Every finding on record at Bria of Godfrey

Based on interview, observation, and record review, the facility failed to provide Oxygen (O2) to a resident while the resident is out of their room for 2 of 3 residents (R4, R7) reviewed for residents receiving Oxygen in the sample of 10. The findings include:1. R7's admission Record, dated 7/15/26, documents R7 was admitted to the facility on [DATE] with diagnosis of Cerebral Infarction, Hemiplegia, Chronic Obstructive Pulmonary Disease (COPD), Acute Respiratory Failure, Right Above Knee Amputation (AKA), Obesity, Hereditary and Idiopathic Neuropathy, Hypothyroidism, and Peripheral Vascular Disease (PVD). R7's Care Plan, dated 7/14/26, documents R7 has potential for difficulty in breathing r/t (related to) COPD, Acute Respiratory Failure and recent trachea decannulation. R7 had a tracheostomy prior to admission which is no longer present. Interventions: Administer oxygen as ordered, assess respiratory status: rate, depth, pattern, skin color, head of bed elevated to prevent shortness of breath, monitor every shift for shallow respiration, diaphoresis, dyspnea, observe for changes in breathing pattern. R7's Minimum data Set (MDS) has not been completed. R7's Brief Interview for Mental Status (BIMS), dated 7/10/26, documents R7 has a moderate cognitive impairment. On 7/13/26 at 4:08 PM, R7 was seen lying in bed on O2 at 4 Liters (L)/Nasal Cannula (NC) while hooked to a concentrator. R7 stated she always has her O2 on and has not run out, but if she gets out of her bed or goes out of her room, sometimes the staff will take her concentrator with her and sometimes not. On 7/14/26 at 8:24 AM, R7 was seen in the dining room for breakfast with no O2 on. When asked about her O2, R7 stated, I told them I needed it, and they didn't bring it with me. When asked how she is doing without it, R7 stated, I am a little short of breath right now. R7's Physician Order, dated 7/10/26, documents, Oxygen at 3 LPM (liters per minute) per nasal cannula, every 24 hours as needed for Shortness of Breath. On 7/14/26 at 9:20 AM, R7 was pushed back to her room after breakfast and left sitting in her wheelchair by the side of her bed. R7 had her call light on because she wanted to get back in bed. R7's breathing appeared to be slightly labored with R7 stating, I feel a little short of breath, can you send someone in to help me? On 7/14/26 at 9:25 AM, V7, Certified Nursing Assistant (CNA), was outside R7's door and advised R7 requested someone to help her. V7 entered, turned off the call light, saw R7 breathing heavy and stated, Are you alright? R7 stated, I'm out of breath and want to get back in bed. V7 stated, I have to go get someone to help me with the (full body mechanical lift) and left the room. V7 was seen going down the hall and assisting other residents sitting in wheelchairs by the nurse's desk and taking them to their rooms. V7 did not tell the nurse at the desk that R7 was Out of breath, so no nurse arrived to assess R7. On 7/14/26 at 9:35 AM, V7, and V8, CNA, entered to transfer R7 to bed. Upon getting R7 back in bed, R7 instantly stated, Raise my head, raise my head. V7 raised R7's head of bed, put R7's O2 NC on her and then turned on the O2 concentrator. R7 stated, I feel better, much better with the O2 on. and calmed herself down. On 7/14/26 at 12:20 PM, when asked if she was going to the dining room for lunch, R7 stated, I'm just going to eat lunch in bed because I am still a little short of breath. On 7/14/26 at 2:18 PM, V13, Registered Nurse (RN), stated, No one told me that (R7) was short of breath. This is my first time working with her. I'm not sure if they always take her O2 with her to the dining room. V13 asked R7 Do they usually take your Oxygen with you to the dining room? How many times out of 10 would you say they take it with you?, with R7 responding One. V13 asked R7 how she feels now, R7 responded, I'm ok now with my Oxygen on. V13 stated, They should have told me that (R7) was short of breath, I would have checked on her. On 7/15/26 at 8:40 AM, V17, R7's family member, stated, I have not seen (R7) out of her room when I visit. Every time I have been here she has been on her Oxygen. I think at this point, she is going to have it on all the time because she gets short of breath when she's not on it. She's getting discharged from this facility and going back to her previous facility where her friends are. They always gave her a portable Oxygen tank on the back of her wheelchair that she used when leaving her room. 2. R4's admission Record, dated 7/15/26, documents R4 was admitted to the facility on [DATE] and was discharged on 6/24/26 with diagnosis of Metabolic Encephalopathy, COPD, Chronic Respiratory Failure, Obstructive and Reflux Uropathy, Dementia, Major depressive disorder, Anxiety disorder, Post Traumatic Stress Disorder (PTSD), Hypertension (HTN), Congestive Heart Failure (CHF), Atrial Fibrillation, Diverticulitis, Irritable Bowel Syndrome (IBS), Fibromyalgia, Cardiac Pacemaker, and is Dependent on Oxygen.R4's Care Plan, dated 3/30/26, documents R4 requires assist with daily care needs. 4/7/26: R4 has potential for difficulty in breathing r/t COPD, Chronic Respiratory Failure and CHF. