, at 12:47, V2 and V9 stated R21's behavior had been stable for months. The GDR recommendation dated April 29, 2025, had not been presented to the prescriber for review as of June 4, 2025, despite stable behavior and R21 remains on psychoactive medication without documented indication for continued use. The facility's policy titled Psychotropic Medication Use dated February 2025, showed Policy: Residents will only receive psychotropic medications when necessary to treat specific symptoms for which they are indicated and effective.Procedure: .4. Based on assessing the resident's symptoms and overall situation, the medical practitioner will determine whether to continue, adjust, or stop existing psychotropic medication.6. The timeframe for PRN (as needed) psychotropic medications, which are antipsychotic medications is limited to 14 days without exception, unless the attending provider evaluates the resident and deems it necessary.

Based on interview and record review, the facility failed to develop comprehensive care plans for residents' oxygen use and need for trauma-informed care. This applies to 2 of 14 residents (R19 and R25) reviewed for care plans in a sample of 14. The findings include: On June 5, 2025, at 10:38 AM, V2 (Director of Nursing) stated R19 and R25 should have had care plans developed for their oxygen use and their post-traumatic stress disorder. 1. R25's admission record showed R25 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, history of pneumonia and bipolar disorder. R25's physician order summary showed R25 had an order for oxygen 2-3L (liters) per NC (Nasal Cannula) as needed for shortness of breath, initiated on May 31, 2025. R25's progress note dated May 22, 2025, at 3:10 PM showed R25 experienced shortness of breath and used oxygen 3L (Liter) per NC (Nasal Cannula) for oxygen saturation 80-82 % on room air. R25 was transferred to the local emergency roiagnom on [DATE], at 8:50 AM and diagnosed with pneumonia and returned to the facility at 6:05 PM. R25's care plan initiated on April 1, 2025, for asthma and shortness of breath while lying flat, did not address the use of oxygen, monitoring parameters for when to use oxygen or safety precautions for the use of oxygen. 41855 2. R19's EMR (Electronic Medical Record) showed R19 was admitted to the facility on [DATE]. 2023, with diagnoses that included dementia unspecified severity with psychotic disturbances, anxiety, depression, and PTSD. R19's MDS (Minimum Data Set) dated March 31, 2025, showed R19 had mild cognitive impairment, and her active diagnoses included anxiety, depression, psychotic disorder, and PTSD (Post-traumatic stress disorder). R19's care plan showed there was no assessment of R19's diagnosis of PTSD, identification of PTSD triggers, or interventions to assist with R19's PTSD. R19's Social Service Quarterly Assessments showed there was no documentation that R19 had PTSD. On June 2, 2025, at 2:27 PM, R19 said she has had a lot of trauma in her life and she didn't know if facility knew that or knew what her triggers were. On June 4, 2025, at 12:22 PM, V7 (LCSW/Licensed Clinical Social Worker) said R19 does have a diagnosis of PTSD (Post Traumatic Stress Disorder) but said R19's PTSD is not active, meaning she has no symptoms related to her PTSD. V7 went on to say that R19 had experienced some childhood trauma that included physical abuse, mental abuse, verbal abuse, and neglect by her parents. R19 also experienced sexual assault sometime between her teenage years and adulthood. R19 also had a history of domestic abuse by her significant others. V7 said R19 does not have any triggers that she is aware but then stated R19 has nightmares about the abuse by her parents and displays anger issues with other residents. R19 also demonstrates abandonment issues when her family member leaves town by claiming she has physical ailments. For example, a couple weeks ago when R19's family member went out of town, R19 complained of breast pain. The facility provided their December 2024 policy titled Trauma Informed Care. The policy showed, It is the policy of this facility to consider residents past traumatic experiences in developing person centered care plans designed to avoid re-traumatization through the application of the principles of trauma-informed care .Procedure: Identification of trauma survivors during the admission/intake process, residents and/or residents' representatives are given the voluntary opportunity to answer questions regarding trauma and to discuss their experiences to the extent they are comfortable. At least annually, residents and/or their representatives are again given the voluntary opportunity to answer questions regarding trauma and to discuss their experiences to the extent they are comfortable. Residents/representatives may disclose information regarding trauma at any time they feel comfortable in doing so. Care Planning for Trauma Survivors- Interdisciplinary staff work together with the resident/resident's representatives to assess the resident's needs and to identify triggers that may cause the survivor to remember the traumatic event and induce a reaction similar to when the resident was originally traumatized. Care plan should describe the resident's cultural preferences, values, and practices and include approaches to meet the resident's cultural needs. Care plan should describe interventions which consider the resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization and psychosocial harm. Care plans are reviewed and revised as needed on at least a quarterly basis . Facility provided their December 2024 policy, titled Care Planning. The policy showed, Purpose: 1. To assess each resident's strengths, weaknesses, and care needs 2. To use this assessment data to develop a comprehensive Plan of Care (POC) for each resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning, and wellbeing as possible .

Based on observation, interview, and record reviewed the facility failed to date and contain resident's oxygen equipment for a resident with oxygen concentrator in their room. This applies to 1 of 1 resident (R25) reviewed for oxygen use in the sample of 14. The findings include: R25's admission record showed R25 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, history of pneumonia and bipolar disorder. R25's physician order summary showed R25 had an order for oxygen 2-3L (liters) per NC (Nasal Cannula) as needed for shortness of breath, initiated on May 31, 2025. On June 2, 2025, at 12:51 PM, R25's room had an oxygen concentrator in the room with tubing and nasal cannula that was undated and stored draped over the concentrator and touching the floor. There was no oxygen in use sign on the door to the room. R25's progress note dated May 22, 2025, at 3:10 PM showed R25 experienced shortness of breath and used oxygen 3L per NC for oxygen saturation 80-82 % on room air. R25 was transferred to the local emergency roiagnom on [DATE], at 8:50 AM and diagnosed with pneumonia and returned to the facility at 6:05 PM. On June 4, 2025, at 1:00 PM, R25's oxygen concentrator remained in the room with the tubing draped over the concentrator and touching the floor, there was no date on the tubing of the last tubing change. There was no oxygen in use sign on the door to the room. On June 4, 2025, at 1:10 PM, V2 (Director of Nursing) stated there should always be an oxygen in use sign on the door when there is oxygen in the room. V2 stated R25 still had an active order for oxygen use and the tubing should be labeled with the date of last change and the tubing should be changed weekly. The facility's policy titled Oxygen Administration, undated, showed Preparation 1. Verify that there is a physician order for oxygen administration and .Steps in the Procedure .3. Place an Oxygen in use sign on the outside of the room entrance door. Close the door.

Based on observation, interview, and record review, the facility failed to assess a resident with PTSD (Post-Traumatic Stress Disorder) and identify triggers. This applies to 1 of 1 resident (R19) reviewed for trauma informed care in a sample of 14. The findings include: R19's EMR (Electronic Medical Record) showed R19 was admitted to the facility on [DATE]. 2023, with diagnoses that included dementia unspecified severity with psychotic disturbances, anxiety, depression, and PTSD. R19's MDS (Minimum Data Set) dated March 31, 2025, showed R19 had mild cognitive impairment, and her active diagnoses included anxiety, depression, psychotic disorder, and PTSD. R19's Social Service Quarterly Assessments showed there was no documentation that R19 had PTSD. R19's POS (Physician Order Set) showed there were no orders to monitor for triggers or behaviors related to R19's diagnosis of PTSD. On June 2, 2025, at 2:27 PM, R19 said she has had a lot of trauma in her life and she didn't know if facility knew that or knew what her triggers were. On June 4, 2025, at 12:22 PM, V7 (LCSW/Licensed Clinical Social Worker) said R19 does have a diagnosis of PTSD (Post Traumatic Stress Disorder) V7 said R19's PTSD is not active, meaning she has no symptoms related to her PTSD. V7 went on to say that R19 had experienced some childhood trauma that included physical abuse, mental abuse, verbal abuse, and neglect by her parents. R19 also experienced sexual assault sometime between her teenage years and adulthood. R19 also had a history of domestic abuse by her significant others. V7 said R19 does not have any triggers that she is aware of but then stated R19 has nightmares about the abuse by her parents and has anger issues with other residents. R19 demonstrates abandonment issues like claiming to have physical ailments when her family member leaves town. For example, a couple weeks ago when R19's family member went out of town, R19 complained of breast pain. On June 4, 2025, at 10:47 AM, V6 (MDS Nurse) provided copies of hospital records she reviewed and used to obtain R19's medical diagnoses. The hospital records showed R19 has PTSD. V6 said she talked to V9 (Social Services) and was told R19 had no issues. V6 said she does not know what R19's trauma is or what the triggers are. The facility provided their December 2024 policy titled Trauma Informed Care. The policy showed, It is the policy of this facility to consider residents past traumatic experiences in developing person-centered care plans designed to avoid re-traumatization through the application of the principals of trauma-informed care. Definitions: Trauma: Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. The individual's experience of the event(s) determines whether it is a traumatic event. An event may be traumatic for one individual & not for another. The individual's interpretation will determine whether it is experienced as traumatic. Trauma: Informed Care: An approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma; recognizing the widespread impact and signs and symptoms of trauma; and avoiding re-traumatization . Trigger: Something that causes the survivor to remember the traumatic event and induces a reaction like when they were originally traumatized. Triggers can re-traumatize survivors .Procedure: Identification of trauma survivors during the admission/intake process, residents and/or residents' representatives are given the voluntary opportunity to answer questions regarding trauma and to discuss their experiences to the extent they are comfortable. At least annually, residents and/or their representatives are again given the voluntary opportunity to answer questions regarding trauma and to discuss their experiences to the extent they are comfortable. Residents/representatives may disclose information regarding trauma at any time they feel comfortable in doing so.

Based on interview and record review, the facility failed to ensure a resident did not receive an unnecessary medication. This applies to 1 of 5 residents (R4) reviewed for unnecessary medications in a sample of 14. The findings include: Face sheet, dated June 4, 2025, shows R4's diagnoses included urinary tract infection. Hospital records, printed December 14, 2024, show R4's diagnoses included complicated UTIs (Urinary Tract Infections). POS (Physician Order Sheets), printed June 4, 2025, shows the following physician orders: Bactrim 400-80 mg (milligrams) one tablet daily every Monday, Wednesday and Friday- start date April 1, 2025, and to be given indefinitely. Nursing progress note, dated April 13, 2025, shows R4 was sent to the hospital after experiencing weakness and lack of responsiveness. Review of R4's hospital discharge record, printed April 13, 2025, shows no orders for Keflex or Bactrim on the after visit summary medication list. The discharge record shows R4's diagnoses included UTIs (Urinary Tract Infection). Nursing progress notes, dated April 13, 2025, shows R4 returned to the facility from the hospital. The progress notes shows R4 had a new order for Keflex 500 mg twice daily for seven days. POS (Physician Order Sheets), printed June 4, 2025, R4 received a physician order on April 13, 2025, for Keflex 500 mg two capsules twice daily for UTI. The order shows no stop date was provided when the order was entered into the clinical record. The POS shows the antibiotic was discontinued on May 8, 2025. The POS shows R4 continued to receive the Bactrim as ordered on April 1, 2025, while receiving the Keflex. POS, printed June 4, 2025, shows R4 received another physician order on May 8, 2025, extending R4's order for Keflex 500 mg two capsules twice daily for UTI. The POS shows the Keflex was discontinued May 13, 2025. The POS shows R4 continued to receive the Bactrim as ordered on April 1, 2025. Review of the clinical record shows no documentation that supported the use of Keflex and Bactrim concurrently or that the Keflex to be continued for more than 7 days. On June 4, 2025, at 10:18 AM, V2 (Director of Nursing) reviewed the hospital records that were sent with R4 on readmission and no antibiotic order for Bactrim or Keflex were identified. V2 stated the nurse on duty placed an order in R4's clinical record for Keflex when R4 was readmitted to the facility. V2 stated she was unable to locate any clinical documentation by R4's nurse as to where the nurse received R4's order for Keflex. V2 stated she was not sure if the original order for Keflex was given for 7 days or more because the order was entered into the system differently than what was written on the progress note indicating the Keflex was to be given for 7 days. V2 stated it appeared the Keflex order was placed in the clinical record system to be given for 30 days however the nurse documented in the progress notes R4 was only supposed to only get the Keflex for a total of 7 days. V2 stated R4's order for prophylactic Bactrim should have been on hold while R4 was receiving Keflex so R4 did not receive Keflex and Bactrim at the same time. V2 stated she was behind on tracking the facility antibiotic use during April 2025 because she was working as a floor nurse often and was not keeping up with her work. Resident Infection Control and Antimicrobial Log, dated April 2025, shows R4 received Keflex 100 mg (milligrams) twice daily for 30 days from April 13, 2025, to May 13, 2025. The log indicated that there was clinical documentation to support the antibiotic use. The log also shows R4 was receiving Bactrim on Mondays, Wednesdays and Fridays, beginning on April 1, 2025, for UTI (Urinary Tract Infection) prophylaxis. The log indicated that clinical documentation was available to support the antibiotic use.

Based on observation, interview, and record review, the facility failed to puree food items to a smooth consistency per their facility policy. This applies to 3 of 3 residents (R2, R18, R22) reviewed for pureed diets in the sample of 14. The findings include: On June 3, 2025, at 11:25 AM, V4 (Cook) was preparing pureed diets. He said there are three residents with pureed diet orders in the facility. V4 was preparing pureed spaghetti with meat sauce and pureed green beans. V4 used tongs and placed three servings of noodles into the food processor and then he used the four-ounce scoop per the recipe and placed three scoops of meat sauce into the food processor with the noodles. Per the recipe, he also added three ounces of water and blended it. Visually, there were small pieces of unblended noodles and meat. When tasted, there were small pieces of noodles and meat that needed to be chewed. V4 pureed fresh green beans by taking the four-ounce scoop and placing three servings into the food processor with 1/4 tsp chicken base, three ounces of water, 2 3/4 tsp of thickener. After he pureed the green beans, the consistency was not smooth and when tasted there were pieces of skin in the pureed green beans. V3 (FSM/Food Service Manager) tasted both the spaghetti with meat sauce and the green beans and said they both needed to be pureed more to a smooth, pudding like consistency. V4 was asked to puree the spaghetti and green beans again. V4 was not able to get the green beans to a smooth pudding like consistency and was told he could not serve the green beans. The facility provided a list of residents in the facility that required a pureed diet which included R2, R18 and R22. The facility provided their undated policy titled, Pureed Foods. The policy showed . measure and add commercial thickener, stabilizer or shaping/enhancing product as directed in the recipe and process until blended. Scrape down the sides and reprocess until very smooth like pudding .

Based on observation, interview, and record review, the facility failed to properly label/date/seal/store items, discard expired items, ensure the chloride dishwasher and quaternary sanitation bucket strips are not expired, and wear hair restraints while in the facility kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated [DATE] documents that the total census was 30 residents. On [DATE] at 10:38 AM, V11 (Dietary Manager) said all residents eat from the facility kitchen; there are no NPO (Nothing by Mouth) residents. On [DATE] starting at 10:10 AM, the facility kitchen was toured in the presence of V11 (Dietary Manager). For the entirety of the kitchen tour, V11 did not wear a hair restraint or beard restraint. During the kitchen tour, the following was found: In the kitchen refrigerator: 1. A package of opened turkey breast deli meat. Deli meat was in its original package but was not sealed and not labeled or dated. Surveyor showed the package to V11, and he said, it's not good and he removed the meat from the refrigerator. In the dry storage: 2. Three boxes of 11-ounce vanilla wafers dated with a best by date of [DATE]. While testing the quaternary sanitizer bucket: 3. V11 tested sanitizer bucket with QT-40 strip and got a result of 400ppm first, then retested with a new strip and got a result of 300ppm. Surveyor asked V11 what the result should be, and he said he thought 300ppm. Surveyor asked V11 to look up what the result should be and get back to her. The QT-40 strips had an expiration date of [DATE]. While testing the low temperature dishwasher: 4. The chloride strips were used to test the dishwasher and the strips had an expiration date of [DATE]. V11 said he just opened those strips and did not notice the expiration date. V11 said he has been the Dietary Manager at the facility since [DATE], and he has never ordered new testing strips. On [DATE] at 10:38 AM, V11 (Dietary Manager) said the results from the sanitation bucket and the low temperature dishwasher were not accurate because the strips were expired. On [DATE] at 12:15 PM, V11 said he doesn't wear a hairnet because his hair is usually shaved, but he knows his hair was not currently shaved. V11 said the facility does not have any beard nets; he has to order some. On [DATE] at 1:11 PM, V11 said all expired food items should be removed from storage because once expired the food loses flavor and it could make the residents sick if it is fed to them. V11 said all foods including deli meats, should be labeled, dated, and sealed to avoid any contamination, cross-contamination, and/or feeding expired or contaminated foods to a resident with the potential to make them sick. V11 said kitchen staff need to check test strip expiration dates before using them for low temperature dishwasher and sanitation bucket to ensure they get an accurate result. V11 said the correct level for the sanitizer is ,d+[DATE]ppm. V11 said he blames the high result obtained on [DATE] on the strips being expired. V11 said those results with the expired strips were inaccurate. V11 said all kitchen staff needs to wear hair and beard restraints as appropriate to make sure their hair does not fall out into the food, contaminating it, and making the residents sick. The facility's policy titled, Personal Hygiene and Dress Code last revised ,d+[DATE] states, .the food service employees adhere to the facility's dress code that will ensure safe, sanitary meal production and service and presents a professional appearance. Procedure: Food service staff involved in food production and clean-up will adhere to the department dress code that includes: .8. Hair net or appropriate hair coverings, including facial hair covering . The facility's policy titled, Storage revised ,d+[DATE] states, Storage .Procedure: .6. When using only part of a product, the remaining product should be in the original package or airtight container and labeled and dated . The facility's policy titled, In-place Equipment revised ,d+[DATE] states, Policy: .Procedure: .5. Before sanitizing in-place equipment or surface, use an appropriate test strip to check the sanitizer level in the sanitizing bucket .b. For Quat sanitizers, the level should be 200 ppm .

Based on interview and record review the facility failed to enter a physician's order that reflects the resident chosen code status. This applies to 2 of 3 residents (R7 and R21) reviewed for advanced directives in a sample size of 18. Findings include: 1. R7 was admitted to the facility on [DATE]. R7 has medical diagnoses that includes cerebral infarction, aphasia, hypertension, lymphedema, morbid obesity, hemiplegia and hyperlipidemia. On [DATE] at 11:24 AM, V13 RN (Registered Nurse) stated residents are identified as a DNR (Do Not Resuscitate) by the red circular sticker on their chart and the advanced directives at the front of their chart. V13 stated R7 was a DNR although R7 had a red sticker on her chart. The chart had no advanced directives or POLST (Practitioner Order fir Life Sustaining Treatment) form or current DNR physician's order. On [DATE] at 12:20 PM, V8 LPN (Licensed Practical Nurse) assigned to R7 stated R7 is considered a full code because there is not a completed POLST or current physicians order for DNR (Do Not Resuscitate). On [DATE] at1:45 PM, V9 LPN / MDS (Minimum Data Set) Coordinator stated V14 Social Worker was responsible for assuring the POLST form is completed. On [DATE] at 1:52 PM, V14 Social Worker stated she obtains the POLST / advanced directives during the admission when the residents or their POA (Power of Attorney) signs the admission contract. The POLST is then placed in V19 Physician's folder at the nursing station. V14 stated it is up to the V19 Physician and nursing to assure there is a DNR order and the POLST form is signed by the physician. On [DATE] at 2:00 PM, V13 RN provided access to V19's folder. No POLST form for R7 was in the folder. V13 stated V19 Physician looks in the folder when she rounds in the facility. V13 RN stated she has never placed a POLST form in V19's Physicians folder. V8 LPN and V15 RN denied ever placing a POLST form in V19's Physician folder or obtaining V19's signature on a POLST form. The facility provided a copy of the POLST form that was not in R7's medical record that was signed by R7's health care power of attorney on [DATE] requesting DNR (Do Not Resuscitate) comfort focused treatment. V19 Physician signed the POLST on [DATE] approximately two months after it was initiated. 46409 2. On [DATE], at 1:11 PM, R21's Advance Directives form, dated [DATE], showed she was Full Code but would only want comfort focused treatment in the instance the resident was coding. On [DATE], at 1:47 PM, R21 said she would want everything done to bring her back if she stopped breathing or her heart stopped. On [DATE], at 12:45 PM, V17 (RN/Registered Nurse) said R21 was a full code and wanted everything done, but her POLST (Physician Orders for Life-Sustaining Treatment) form showed she was a full code with comfort focused treatment. V17 said the comfort focused treatment meant they would relieve pain, give oxygen to make sure the patient felt comfortable, and if they request to go to the hospital, to send them. On [DATE], at 3:27 PM, V14 (Social Services/Admissions) said she was the one who coordinated the POLST form with the residents and doctors. V14 said the residents can be full code and receive comfort focused treatment. V14 said if full code was checked, it meant she wanted CPR (Cardio-Pulmonary Resuscitation) and the comfort focused treatment meant they would not want to be in pain and would not want a tube, but that should be explicitly stated on the POLST form. At 3:32 PM, V14 said the form needed to be fixed to reflect full code and full treatment. On [DATE], at 3:30 PM, V3 (DON/Director of Nursing) said the residents could not be full code and have comfort focused treatment. V3 said comfort focused treatment would limit what kind of treatment the resident received. On [DATE], at 2:01 PM, V19 (Medical Director) said if a resident's Advance Directive form shows full code, they must have full treatment. V19 said a resident could not have full code with comfort focused treatment, which was clearly stated on the form. R21's face sheet showed she was admitted with diagnoses including generalized anxiety disorder, major depressive disorder, tremor, and hypothyroidism. R21's MDS (Minimum Data Set) [DATE], showed R21 was cognitively intact. The facility's Advanced Directives Policy revised [DATE], showed Advance directives will be respected in accordance with state law and facility policy. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive.

Based on observation and interview the facility failed to preserve a resident's privacy and dignity. This applies to one resident R8 reviewed for privacy in a sample size of 18. Finding include: R8 was admitted to the facility on [DATE] with diagnoses that includes transient ischemic attack, peripheral vascular disease, gastro-esophageal reflux disease, hypertension, hyperlipidemia, heart failure, leg weakness, hypothyroidism, osteopenia and macular degeneration. On 8/13/24 at 1:51 PM, V5 CNA (Certified Nursing Assistant) provide R8 incontinence care and left the bedroom window curtains open. R8's first floor room window is clearly visible to the parked cars near her window. As V5 stepped away from R8 to retrieve supplies from the bathroom leaving R8 exposed from the waist down; R8 exclaimed my butt, and everything is on display. V5 CNA informed R8 she only exposed her to get her cleaned up. On 8/14/24 at 3:44 PM, V3 DON (Director of Nursing) stated the standard practice is to close the curtains while providing residents' care. Window curtains near the parking lot should be closed to provide the resident privacy. The facility provided policy Incontinence Care dated 5/16/22 states drape residents for privacy.

Based on observation, interview, and record review, the facility failed to have an accurate fall risk assessment after a fall. This applies to 1 of 1 resident (R16) reviewed for falls in a sample of 18. The findings include: R16 is an [AGE] year-old female admitted on [DATE] having severe cognitive impairment as per the MDS (Minimum Data Set) dated 5/3/24. Record review on fall risk assessment dated [DATE] documents that R16 is at high risk for falls. Record review of the facility presented fall policy revised on 11/10/18 document: 1. Conduct fall assessment on the day of admission, quarterly, and with a change in condition. 2. Identify the resident's risk for falls on admission. A visual prompt (red star) may be placed on the name plaque by the entrance to the residents' room This system provides staff with a visual alert to monitor those at risk for falls. On 8/14/24 at 1:00 PM, no red star was observed with R16's name plaque at the door side. On 8/14/24 at 2:10 PM, during the infection control task, V3 (Director of Nursing) stated that R16 is not on high risk for fall, that's why they didn't put the red star with name plaque at door side. Record review on nursing progress note dated 8/9/24 and fall log for 8/2024 documented that R16 had a fall on 8/9/24 and was sent out to the local hospital for further evaluation. Record review of the Physician Order Sheet (POS) for 08/24 and Medication Administration Record for 08/24 documented that R16 is getting antihypertensive medication (Coreg 6.25 milligrams twice daily). A record review of the fall risk assessment dated [DATE], after the fall, showed documentation of an inaccurate assessment by not counting the score for antihypertensive medication towards the total score for fall risk, yielding a low risk for falls. On 08/15/24 at 11:23 AM, V9 (MDS Coordinator) stated, An inaccurate fall risk assessment can cause the resident to fall. With an accurate fall risk assessment, R16 could have been at high risk for falling, and staff could have implemented the high-risk fall interventions. On 8/15/24 at 2:00 PM, V9 presented a corrected fall risk assessment showing that R16 is at high risk for falling.

Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care for residents who required assistance from staff. This applies to 2 of 2 residents (R15, R8) reviewed for ADL care in a sample of 18. The findings include: 1. On August 13, 2024, at 11:25 AM, R15 appeared to have fingernails which were 1.5 inches long on both hands. R15 said the staff do not cut his nails and the staff do not do anything for him. On August 14, 2024, at 9:28 AM, R15 still had long fingernails and his toenails were between 0.5 inches to 1 inch long. On August 15, 2024, at 10:42 AM, R15's fingernails and toenails were still long. R15 said he did want his nails cut, but the staff won't cut them for him. R15 said they cut his fingernails a long time ago. On August 15, 2024, at 10:47 AM, V20 (CNA/Certified Nurse Assistant) said the CNAs were not allowed to cut the nails of residents who have diabetes but were allowed to clean his nails. On August 15, 2024, at 10:50 AM, V13 (RN/Registered Nurse) said the nurses cut the nails of the residents with diabetes. V13 said the residents should not have nails past their fingers because it increases their risk for injuries and ingrown nails. V13 also said it can break the skin and cause infections. V13 said R15 refused to have his nails cut and he was care planned accordingly, but she could not say for certain it was in the care plan. On August 15, 2024, at 11:27 AM, V9 (MDS/Minimum Data Set Coordinator) said nail care should be offered once a week and if a resident refused care, they should be care planned for refusal. R15 was admitted to the facility with diagnoses including type 2 diabetes mellitus, hyperlipidemia, hepatomegaly, and diseases of intestine. R15's MDS dated [DATE], showed R15 had severe cognitive impairment and required moderate assistance from staff for personal hygiene. R15's care plan dated April 16, 2024, showed R15 had diabetes mellitus, with interventions including to Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. R15 also had a care plan for potential for impairment to skin integrity [related to] fragile skin, use/side effects of medications and diabetes, with interventions including to Avoid scratching .keep fingernails short. R15's care plan did not address refusal of nail care as a problem area. The facility's undated Nail Care policy showed Resident's nails will be trimmed, clean and free of rough edges. If a resident is alert and oriented and refused nail care, it will be reflected on the care plan. The facility's undated AM care policy showed Provide nail care. 46003 2. R8 was admitted to the facility on [DATE] with diagnoses that includes transient ischemic attack, peripheral vascular disease, gastro-esophageal reflux disease, hypertension, hyperlipidemia, heart failure, leg weakness, hypothyroidism, osteopenia and macular degeneration. R8's MDS (Minimum Data Set) dated 6/17/24 states R8 is completely dependent on staff for personal and toileting hygiene. R8's care plan dated 6/17/24 states R8 is dependent for ADLs (Activities of Daily Living) due to further decline in ability / participation. R8 has altered bladder incontinence related to dementia, limited mobility, medication use. Interventions include clean peri-area with each incontinence episode. Check every two hours or as needed and as required for incontinence. Wash, rinse and dry perineum. On 08/13/24 at 9:40AM, at entrance of the facility, in the conference room and throughout the facility a strong stench of urine was noted. The facility had an odor of urine during the entire day and on 8/14/24 and 8/15/24 as well. On 8/13/24 at 1:51 PM, V5 CNA (Certified Nursing Assistant) provided incontinence care to R8. R8's incontinence brief was overly saturated with urine. R8's buttocks and peri-area were reddened. During incontinence care R8 complained that her buttocks and peri area were sore. V5 stated R8 was gotten out of bed by the night shift staff and that was the first time she was receiving incontinence care since getting up that morning. V5 stated R8's usual routine is to be left up in her chair. During incontinence care V5 CNA wiped R8's stool covered buttocks with a moist washcloth folded it and proceeded to wipe urine and stool covered labia / perineum with the same washcloth five times. On 8/14/24 at 3:44 PM, V3 DON (Director of Nursing) stated residents are provided incontinence care at least every two hours and as needed or upon request. V3 stated R8 should have been provided incontinence care two hours after she was gotten out of bed. V3 stated waiting until after lunch to provide incontinence care to R8 was too long if she was gotten up in the early morning. V3 stated sitting in a urine-soaked incontinence brief will contribute to skin break down. The facility provided policy Incontinence Care dated 5/16/22 states all incontinent residents will receive incontinence care in order to keep skin clean, dry and free of irritation and or odor. Incontinence care will be provided as required. It is the responsibility of the CNA to provide incontinence care. It is the responsibility of the charge nurse to ensure all incontinent residents receive appropriate incontinence care. It is the responsibility of the Director of Nursing to ensure that all nursing staff have received adequate training on the provision of proper incontinence care.

Based on observation, interview and record review the facility failed to provide meals that meet a resident's health care needs as ordered by the physician. This applies to 1 of 1 resident (R5) reviewed for diet orders in a sample size of 18. Findings include: R5 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes, depression, recurrent falls, arthritis, essential tremors, high cholesterol, hypertension, tachycardia, vitamin D deficiency, and depression. R5's MDS (Minimum Data Set) dated 6/27/24 shows moderate cognitive impairment with a BIMS (Brief Interview for Mental Status) score of 12. On 8/13/24 at 10:12 AM, R5 stated she is served too much starchy / carbohydrates and needs to eat more vegetables. R5 stated she is diabetic and that was not noted on her meal card. R5 stated that all residents get the same food items. R5 stated she informed the facility she was a diabetic during her admission to the facility. On 08/13/24 at 12:11 PM, R5's meal card had a blue dot and read regular diet thin liquids dislikes beef. R5's lunch consisted of a large serving of potatoes, a pastry with egg, ham and cheese, a regular sized piece of chocolate cake with white icing the same size as other residents. On 8/13/24 at 12:20 PM, V7 [NAME] stated the meal served to all the residents was potatoes and a flour tortilla with egg, ham, cheese, onion, green pepper and cheddar cheese. V7 stated the blue dot on the meal card indicates a regular diet. On 8/14/24 at 12:31 PM, R5's meal card had a blue dot and read regular diet thin liquids dislikes beef. V5's lunch consisted of a large amount of rice with chicken bits, green beans, wheat bread, a glass of milk, coffee, and vanilla pudding with whipped cream the same serving size as other residents. On 8/14/24 at 12:36 PM, V7 [NAME] stated the dietary manager fills out the meal card and the cook will prepare the meal tray based on the meal card. On 8/14/24 at 12:39 PM, V11 Dietary Manager stated he fills out the resident meals cards with the meal ordered based on information provided by the resident's nurse. V11 Dietary Manager stated he interviews residents for their food preferences. V11 stated diabetics are ordered the low carbohydrate and sugar free meal choices, but the only difference between the regular diet and the diabetic diet is diabetics are not given a regular sugar packet. V11 stated the only specialized diets are renal, pureed, mechanical and vegetarian. The vanilla pudding served to the residents is regular pudding with whipped cream, not sugar free pudding. V11 stated the cook plates the food based on the meal card. V11 stated he did not know anything about a facility dietary manual. On 8/14/24 at 3:44 PM, V3 DON (Director of Nursing) stated diabetics are served low concentrated sweets and it is not the same as a regular diet. The nurse that receives the diet order is responsible to communicate the diet order to dietary. Dietary completes the meal card based on the current diet order they receive from the nurse. V3 DON stated she submits the current diet ordered for residents to the dietary manager monthly. R5's nutritional assessment completed by the dietician on 6/27/24 diagnosis of uncontrolled diabetes mellitus. R5's diet ordered LCS (Low Concentrated Sweets). R5 was identified as being obese / overweight. Likes 2% milk with all meals and dislikes beef. R5's physician orders include low concentrated sweets carbohydrate-controlled diet and sliding scale insulin coverage. R5's care plan dated 6/22/24 states R5 has an altered endocrine system related to diabetes mellitus II. Interventions include dietary consult for nutritional regimen and ongoing monitoring. Diabetes is a chronic disease and compliance is essential to prevent complications of the disease. Encourage R5 to practice good general health practices- compliance with dietary restrictions. The undated facility provided policy Diet Orders states the physician initially writes a diet order in the medical record indicating they type of diet to be served and / or any all-subsequent changes in the diet. A diet order form is completed and sent to the dietary department. The facility provided policy Dietary Services Communication dated 4/16 states the food service manager or designee is responsible for monitoring the proper completion of the dietary services communication. The facility provided policy Cycle Menu dated 4/14 states LCS (Limited Concentrated Sweets) - concentrated sugar items are replaced with reduced carbohydrate items. Regular desserts are allowed in controlled portions. The LCS diet includes artificially sweetened beverages and condiments. The policy does not specify a carbohydrate-controlled diet.

Based on observation, interview, and record review the facility failed to make efforts to resolve grievances. This applies to all 37 residents residing in the facility. The findings include: The facility Census and Condition of residents form #672 dated 7/18/23 documents there are 37 residents residing in the facility. R24's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include hypothyroidism, panic disorder, lack of coordination, major depressive disorder, and dissociative and conversion disorder. R24's facility assessment dated [DATE] showed she has no cognitive impairment. R29's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include polyosteoarthritis, spinal stenosis, and depression. R29's facility assessment dated [DATE] showed she has no cognitive impairment and is dependent on staff for all cares. On 7/20/23 at 11:06 AM, R29 said she has mentioned concerns in resident council and has received no follow up. R29 said clothing gets lost when it is sent to laundry. R29 said she was told that sometimes the CNAs might put laundry in the garbage bin instead of the laundry bin. R29 said she is missing tops and slacks. R29 said the facility hasn't followed up with her on the missing items and hasn't replaced anything but maybe they have it in the back of their mind to do it later. On 7/20/23 at 11:06 AM, R24 (Resident Council President) said the facility used to post the menus each day so they would know what they were having. R24 said they have asked them to put the menus up again because that would give them time to choose something different if they did not like what was on the menu to be served. R24 said they thought maybe even if there was a chalkboard or something they could just quickly write the menu on that would work too. R24 said they would just like to know what they are having for the day. R24 said there is some sort of menu up on the wall behind the piano, but the piano is always there, so it is never visible. On 7/18/23 at 11:30 AM, there was an old menu on the wall behind an upright piano, but the menu was not accurate. The facility's resident council meeting minutes dated 5/24/23 showed, . Dietary, Residents would like the daily food menus to be posted. What are the food substitutes? . Housekeeping/Laundry, Laundry goes missing for a couple of months . The facility's resident council meeting minutes dated 6/21/23 showed, . Dietary . The daily menus are not posted. Get a black/white board and write the daily menus on it . Housekeeping/Laundry . [R20] is missing gray [NAME] shirt, Residents want to be able to search the laundry room for their belongings . On 7/18/23 at 11:16AM, V7 (Dietary Manager) said he hasn't put the menu out yet this month, but he will. On 7/20/23 at 12:37 PM, V2 DON (Director of Nursing) said she is not aware of any grievances. V2 said the grievances are usually given to V3 (Activity Director) or V6 (Social Services Director). V2 said if there are any nursing concerns brought up in resident council V3 would come tell her. The process does not include anything written. On 7/20/23 at 12:58 PM, V3 (Activity Director) said they hold a resident council meeting once a month. V3 said when the meeting is over, he types up the minutes. V3 said there is follow up to the resident's concerns through resident council. V3 said, After the resident council meeting, the President comes to me and we go through the concerns. After that I tell each department head what the concerns were that pertain to them. We don't fill out a grievance form or anything in writing. Sometimes it's verbal, sometimes I just hand them the meeting minutes. I think I told [V7 Dietary Manager] about the menus. If the concern was missing laundry, I would give that to [V9] (Laundry Supervisor) and she would take care of it. The follow up is all verbal as well. [Environmental Specialist] is not here right now she is on vacation this week. [V6 Social Services Director] would only get involved if the concern was a resident that was having behaviors, she does not follow up on resident council concerns. On 7/20/23 at 1:04 PM, V6 (Social Services Director) said, We have a grievance process, but we haven't had any grievances this year at all. Resident council has their meetings and the president and [V3 Activity Director] usually meet with whoever the administrator is at that time and would go over the minutes with them. Depending on what the concern is it. would get directed to that manager that handles that specific area. We have a log of grievances, but we haven't had any grievances this year. Resident council concerns are not necessarily grievances, its more residents expressing preferences. Usually, it's something so minor that it is a quick fix. It all works verbally. The menus were being posted then all of a sudden, they weren't being posted. A concern like that would be verbally given to [V7 Dietary Manager]. It has been posted but some people don't even come out of their rooms. It has not been posted at all this week I did notice that. In the case when they repeat concerns each month through resident council, the administrator would meet with that manager to ensure things gets fixed. I agree, how are they supposed to choose what they want if they don't even know what is on the menu as it is. In the case of missing laundry, the process would be a [V9] (Laundry Supervisor) thing but she is on vacation. [V9] will replace clothing that isn't found but most of the time she will find it. A lot of times, it's called the resident misplaced stuff and they don't remember. [R29] can't misplace anything because of her condition but she is a fabricator. I am not aware of any of clothing missing but [R29] knows to ask [V9] so she would have worked with [V9] on that. She fixes the situation. The facility's policy revised 11/1/17 titled Resident Grievances/Complaints showed, Policy: It is the policy of [the facility] to actively encourage residents and their representatives to voice grievances and complaints on behalf of themselves or others without discrimination or reprisal. Grievances and/or complaints may be reported to the Administrator, any staff member, Resident Council, and to State agencies . Procedure: 2. Resident Council meetings are to allow time for residents to address complaints, grievances and other concerns which shall be reflected in minutes of the meeting. The facility liaison to the Resident Council shall direct complaints and grievances to the grievance official who will take it to the following morning Quality Assurance meeting . 5. When a resident or resident's representative brings a concern or grievance to a staff member and they are unable to resolve the situation immediately, that staff member shall explain the issue to the Social Service Director or their immediate Supervisor. The Supervisor in turn will discuss the concern/grievance with the SSD (Social Service Director). Together they shall review the concern/grievance and initiate an investigation and work to resolve the concern/grievance. 6. Once a concern or grievance has been reported and is not easily resolved, a Grievance/Complaint Report form will be initiated . The facility's undated policy titled Resident Council showed, . It is the policy of [the facility] to establish a Resident Council for the purpose of residents sharing in the planning and controlling of their lives. The Resident Council shall provide a setting where personal choices, opinions, concerns, interests and complaints can be openly discussed. All decisions made by this council shall be made democratically and all residents shall be encouraged to participate in the council . The Resident Council shall communicate to the Administrator the opinions and concerns of the residents. The council shall review procedures for implementing resident rights and facility responsibilities and make recommendations for changes or additions . The council may present complaints or grievances on behalf of a resident to the governing agencies or to any other person the council considers appropriate.

Based on interview and record review, the facility failed to recognize, identify, evaluate and monitor detailed bowel habits to prevent constipation and fecal impaction. The facility also failed to follow physician's orders [REDACTED]. This failure resulted in R1's admission to the hospital with [DIAGNOSES REDACTED]. This applies to one of three residents (R1) reviewed for bowel elimination. The findings include: R1 has [DIAGNOSES REDACTED]. R1 was a [AGE] year old admitted to the facility on [DATE] from the hospital. The POS (Physician order [REDACTED]. It is used for chronic pain management. One side effect of this medication is constipation. R1 was on [MEDICATION NAME] 8 mg (milligram) every night when admitted . The dose was increased to 10 mg every night on 2/15/2019. R1 was also placed on [MEDICATION NAME] (stool softener) as [MEDICATION NAME] for prevention of constipation on 12/14/2018. The initial physician history and physical examination [REDACTED]. Further visits by V7 dated 1/8/2019 shows R1 had episodes of restlessness and anxiety. R1 also complained of generalized pain, headaches and neck pain. V7's visit on 2/26/2019 showed R1 had altered mental status change, urine was cloudy, has been sleepier, and that (R1) does get constipated because of opioids. V7's plan of care were urinalysis and [MEDICATION NAME] for constipation (R1 was already on [MEDICATION NAME] since admission of 12/13/2018). There was also an order [REDACTED]. Furthermore, R1's left kidney is not visible secondary to overlying bowel gas. The MAR (Medication Administration Record) for the month of (MONTH) 2019 shows R1 was given (MOM) Milk of Magnesia 30 ml (millileters) on 2/2/2019 at 4:15 P.M.; 2/8/2019 at 8:00 A.M.; 2/21/2019 at 3:00 P.M.; 2/23/2019 at 9:00 A.M.; and 2/25/2019 at 6:00 P.M. R1 was given MOM because R1 complained of constipation. Further review of the MAR indicated [REDACTED]. It does not show details of bowel habits, if R1 had relief from the MOM, or evacuated stools completely. The bowel monitoring for the month of (MONTH) 2019 shows R1 had bowel movement marked as medium stool for 7 times for 28 days; small stool for 17 days; and no stool for 5 days. R1's clinical record including the bowel and bladder monitoring and nurse's notes showed no documentation of detailed bowel habits to determine and prevent impending obstipation/fecal impaction. There were no comprehensive assessment(s) to identify and manage R1's constipation. The bowel monitoring suggested a none to minimal bowel elimination pattern. However, no assessment was done to identify, recognize, and provide alternate interventions to prevent obstipation and fecal impaction. The clinical chart also showed there was no care plan for R1's bowel management considering R1 was a risk for constipation due to chronic use of opioids. On 3/14/2019 at 11:30 A.M., V2 (Director of Nursing) stated R1 had no care plan for constipation/bowel management. On 3/13/2019 at 11:10 A.M., V5 (Certified Nurse Assistant) stated that she provided care to R1 most of the day/pm shift while R1 was at the facility. V5 also added that R1 was able to verbalize R1's needs. V5 also added R1 needed assistance to go to bathroom for bladder and bowel elimination. V5 stated that she assisted R1 to bathroom. However, R1 complained R1 had difficulty evacuating R1's stools and R1 felt R1 was not emptying the bowel fully. V5 added that she assisted R1 for bowel elimination, but R1 failed to evacuate R1's stools. V5 also stated V8 (R1's family member) had stated to her R1 has constipation problem due to the opioid medication. V5 said she informed the nurse and the nurse gave MOM but V5 was not aware of the result of the MOM and that R1 continued with difficulty passing stools. On 3/13/2019 at 10:30 A.M., V3 (Licensed Practical Nurse) stated care planning regarding R1's care was held with V8 on 2/27/2019. V3 stated V8 had complained regarding R1's constipation. V3 also stated she updated V7 and an order for [REDACTED]. However, R1 remained constipated and V8 requested for a fleet enema to be given to R1. V3 also stated that when she came in the following day on 2/28/2019 (day shift), R1 had not received the fleet enema that was ordered on [DATE] evening time. V3 also added the facility had no stock of fleet enema and that V4 (Assistant Director of Nursing) was about to buy from a local drug store. However, around lunch time of 2/28/2019, V8 came to facility and administered fleet enema without staff's knowledge. V3 also stated that V8 was very involved with R1's care and V8 also is a nurse by profession. V3 also added R1 complained of constipation and MOM was provided occasionally. V3 also stated she did not perform a rectal examination on R1 to check if R1 was impacted. On 3/13/2019 at 11:00 A.M., V4 (Assistant Director of Nursing) stated she was about to buy fleet enema for R1 at a local drug store that day of 2/28/2019. V4 also added around lunch time V8 came to facility with fleet enema and administered the fleet enema to R1. V4 also added that there was no fleet enema stock at the facility at that time. V4 also added she did not perform a rectal examination on R1 to check if R1 was impacted. On 3/13/2019 at 12:15 P.M., V6 (Licensed Practical Nurse) stated V8 informed her on 2/27/2019 before 9:00 P.M., for R1 to have fleet enema to evacuate R1's stools. V6 also added that V8 informed her that [MEDICATION NAME] medication was not enough to relieve R1 of constipation. V6 added that she called V7 and was able to obtain an order for [REDACTED]. On 3/13/2019 at 2:00 P.M., V2 (Director of Nursing) stated V6 can perform rectal examination. However, if V6 was not comfortable doing the rectal examination,V6 should have sought assistance from other nurse(s) to perform rectal examination and determine if R1 was impacted. The nurse's notes dated 2/28/2019 shows R1 was sent to hospital for evaluation and treatment regarding constipation. The nurse's notes also shows that R1 was admitted to the hospital for constipation. The hospital record dated 2/28/2019 shows R1's admitting [DIAGNOSES REDACTED]. The abdominal x-ray dated 2/28/2019 done at the hospital shows R1 has Prominent amount of fecal material in the rectum and colon consistent with obstipation. The Assessment /Plan for R1 at the hospital shows that due to obstipation/fecal impaction, and with failed enemas, stool softeners, and chronic use of [MEDICATION NAME], R1 was given [MEDICATION NAME] to cleanse bowel by causing diarrhea, disimpacted every 4 hours, and a [MEDICATION NAME] consultation. The hospital discharge summary dated 3/7/2019 shows that R1 final [DIAGNOSES REDACTED]. R1's secondary [DIAGNOSES REDACTED]. On 3/14/2019 at 10:30 A.M., V7 (Attending Physician) stated R1 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. V7 stated R1's fecal impaction was preventable if only there was a close monitoring of detailed bowel habits. V7 also stated she should have been informed of R1's minimal evacuation of stool based on the bowel monitoring for the month of (MONTH) 2019. V7 also added this fecal impaction could have been prevented if alternate interventions were implemented and if she would been informed of the minimal stool elimination. V7 also added that her expectation was the facility should have done a comprehensive assessment including rectal examination to determine and recognize impending impaction and that applicable treatment could have been provided timely. V7 also added the fleet enema she ordered on [DATE] should have been administered as soon as she had ordered. V7 also stated the fleet enema would not help due to R1's severe obstipation, however, it might have helped relieve some discomfort.

Based on observation, interview and record review, the facility failed to ensure that a resident was assessed for the need to use bedrails; consent was obtained for the use of the bedrails and a physician order [REDACTED]. This failure resulted in R1 being trapped between the bedrail and the mattress resulting in several abrasions, swollen face and knee, broken shoulder and hospitalization . This applies to one of three resident (R1) reviewed for bedrails in the sample of 3. The findings include: On 12/3/18 at 9:30am, V1 (Administrator) stated R1 is hospitalized due to the incident that occurred at the facility on 11/29/18. V1 stated R1 is yet to be transferred back to the facility. R1's face sheet showed R1 was originally admitted to the facility 3/20/14 with [DIAGNOSES REDACTED]. R1's health records showed R1 with annual minimum (MDS) data set [DATE]. The MDS showed R1 requires extensive assistance of one person physical assist with transfer, bed mobility, toilet use, dressing and hygiene. R1's fall risk assessment dated [DATE] showed R1 with a score of 20 (high risk for falls). R1's fall risk assessment dated [DATE] after an un-witnessed fall was 22. R1's physician order [REDACTED]. R1's bed rail assessment dated (MONTH) 3, (YEAR) identifies R1 as a risk for climbing over bed rails and documents that Resident gets out of bed unassisted during HS (evening hours) at times. Side rails removed for safety. On 12/4/18 at 2:10pm, V14 (CNA) certified nursing assistant stated she cared for R1 on the evening shift of 11/28/18. V14 stated after dinner, she took R1 to his room, changed him and brought R1 back to the dining area. V14 stated she took R1 back to room between 9:30pm and 9:45pm. V14 stated R1 is usually the last resident to be taking to his room because R1 would attempt to get out of bed. V14 stated she had R1's bed in low position before she left R1's room. V14 stated R1's bed alarm was placed but she did not check if the bed alarm was working. V4 (CNA) cared for R1 on the night shift of 11/28/18 was interviewed on (MONTH) 4, (YEAR) at 12:15PM. V4 stated she did not check whether R1's alarm was on but that R1's two side rails were up when she checked R1 around 10:30pm. V4 stated she did not check whether R1's bed alarm was working or not. V4 stated she made round again around between 2am and 3am. Then the next time she made rounds was at 5am. V4 stated that on 11/29/18 at 5am, she saw R1's head trapped between the bedside rail and the mattress. V4 stated R1's face was down on the bed frame because R1's mattress has been pushed against the wall. V4 stated she did not think the alarm was on because usually when R's alarm goes off, the other neighboring residents will call the nursing staff. V4 stated she immediately alerted V3 (Nurse) and then V3 called 911. On 12/4/18 at 12:28pm, V4 went to R1's old room and demonstrated the position she found R1. The position showed R1's head was trapped against the bedside rail and the head board with face on the bed frame. The mattress in this position has been pushed against the wall. On 12/4/18 at 9:07am, V3 (Nurse) stated he worked the night shift on 11/28/18 and cared for R1 with V4. V3 stated around 5am on 11/28/18 she was prompted by V4 to go to R1's room. V3 stated he saw R1 face down, with the right arm under him and the head and left arm hanging outside the bed. V3 stated he flipped R1 over to his back and noticed R1 with some facial swelling, neck indentations and abrasions, both eyes swollen around the orbital. V3 also stated R1 was bleeding from his right ear and nose. V3 stated he panicked and called 911 immediately. V3 stated he did not do a head to toe assessment or check whether R1 had other bruises or abrasions. On 12/5/18 at 12:21pm, V15 (ER Charge Nurse) stated on 11/29/18 she got a call from the ambulance/paramedics on route to the emergency room (ER). V15 sated she received R1 in the ER with excessive abrasions to the face, neck and left knee. V15 stated R1 had diffuse swelling to the right neck and face. V15 stated she called V3 and V3 stated R1 moved a lot in the bed and that R1's head was stuck in the side rail On 12/3/18 at 11:50am, V9 (Hospital social worker) stated emergency room (ER) staff were concerned of the extent of R1's injuries. On 12/5/18 at 2:35pm, V17 (ER Nurse) stated she cared for R1 on 11/29/18 in the hospital ER. V17 she was taken aback about the extent of injuries and abrasions R1 presented with. V17 stated R1's left knee was red, and swollen. V17 stated R1's right eye was swollen, red and his right jaw area was extremely swollen and red. V17 stated there were abrasions on R1's right neck. V17 further stated R1's shoulder area had several abrasions. V17 concluded R1 was in some pain but could not detect how much pain because R1 is non verbal. On 12/5/18 at 2:35pm, V16 (ER Doctor) stated she treated R1 in theER on [DATE]. V16 stated R1 came in with multiple injuries/abrasions in the face, shoulder, knee, neck. V16 stated R1 has [MEDICAL CONDITION]'s so he was not a good historian. V16 further stated R1's injuries showed R1 was trapped in some type of position but that it's hard to tell the position because of the abrasions all over R1's body. V16 stated R1 had fractures to his shoulder and pelvic area. V16 stated no surgery is indicated. On 12/5/18 at 3.24pm, V19 (Doctor) stated she is R1's primary physician at the nursing home. V19 admitted R1 has been at the facility for few years and that this was the first bad injuries R1 had. V19 stated she was informed of the extent of R1's injuries by the hospital records she received. V19 stated she just realized R1 had fractures to the right shoulder and the right pelvic area. V19 stated nursing staff should have followed her orders and have R1 with working bed alarm. V19 further stated the facility should not have put R1's bed side rail up because she did not write order for bedside rail and should have performed more frequent rounding on R1. On 12/3/18 at 1:37pm, V6 (Family member) stated she received a call from V3 that R1 was stuck and had marks on his neck. V6 stated she went to the hospital to check on R1 and could not recognize R1 because of the injuries to R1's face, neck and body. On 12/3/18 at 9:45am, V2 (Director of Nursing) stated she received a call from V3 on 11/29/18 stating that R1's head was face down and hanging off the bed. V2 stated R1's bed side rail was discontinued after the care plan meeting on 10/3/18. V2 stated she informed the nursing staff to no longer use R1's bed side rail. On 12/4/18 at 2:55pm, V2 stated there was no formal in service as per side rail use but she informed the nursing staff by words of not to use R1's bed side rails. R1's hospital records showed R1 was admitted to the ER [DATE] with injuries that included the following: rhabdomyolysis after an entanglement with bed rail, right sided facial and right scalp soft tissue swelling and parotid gland, small right shoulder avulsion fraction, small right hip avulsion fracture, multiple abrasions, several bruises. The hospital report also showed a progress note dated 11/29/18 5:50am R1 was noted to have his neck stuck in the side rail of the bed, with swelling to the right face/eye. When asked for the side bed rails, V2 stated we are not allowed to use the rails and it was removed few days ago after the incident to R1. On 12/3/18 at 3:26pm, V12 (Facility Maintenance Director) stated V1 asked him to remove the bedside rails. V12 stated R1's bed rails were removed 11/30/18 and put in the facility's garage. V12 was asked to retrieve R1's bedside rails and re-applied one upper and one lower left side of the bed rails. A review of R1's plan of care dated (MONTH) 3, (YEAR) does not include a plan of care for the use of bed rails. R1's plan of care was updated after the incident on (MONTH) 30, (YEAR) to include a special mattress. A review of R1's record did not include consent for the use of the bed rails that was used to keep R1 in bed nor an assessment for the use of the side rail. A review of R1's physician orders [REDACTED]. bed rails. Review of facility's policy titled, 'Physical restraint/enabler policy' with a revised date 7/24/18 showed, a device that may constitute a physical restraint may include, but is not limited to: bed rails The policy also showed, complete physical enabler evaluation is required prior to using an enabler. The policy also showed facility must obtain verbal or written consent from resident's responsible party prior to use of an enabler. The facility's policy also showed doctors order must be obtained that would show specific medical/physical reason, type of enabler to be used.

Based on observation, interview and record review the facility failed to monitor a full thickness burn (3rd degree burn) for a resident. As a result R1 was in the facility from August 31, 2017 until September 7, 2017 (7 days) without treatment of [REDACTED]. This applies to 1 of 3 residents (R1) reviewed for injuries. The Findings Include: The Face Sheet documents that R1 was admitted on [DATE] with pertinent [DIAGNOSES REDACTED]. On September 12, 2017 at 1:35PM, R1 was in the room at another nursing facility with Z2(Family Member). Z3 (Wound Care Nurse/Other Nursing Home/Facility B) rolled R1 over to her abdomen and on the posterior and lateral aspect of R1's left thigh was a large 4 by 4 gauze. Upon removal of the gauze and non-adherent dressing by Z3 (Wound Care Nurse at Facility B), a large opened area of redness with a scattered yellow center was observed. Z3 (Wound Care Nurse/ Facility B) said R1 came from the hospital with an order for [REDACTED]. became flushed with redness, and eyebrows heightened, Z2 began to rub R1's face and consoled R1 with a hug Progress Note dated August 31, 2017 at 5:10PM, documents Writer preparing medication when loud moaning observed/heard from R1 in the dining room. R1 unable to state what happened. Water, ice spilled on the table, coffee mug noted on the floor. Writer and CNA (Certified Nursing Assistant) assisted resident back to room and removed clothing. Left thigh pants noted wet. Left lateral thigh area reddened, blanchable, kept resident comfortable. Facial grimacing/moaning observed. As needed [MEDICATION NAME] 50 milligrams given by mouth. No distress noted. No shortness of breath noted. Doctor paged. Vital signs are temperature, (96.7F), pulse (69), Respiration (18), and blood pressure (130/64). At 5:15PM, Return call from medical doctor, no new orders received, Stated to monitor resident Progress Note dated August 31, 2017 at 10:30PM states, R1 is alert, responsive, sleeping comfortable in bed, easily aroused. No signs and symptoms of distress noted. No signs/symptoms of pain or discomfort. Left lateral thigh redness subsides, small reddened area apparent, no open area noted to area . Progress Note dated September 1, 2017 at 6AM documents, . No redness, no blister noted to the left thigh Progress Note dated September 3, 2017 at 8AM documents .left thigh without signs of infection . There was no documentation of the burn/ wound description after September 3, 2017 at 8AM. Progress Note dated September 7, 2017 states, R1 was noted lethargic, slow to response, generalized weakness, poor appetite, pertinent vitals blood pressure was 96/55, oxygen was 94 percent on room air. The doctor was notified and R1 was sent out to the hospital and admitted with diagnosis' of dehydration and pneumonia. The Treatment Administration Record dated September 1, 2017 through September 7, 2017 was reviewed. An O for other skin issues was marked on each day for the 6-2 AM shift only (one shift of monitoring). There was no description of the thermal burn wound documented. On September 12, 2017 at 11:09AM via telephone E4 (Nurse) said she recalls on August 31, 2017 at 5PM, she was passing medication and heard a loud noise . E4 said she came into the dining room and saw R1 moaning. There was ice and water on the table and a coffee mug on the floor. Only residents were in the dining room/no staff. E4 said she went to get a CNA and does not recall who the CNA was and that the CNA helped her move R1 from the dining room to the room. In the room they took off R1's clothes and there was a reddened area to the thigh. E4 did not recall which thigh or the location of the wound. E4 said it was a burn, she made R1 comfortable gave pain medication, notified the doctor, family and the E2 (DON). The Hospital Record dated September 7, 2017 through September 12, 2017 was reviewed. The description of the wound states, Left hip region reported thermal injury prior to admission measuring 9 Centimeters in length by 4.5 centimeters in width by less than 1 cm in depth. Red perimeter with yellow slough tissue to center. Small amount of yellow exudate noted. (Exudate is defined as a mass of cells and fluid that has seeped out of blood vessels or an organ , especially in inflammation.) Surrounding tissue free of infection. The recommendation; cleanse the wound and apply [MEDICATION NAME] ointment and an oil [MEDICATION NAME] gauze and cover with gauze daily. On September 14, 2017 at 9:21AM, Z4 (Wound Care Nurse/Hospital) said she was the wound care nurse that took care of R1 during R1's hospital stay. Z4 said the emergency room staff noted the burn on September 7, 2017, applied a dressing and alerted her to assess the wound. Z4 said it was a full thickness burn with slough. She called the social worker to report this suspicious injury. Z4 said the nursing home staff E4 (Nurse) said she did not know how the burn happened. Z4 said they should have noticed a burn of full thickness if they were monitoring it. Z4 said the burn required [MEDICATION NAME] to prevent infection and daily dressing changes, which was provided in the hospital. On September 19, 2017 at 1:21PM, Z5 ( R1's, Attending Physician) said the nurses alerted him to a hot liquid spill on R1. Z5 said the facility never called him back and he was not aware that R1 suffered a full thickness burn. Z5 said he did not see R1 while R1 was in the hospital. After reading the measurements recorded from the hospital record, Z5 said a 9 centimeter in length by 4.5cm in width by less than 1 cm in width burn that's a Huge Burn, Very Significant'' R1 did not get any treatment while in the nursing home. The nurses should have definitely been aware of a significant burn of that size/description and notified me so that I could treat it. They should have been looking at the wound twice a day. They should have found that if they were monitoring it. On September 20, 2017 at 8:52AM, E2 (Director of Nursing) said she expects the nurses to call the doctor and follow orders for a burn and if the wound/burn deteriorates she expects the nurses to notify the doctor who can make a referral for a wound care physician to treat the wound. E2 said I have no response as to how a resident can sustain a full thickness burn without the nurses observing it.

Based on observation, interview and record review the facility failed to notify the doctor of burn/wound deterioration and provide treatment for [REDACTED]. This applies to 1 of 3 residents (R1) reviewed for injuries. The Findings Include: The Face Sheet documents that R1 was admitted on [DATE] with pertinent [DIAGNOSES REDACTED]. On September 12, 2017 at 1:35PM, R1 was in the room at another nursing facility with Z2(Family Member). R1 was laying in bed thin with dry lips. Z3(Wound Care Nurse/Other Nursing Home/Facility B) rolled R1 over to her abdomen and on the posterior and lateral aspect of R1's left thigh was a large 4 by 4 gauze. Upon removal of the gauze and non-adherent dressing by Z3 (Wound Care Nurse at Facility B), a large area of redness with a scattered yellow center was observed. Z3 (Wound Care Nurse) said R1 came from the hospital with an order for [REDACTED]. Z2 said she had R1 moved to another facility because R1 was admitted to the hospital for severe dehydration and it was unknown to Z2 why R1's dehydration was severe. Upon asking R1 about the burn on the left thigh, R1 began to utter inaudible words in a high pitched voice as R1's face became flushed with redness, and eyebrows heightened, Z2 began to rub R1's face and consoled R1 with a hug. It was undetermined what R1 was trying to communicate about the burn. Progress Note dated August 31, 2017 documents Writer preparing medication when loud moaning observed/heard from R1 in the dining room. R1 unable to state what happened. Water, ice spilled on the table, coffee mug noted on the floor. Writer and CNA assisted resident back to room and removed clothing. Left thigh pants noted wet. Left lateral thigh area reddened, blanchable, kept resident comfortable. Facial grimacing/moaning observed. As needed [MEDICATION NAME] 50 milligrams given by mouth. No distress noted. No shortness of breath noted. Doctor paged. Vital signs are temperature (96.7F), pulse (69), Respiration (18), and blood pressure(130/64). At 5:15PM, return call from medical doctor, no new orders received, Stated to monitor resident. At 5:17PM, Family notified. At 5:25PM, Director of Nursing made aware. Dietary Manager here education provided. Progress Note dated August 31, 2017 at 10:30PM states, R1 is alert, responsive, sleeping comfortable in bed, easily aroused. No signs and symptoms of distress noted. No signs/symptoms of pain or discomfort. Left lateral thigh redness subsides, small reddened area apparent, no open area noted to area . Progress Note dated September 1, 2017 at 6AM documents, . No redness, no blister noted to the left thigh Progress Note dated September 3, 2017 at 8AM documents .left thigh without signs of infection . There was no documentation of the wound description after September 3, 2017 at 8AM. Progress Notes were reviewed from August 31, 2017 through September 7, 2017. The only notes that provide any detail of the burn were on August 31, 2017, September 1, 2017 and September 3, 2017. Again, there was no documentation of the description of the burn after September 3, 2017. Progress Note dated September 7, 2017 states, R1 was noted lethargic, slow to response, generalized weakness, poor appetite, pertinent vitals blood pressure was 96/55, oxygen was 94 percent on room air. The doctor was notified and R1 was sent out to the hospital and admitted with [DIAGNOSES REDACTED]. The Treatment Administration Record dated September 1, 2017 through September 7, 2017 was reviewed. An O for other skin issues was marked on each day for the shift 6-2 AM only. There was no description of the thermal burn wound documented. On September 12, 2017 at 11:09AM via telephone E4 (Nurse) said she recalls on August 31, 2017 at 5PM, she was passing medication and heard a loud noise . E4 said she came into the dining room and saw R1 moaning. There was ice and water on the table and a coffee mug on the floor. Only residents were in the dining room. E4 said she went to get a CNA and does not recall who the CNA was and that the CNA helped her move R1 from the dining room to the room. In the room they took off R1's clothes and there was a reddened area to the thigh. E4 did not recall which thigh or the location of the wound. E4 said it was a burn, she made R1 comfortable gave pain medication, notified the doctor, family and the E2 (DON). The Hospital Record dated September 7, 2017 through September 12, 2017 was reviewed. The description of the wound states, Left hip region reported thermal injury prior to admission measuring 9 Centimeters in length by 4.5 centimeters in width by less than 1 cm in depth. Red perimeter with yellow slough tissue to center. Small amount of yellow exudate noted. Surrounding tissue free of infection. The recommendation were to cleanse the wound and apply [MEDICATION NAME] ointment and an oil [MEDICATION NAME] gauze and cover with gauze daily. On September 14, 2017 at 9:21AM, Z4 (Wound Care Nurse/Hospital) said she was the wound care nurse that took care of R1 during R1's hospital stay. Z4 said the emergency room staff noted the wound on September 7, 2017, apply a dressing and alerted her to assess the wound. Z4 said it was a full thickness burn with slough. Z4 said the nursing home staff E4 (Nurse) said she did not know how the burn happened. Z4 said they should have noticed a burn of full thickness if they were monitoring it. Z4 said the burn required [MEDICATION NAME] to prevent infection and daily dressing changes. On September 19, 2017 at 1:21PM, Z5 (R1's Attending Physician) said the nurses alerted him to a hot liquid spill on R1. Z5 said the facility never called him back and he was not aware that R1 suffered a full thickness burn. Z5 said he did not see R1 while R1 was in the hospital. After reading the measurements recorded from the hospital record, Z5 said that's a Huge Burn'' R1 did not get any treatment. The nurses should have definetely been aware of a significant burn of that size/description and notified me so that I could treat it. They should have been looking at the wound twice a day. On September 20, 2017 at 8:52AM, E2 (Director of Nursing) said she expects the nurses to call the doctor and follow orders for a burn and if the wound/burn deteriorates she expects the nurses to notify the doctor who can make a referral for a wound care physician to treat the wound. E2 said I have no response as to how a resident can sustain a full thickness burn without the nurses observing it.

Based on observation, interview and record review the facility failed to provide supervision of a severely cognitively impaired resident while drinking a hot beverage. As a result, R1 sustained a full thickness burn (3rd degree) to her left thigh. This applies to 1 of 3 residents (R1) reviewed for injuries. The Findings Include: The Face Sheet documents that R1 was admitted on [DATE] with pertinent [DIAGNOSES REDACTED]. The Minimum Data Set, dated dated dated [DATE] documents additional [DIAGNOSES REDACTED]. The MDS also documents a Brief Interview for Mental Status Score of 3, indicating severe cognitive impairment. physician progress notes [REDACTED]. Requires total assistance on her activity of daily living skills. physician progress notes [REDACTED]. physician progress notes [REDACTED]. The Nutrition Care Plan started on May 9, 2017 states, R1 is a slow eater. Restorative Nursing Care Plan dated April 4, 2017 states, Resident requires set-up, verbal cueing and staff to assist with feeding. Restorative Nursing Program for Eating started on April 5, 2017 documents R1 requires set- up, verbal cueing and staff to assist with feeding. One intervention is to give cues as necessary to stimulate chewing and swallowing. On September 12, 2017 at 1:35PM, R1 was in the room at another nursing facility with Z2(Family Member). Z3 (Wound Care Nurse/Other Nursing Home/Facility B) rolled R1 over to her abdomen and on the posterior and lateral aspect of R1's left thigh was a large 4 by 4 gauze. Upon removal of the gauze and non-adherent dressing by Z3 (Wound Care Nurse at Facility B), a large area of redness with a scattered yellow center was observed. Z3 (Wound Care Nurse) said R1 came from the hospital with an order for [REDACTED]. Z3 (Wound Care Nurse) said it was a 2nd degree burn and was probably a 3rd degree burn previously. Z2 said the burn is much better now and that the previous facility(Facility A) where R1 sustained the burn, informed Z2 of the burn. Z2 said she had R1 moved to another facility because R1 was admitted to the hospital for severe dehydration and it was unknown to Z2 why R1's dehydration was severe. Upon asking R1 about the burn on the left thigh, R1 began to utter inaudible words in a high pitched voice as R1's face became flushed with redness, and R1's eyebrows heightened as Z2 began to rub R1's face and consoled R1 with a hug. It was undetermined what R1 was trying to communicate about the burn. Progress Note dated August 31, 2017 at 5:10PM documents Writer preparing medication when loud moaning observed/heard from R1 in the dining room. R1 unable to state what happened. Water, ice spilled on the table, coffee mug noted on the floor. Writer and CNA assisted resident back to room and removed clothing. Left thigh pants noted wet. Left lateral thigh area reddened, blanchable, kept resident comfortable. Facial grimacing/moaning observed. As needed Tramadol 50 milligrams given by mouth. No distress noted. No shortness of breath noted. Doctor paged. Vital signs are temperature (96.7F), pulse (69), Respiration (18), and blood pressure (130/64). At 5:15PM, return call from medical doctor, no new orders received, Stated to monitor resident. At 5:17PM, Family notified. At 5:25PM, Director of Nursing made aware. Dietary Manager here education provided. Progress Note dated August 31, 2017 at 10:30PM states, R1 is alert, responsive, sleeping comfortable in bed, easily aroused. No signs and symptoms of distress noted. No signs/symptoms of pain or discomfort. Left lateral thigh redness subsides, small reddened area apparent, no open area noted to area . Progress Note dated September 1, 2017 at 6AM documents, . No redness, no blister noted to the left thigh Progress Note dated September 3, 2017 at 8AM documents .left thigh without signs of infection . Progress Notes were reviewed from August 31, 2017 through September 7, 2017. The only notes that provide any detail of the burn were on August 31, 2017, September 1, 2017 and September 3, 2017. There was no documentation of the description of the burn after September 3, 2017. Progress Noted dated September 7, 2017 states, R1 was noted lethargic, slow to response, generalized weakness, poor appetite, pertinent vitals blood pressure was 96/55, oxygen was 94 percent on room air. The doctor was notified and R1 was sent out to the hospital and admitted with [DIAGNOSES REDACTED]. The Treatment Administration Record dated September 1, 2017 through September 7, 2017 was reviewed. An O for other skin issues was marked on each day for the 6-2 AM shift only. There was no description of the burn wound documented. On September 12, 2017 at 10:06AM, E3 (Nurse) said R1 is alert and oriented to self only, requires assistance with activity of daily living skills and transfers. E3 said R1 uses a ambulation device when in the common area. E3 said R1 can feed herself but needs to be cued and supervised. E3 said E4 was the nurse assigned on August 31, 2017 the second shift. E3 said she worked the first shift. E3 said the incident for August 31, 2017 is documented in the chart on the progress note. E3 said for residents with redness the nurses intervene right away with assessment , physician notification, treat and monitor. E3 said skin conditions and falls are documented on incident reports and in the progress notes. On September 12, 2017 at 10:43AM E2 (Director of Nursing) said R1 is currently in the hospital. E2 said R1 was in the dining room and spilled a hot beverage on herself. The staff saw it and told the nurse. Incidents reports are for the quality assurance department and not for the Illinois Department of Public Health to view, because it was not reportable, it was not a 3 rd degree burn. The doctor just said to monitor it. I did not see the injury. E2 said the facility reports injuries of unknown origin to the State Agency. On September 12, 2017 at 11:09AM via telephone E4 (Nurse) said she recalls on August 31, 2017 at 5PM, she was passing medication and heard a loud noise . E4 said she came into the dining room and saw R1 moaning. There was ice and water on the table and a coffee mug on the floor. Only residents were in the dining room. E4 said she went to get a CNA and does not recall who the CNA was and that the CNA helped her move R1 from the dining room to the room. In the room they took off R1's clothes and there was a reddened area to the thigh. E4 did not recall which thigh or the location of the wound. E4 said it was a burn, she made R1 comfortable gave pain medication, notified the doctor, family and the E2 (DON). On September 12, 2017 at 2:59PM, E5 (Minimum Data Set Coordinator/Assistant Director of Nursing) said she is the restorative coordinator. E5 said R1 would lower her head and had difficulty eating and required set-up and supervision. E5 said R1 should be assisted to eat during meals and the the staff should follow the written plan of care. On September 12, 2017 at 3:21PM, E6 (Certified Nursing Assistant, CNA) said she worked on August 31, 2017. E6 said she heard about R1 being burned but did not see the incident. E6 said there is a possibility that no aide was in the dining room when R1 was burned. E6 said we have to encourage R1 to eat, R1 has to be watched. On September 12, 2017 at 3:37PM,. E7 (CNA) said, she was assigned as R1's aide on August 31, 2017 the 2 nd shift. E7 said she did not see what happened to R1 but helped E4 (Nurse) take vitals signs of R1 when R1 was in the room. E7 said she does not remember which leg or the size or anything other than the nurse did what she was supposed to do. On September 12, 2017 at 3:59PM, E8 (Dietary Manager) said he was working on August 31, 2017 and the aides brought R1 into the dining room. E8 said R1 was agitated so he gave R1 hot tea and proceeded to serve coffee to the other residents. E8 said he did not see how R1 got tea spilled on her and was alerted by E4 (Nurse) later in the day that tea was spilled on R1. E8 said , I was asked not to give R1 hot beverages without supervision. On September 13, 2017 at 10:33AM, E8 (Dietary Manager) took temperature of coffee that was being served to residents, the temperature was 164.8 degrees Fahrenheit. E8 also took a temperature of hot water for tea the temperature was 179.6 degrees Fahrenheit. The Hospital Record dated September 7, 2017 through September 12, 2017 was reviewed. The description of the wound states, Left hip region reported thermal injury prior to admission measuring 9 Centimeters in length by 4.5 centimeters in width by less than 1 cm in depth. Red perimeter with yellow slough tissue to center. Small amount of yellow exudate noted. Surrounding tissue free of infection. The recommendation were to cleanse the wound and apply Silvadene ointment and an oil emulsion gauze and cover with gauze daily. On September 14, 2017 at 9:21AM, Z4 (Wound Care Nurse/Hospital) said she was the wound care nurse that took care of R1 during R1's hospital stay. Z4 said the emergency room staff noted the wound on September 7, 2017, apply a dressing and alerted her to assess the wound. Z4 said it was a full thickness burn with slough Z4 said the nursing home staff E4 (Nurse) said she did not know how the burn happened. Z4 said they should have noticed a burn of full thickness if they were monitoring it. Z4 said the burn required Silvadene to prevent infection and daily dressing changes. On September 14, 2017 at 11:40AM, E1 (Administrator) said the facility does not have a policy/procedure for incidents. E1 was asked for a policy/procedure for hot tea/ Coffee temperatures. There was no policy/procedure provided for neither request. On September 19, 2017 at 1:21PM, Z5 (R1's Attending Physician) said R1 is Extremely Cognitively impaired and should not have been given hot tea and left unattended.

This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to effectively manage pain control for R4, 1 of 1 sampled resident who verbalized complaints of pain in the sample of 13. Findings include: According to the medical record R4 is an [AGE] year old non-ambulatory female with diagnoses including: Insulin Dependent Diabetes, Right AKA (Above the Knee Amputation), [MEDICAL CONDITION], Hypertension, Peripheral [MEDICAL CONDITION] and history of Back Pain. he MDS (Minimum Data Set) Annual assessment dated [DATE] noted in Section C (cognitive patterns) R4 had a summary score of 11 (moderately impaired) and a zero under Acute Mental Status Change (no evidence of acute mental status change from baseline.) R4 was first observed on 07/17/12 at approximately 10:00 AM. in her room. R4 was sitting in an adaptive wheelchair next to her bed. R4 stated at this time she would like someone to put her back in her bed. She also stated she had been up in her chair all morning and her back was really hurting. R4 was observed again on 07/19/12 at approximately 11:30 AM. in her room, lying in bed. R4 was asked about her general care at the facility and she stated she is always in pain. "It goes all the way up my right side. When I'm in the chair it hurts my back." R4 also stated when she is in bed she can stretch out and she doesn't have as much pain. R4 was asked if she gets any medication for pain and she stated she thought she gets [MEDICATION NAME] but it doesn't help. When asked to rate her pain when it occurs on a scale of 1-10, R4 rated the pain as a "9". R4 further described her pain, "my back feels like a needle is sticking me. My tailbone, it feels like [MEDICAL CONDITION], what they give me don't help. I don't like to complain." E7, RN (Registered Nurse) was interviewed at the nurses station at approximately 11:40 AM. E7 was asked if R4 had any pain medication ordered. E7 looked in R4's medical record then stated that R4 was getting Tylenol but she said it wasn't helping so we got an order for [REDACTED]. When asked about the location of her pain she stated the pain goes up her right side and continues all the way up. Further review of the medical record noted on 06/28/12 R4 became unresponsive and was sent by ambulance to the hospital. R4 returned to the facility on [DATE] with a [DIAGNOSES REDACTED].) Lumbar Radiculopathy. The second [DIAGNOSES REDACTED]. These go from high in the neck to the low back. The pain produced by this condition usually starts at the site of the problem and radiates outward and downward towards the arms or legs. an order for [REDACTED]. The physician's orders [REDACTED]. Facility medication records indicate that R4 was administered [MEDICATION NAME] one time on 07/10/12 and once on 07/19/12. The reason listed by the nurse on 07/10/12 states c/o "pain" and the result was documented as "observe." The 07/19/12 administration lists "c/o leg pain" with no results documented. R4's most current care plan dated 05/07/12 was reviewed and there was no update to the plan after R4's hospital visit of 06/28/12. One of the interventions listed in the care plan is to evaluate effectiveness of [MEDICATION NAME]/[MEDICATION NAME] for phantom leg pain. There was no dosage listed for the [MEDICATION NAME] nor was it updated after the [MEDICATION NAME] was increased. There was no current order at all for the [MEDICATION NAME] listed. Another intervention listed was to monitor resident for pain other than phantom pain but there was no other pain listed on the care plan. R4's pain assessment tool completed on 07/05/12 does not document any instances of pain or updates in pain medication administration or pain management. R4's [DIAGNOSES REDACTED]. Medication Administration Records (MARs) for April through July, 2012 include an order to evaluate for pain every shift. (+) = yes, (-) = no. However, the majority of entries were staff initialing each shift and not documenting presence or absence of pain as the order is written. Also R4's care plan notes to use the face scale when assessing for pain. This conflicts with the pain documentation order placed on the MAR. On 07/1912 the facility notified the physician of R4's complaints of pain and a new order for scheduled pain medication was initiated. Based on observation, interview and record review the facility failed to properly assess, monitor and intervene for 1 of 1 resident (R6) with a history of aspiration pneumonia in a sample of 13. This put R6 at risk for further complications related to aspiration pneumonia. Findings include: R6 is an [AGE] year old male admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R6 has no [DIAGNOSES REDACTED]. R6 is on a mechanical soft diet with low concentrated sweets per physicians order dated 6/11/12 During observation on 7/17/2012 at 12:05 PM R6 received a lunch tray with a submarine sandwich , whole potato chips, cucumber salad and juice of thin liquid consistency. Staff cut the sandwich in four pieces and left the table to assist another resident. R6 began to eat at 12:07 PM using a fork to attempt to spear the potato chips. R6 then used the fork to put a large piece of sandwich in his mouth. Without chewing the first large bite R6 put another large bite of sandwich in his mouth. At 12:10 PM R6 began coughing and letting large pieces of lunch meat, lettuce and tomato fall out of his mouth. R6 continued to hold some food in his mouth. R6 had clear nasal drainage in moderate amounts coming from his nose while coughing. R6 then took a drink of juice. R6 finished the juice of thin liquid consistency but continued to cough. E14 (Business director and CNA) told R6 to stop eating since he was coughing. R6 refused to eat any more of his lunch meal. E14 also stated that R6 feeds himself. On 7/17/2012 at 2:15 PM E6 (dietary supervisor) stated the mechanical soft diet for lunch was a submarine sandwich with whole potato chips, lettuce leaf and tomato slices on the sandwich with cookies and juice. On 7/18/2012 at 10:00 AM, E4 (Registered Dietitian) stated the the mechanical soft diet for lunch on 7/17/2012 should have consisted of potato chips in nickel sized pieces, a submarine sandwich with thin sliced tomato and shredded lettuce and shredded thin sliced lunch meat. E4 agreed that lettuce leaves nor whole potato chips should be given as a mechanical soft diet. On 7/18/2012 at 5:45 PM, R6 ate 2 bites of tuna casserole and one sip of thickened milk which staff assisted by feeding R 6. R 6 held the tuna casserole in his mouth and began coughing. R6 again had clear nasal drainage in moderate amounts coming from his nose. R6 then spit out the tuna casserole and the one sip of thickened milk . R 6 refused to eat or drink anything else. On 7/18/2012 at 5:50 PM , E15 (CNA) stated R6 usually eats better than this for supper, but R6 doesn't like this meal. Staff did not offer a substitute. E15 also stated that R6 frequently coughs at meal time. Nurses notes dated 6/11/2012 -7/18/2012 were reviewed and there were no nursing notes documenting that R6 had a poor appetite or was coughing during meals. The physician was not notified of a poor appetite or coughing during meals for this time either. On 7/19/2012 at 12:20 PM R6 was fed by E2 (DON) in his bed. The head of the bed was at 90 degrees. R6 ate 2 bites of mashed potatoes, but began coughing after the first bite. R6 was also given a 1 inch cube of pork chop which he chewed for approximately 2 minutes never swallowing. E2 asked R6 if he would like to spit the meat out. R6 shook his head yes and spit the partially chewed meat in a napkin. R6 then refused to eat or drink any other part of the meal. E2's nurses note of 07/19/12 documents that the family was then notified of R6's swallowing difficulties. Family informed E2 that R6 has had 2 previous hospitalization s for aspiration pneumonia and that is why he is on a mechanical soft diet. Review of R6's clinical record from 6/11/12- 7/18/12 shows no speech evaluation for holding food in mouth, coughing at meals, or poor oral intake. There were also no documented swallow evaluations in the record. Review of the Nutritional assessment dated [DATE] stated : R6 is able to feed self, had difficulty swallowing thin liquids 7/5/12 at breakfast, recommend trying thickened liquids, but did not tolerate so continue thin liquids, R6 has a fair oral intake. The only intervention by the facility after 07/19/12 was to obtain a physician's orders [REDACTED]. R6's careplan dated 06/21/12 for Nutrition notes that he has a potential for altered nutritional status related to current mechanical soft diet. The careplan further states that R6 will show no signs of aspiration. The only interventions in the plan are to 1) provide diet as ordered, 2) Encourage self feeding, 3) Honor food preferences. There were no specific interventions to address R6's swallowing difficulties or for monitoring specific signs and symptoms of aspiration. No updates were initiated to the careplan after 06/21/12. Based on record review and interview, the facility failed to provide necessary services related to diabetic management for 1 of 5 (R6) residents in a sample of 13. Findings include: Review of Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. An interview with E2 (DON) on 7/19/2012 at 11:20 AM stated that R6 was a stable diabetic at the facility since 6/11/2012 admission. E2 also stated that the hospital had problems with R6's blood sugar being unstable prior to R6's admission to the facility. Review of the physicians order dated 6/11/2012 for R6 shows an order to administer insulin using the following scale based on blood sugar levels: 140 - 180 milligrams/deciliter (mg/dl) = 1 unit 180 - 220 mg/dl = 2 units 221-260 mg/dl = 3 units 261- 300 mg/dl = 4 units 300 mg/dl = 5 units over 400 mg/dl call the physician. No parameters were given which would have provided nursing with the necessary interventions if R6's blood sugar level fell below the acceptable range (70 - 130 mg/dl per the "Standards of Medical Care in Diabetes - 2010" Volume 3, Supplement 1, January 2010). Review of the MAR for 6/11/2012 - 6/30/2012 shows R6 did not receive sliding scale insulin on 6 different days at 8 PM per orders. Blood sugars on the following dates required sliding scale coverage:6/12/2012 level 265, 6/13/2012 level 147, 6/14/2012 level 176, 6/26/2012 level 210, 6/27/2012 level 204. Interview with E2 on 7/19/2012 at 11:20 AM confirmed no sliding scale insulin was given during the month of June 2012 at 8 PM. E2 also confirmed that insulin was given during the month of July 2012 at 8 PM. E2 also confirmed the sliding scale insulin order was not clear as to the frequency R6 was to receive sliding scale insulin.

Based on observation, interview and record review the facility failed to maintain acceptable parameters of nutritional status for 1 of 1 resident (R6) with observed swallowing difficulties and poor oral intake in a sample of 13. This resulted in a significant weight loss of 16 pounds (10%) in 38 days. Findings include: R6 is an [AGE] year old male admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R6 has no [DIAGNOSES REDACTED]. R6 is on a mechanical soft diet with low concentrated sweets per physicians order dated 6/11/2012. During observation on 7/17/2012 at 12:05 PM R6 received a lunch tray with a submarine sandwich , whole potato chips, cucumber salad and juice of thin liquid consistency. Staff cut the sandwich in four pieces and left the table to assist another resident. R6 then attempted to spear the potato chips with his fork. R6 then used the fork to put a large piece of sandwich in his mouth. Without chewing the first large bite R6 put another large bite of sandwich in his mouth. At 12:10PM R6 began coughing and letting large pieces of lunch meat, lettuce and tomato fall out of his mouth. R6 continued to hold some food in his mouth. R6 had clear nasal drainage in moderate amounts coming from his nose while coughing. R6 then took a drink of juice. R6 finished the juice of thin liquid consistency but continued to cough. E14 (Business director and CNA) told R6 to stop eating since he was coughing. R6 refused to eat any more of his lunch meal. E14 also stated that R6 feeds himself. On 7/17/2012 at 2:15 PM E6 (dietary supervisor) stated the mechanical soft diet for lunch was a submarine sandwich with whole potato chips, lettuce leaf and tomato slices on the sandwich with cookies and juice. On 7/18/2012 at 10:00AM, E4 (Registered Dietitian) stated the the mechanical soft diet for lunch on 7/17/2012 should have consisted of potato chips in nickel sized pieces, a submarine sandwich with thin sliced tomato and shredded lettuce and shredded thin sliced lunch meat. E4 agreed that lettuce leaves nor whole potato chips should be given as a mechanical soft diet. On 7/18/2012 at 5:45 PM, R6 ate two bites of tuna casserole and one sip of thickened milk which staff assisted by feeding R 6. R 6 held the tuna casserole in his mouth and began coughing. R6 again had clear nasal drainage in moderate amounts coming from his nose. R6 then spit out the tuna casserole and the one sip of thickened milk . R 6 refused to eat or drink anything else. On 7/18/2012 at 5:50 PM , E15 (CNA) stated R6 usually eats better than this for supper, but R6 doesn't like this meal. Staff did not offer a substitute. E15 also stated R6 frequently coughs at meal time. On 7/19/2012 at 12:20 PM R6 was fed by E2 (DON) in his bed. The head of the bed was at 90 degrees. R6 ate 2 bites of mashed potatoes, but began coughing after the first bite. R6 was also given a 1 inch cube of pork chop which he chewed for approximately 2 minutes never swallowing. E2 asked R6 if he would like to spit the meat out. R6 shook his head yes and spit the partially chewed meat in a napkin. R6 then refused to eat or drink any other part of the meal. Review of Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 6/11/12 and 6/12/12 R6 weighed 151 pounds. On 6/13/2012 R6 weighed 148 pounds. Monthly weight record for R6 had 144 pounds documented for 7/1/2012. During an observation on 7/19/2012 at 10:25 AM R6's weight in the mechanical lift scale was 135 pounds. R6 was weighed by E8 (certified nurses assistant) and E9 (CNA). The scale was calibrated prior to weight being obtained. Both E8 and E9 stated they were not the staff who had weighed R6 on 7/1/2012. E8 and E9 also stated the usual way a resident who requires a mechanical lift for transfers is weighed is to utilize the mechanical lift scale . Nurses notes dated 6/11/2012 -7/18/2012 were reviewed and there were no nursing notes documenting that R6 had a poor appetite or was coughing during meals. The physician was not notified of a poor appetite or coughing during meals for this time either. Review of R6's clinical record from 6/11/12- 7/18/12 shows no speech evaluation for holding food in mouth, coughing at meals or poor oral intake. There were also no documented swallow evaluations in the record. Review of the Nutritional assessment dated [DATE] stated : R6 is able to feed self, had difficulty swallowing thin liquids 7/5/12 at breakfast, recommend trying thickened liquids, but did not tolerate so continue thin liquids, R6 has a fair oral intake. On 7/19 2012 review of the Food/Fluid Intake Sheet dated July 2012, completed by dietary staff, shows that R6 ate: 25% of breakfast on 7/7/12, 7/11/12, 7/12/12,7/13/12, 7/17/12 and 7/18/12 , 25% of lunch on 7/2/12, 7/12/12, 7/13/12,7/17/12, and 7/18/12, 0% on 7/16/12 at lunch, and 15% of dinner on 7/1/12. R6 was observed on 7/ 17/12 eating 2 bites of food but documentation shows R6 ate 25% of lunch meal. R6 was again observed spitting out the 2 bites of food given at dinner on 7/18/12 and documentation showed R6 ate 75% of his meal. Neither the dietitian nor the doctor were notified of R6's poor oral intake. On 7/ 19/12 at 9:25 AM, E9 (CNA) stated " I would notify the nurse if a resident eats less than normal immediately. On 7/19/12 at 9:30AM , E7 (RN) stated the staff notify the nurse if a resident eats less than 25% of a meal. The nurse ensures a substitute is offered and then assesses the resident for pain or illness. The resident is then monitored for the next meal and the physician is called if the residents eats less than 25% of that meal. The facility policy " Resident Weight Monitoring states #10: All new admissions and re-admissions will be weighed weekly for at least 4 weeks. If weight is stable , weight will be monitored monthly. R6 was weighed the first three days of admission and then monthly after that. On 7/19/2012 at 11:40 AM E2 (DON) stated new admissions are weighed the first three days they are at the facility and then monthly. E2 stated she was not aware the facility policy stated weigh new admissions every week for 4 weeks. E2 also stated nursing would notify the dietitian if a resident was eating poorly. E2 was not aware that R6's weight as of 07/19/12 was 135 pounds, a 16 pound weight loss, (10% in 38 days.)

Based on observation, interview & record review the facility failed to: -Conduct a comprehensive assessment for the development of R 1's Stage IV pressure sore on the coccyx. -Prevent the worsening of R 1 ' s acquired (coccyx) pressure ulcer by not developing & implementing individualized interventions consistent with R 1 ' s needs. -Monitor the impact of the interventions & revised the plan of care as appropriate in order to improve & heal R 1 ' s existing acquired pressure ulcer. -Develop a specific repositioning plan when R 1 ' s up in chair. -Follow the plan of care to provide pressure relieving device on R 1 ' s wheelchair and evaluate a more appropriate assistive sitting device. -Train & educate nurses (E 6) on the correct identification of pressure ulcers stages. This is for one (R1) of two residents in the sample who acquired pressure sores in the facility. These failures contributed to the development and worsening of R 1 ' s avoidable stage IV pressure sore that was acquired in the facility An Immediate Jeopardy was identified on 6/28/11 at 12:05 pm. It began on 1/5/10. The Immediacy was removed on 6/30/11 at 8:00 AM. The facility remains out of compliance at a level 2 due to the need for the facility to assure implementation of removal plan. E1 (Administrator) was informed of the Immediate Jeopardy on 6/28/11 at 12:30 pm. Findings include: On 06-08-11 at 11:00 AM, R 1's sitting in a regular adult reclining chair in the dining room, poorly repositioned, sitting directly on her buttocks and without any pressure relieving device noted. R 1 is non verbal and totally dependent on facility staff with all of her activities of daily living. R 1 ' s Minimum (MDS) data set [DATE] showed R 1 was admitted in the facility on 06-30-07, unable to make self neither understood nor able to understand others, cognitive skills for daily decision making- severely impaired. R1 ' s totally dependent on staff with two person assist on her functional status (bed mobility, transfer, eating & toilet use). R 1's weekly wound tracking for the month of April 2010 showed two areas of pressure ulcer marked in bold letters Acquired these areas are in R 1 ' s sacrum & coccyx. On 04-06-10 the area in the coccyx was measured at 1.0cm X 0.5 cm X 1.0 cm - with no tunneling documented. On 06-08-11 the Director of Nursing (E2) presented a copy of the facility wound tracking report dated 06-01-11. The report showed the following: Acquired pressure ulcer - Stage IV - 0.8 cm (Length) X 0.2 cm (Width) X 1.7 cm (Depth) with 2.3 cm tunneling @3 0 ' clock - Status - improving Drainage- moderate The facility wound tracking report dated 06-07-11 showed a slight decreased on R 1 ' s wound size but increased size with the tunneling. The measurements are: 0.5 cm X 0.2 cm X 1.6 cm, with 3.0 cm tunneling at 3 0 ' clock. On 06-09-11 at 2:00 PM E 5 (Full time Nurse) confirmed that R 1 pressure ulcer on the coccyx was acquired in the facility. On 06-09-11 at 1:35 PM, the Registry Nurse (E 6) conducted wound assessment & dressing change to R 1. R 1 ' s wound progressed and increased in size. E 6 provided the following measurements: (L x W x D) 1.2 cm x 0.4 cm x 1.5 cm with 4.0 cm tunneling at 3 0 ' clock, a Stage IV. E 6 failed to identify the stage of R 1 ' s pressure ulcer correctly. E 6 stated " this is a Stage III, well I can ' t see what's in there, I think it's unstageable because there's tunneling. " E 6 stated she was provided an in service training about everything including pressure ulcer during orientation years ago. The facility administrative Staff (Administrator, Director of Nursing & Corporate Nurse Consultant) failed to present in service training given to E 6 regarding pressure ulcer staging. There was no comprehensive assessment found in R 1 ' s clinical record to show the facility analyzed R 1's risk factors for developing pressure sores or to analyze factors for R 1's delayed wound healing and to indicate if the risk factors could be modified or removed. This finding was confirmed by the Director of Nursing & the Nurse Consultant meeting on 06-09-11. R 1 ' s 06-03- 11 Pressure Ulcer CAA (Care Area Assessment) reads: She (R1) scores a high risk for skin breakdown on the Braden Scale. She has a [DIAGNOSES REDACTED]. She is incontinent of bowel & bladder, barrier cream is used is used PRN (as needed). She is dependent on staff for Activities of Daily Living, mobility, food intake. She is turned & repositioned by staff every 1-2 hours & PRN. She has a low air loss mattress on her bed. Skin checks are done daily ...She currently has 2 wounds ... R 1 ' s Resident Assessment Protocol sheets dated 07-01-09 reads: scores a high risk for skin breakdown on the Braden scale. She has an alternating pressure /low air loss mattress. She is turned & repositioned every 1-2 hours & PRN. Skin checks are done daily ... She currently has 2 wound ... The physician progress notes [REDACTED]. She is in the end stage of Alzheimer ' s, she is bedridden ...shearing forces are unavoidable when transferring the patient to a wheelchair to bring her to the dining room. Shearing forces also occur if the patient has to slide on any surfaces to move her. The patient ' s dementia has also resulted in urinary & bowel incontinence causing maceration of the skin in the perineal & buttocks region. The presence of feces & urine also makes it difficult to treat existing ulcer due to possible contamination of the existing wounds. The patient is also mildly dehydrated at times... These concerns identified by the physician were not addressed in R 1 ' s care plan. R 1 ' s plan of care to apply pressure relieving device while in her wheelchair & to offer fluid during care was not followed on 06-08-11 & 06-09-11. There has no specific plan based on R 1 ' s needs in order to promote healing & prevent the wound from progressing. The surveyor confirmed the facility took the following actions to remove the immediacy of the situation: 1. Nursing management immediately completed a " full- house " skin audit to identify any new pressure areas or skin problems. 2. Contracted with the wound Medical Doctor to conduct weekly rounds for residents with compromised skin for assessment & additional treatment. 3. Random audits of residents with compromised skin will be conducted by the Director of Nursing &/or designee weekly for three residents times six weeks to ensure effectiveness of treatment. 4. Skin integrity & wound issues will be discussed with the Medical Director as part of the facility Quality Assurance process. 5. Director of Nursing will assess resident ' s with pressure ulcer using the avoidable /unavoidable pressure ulcer assessment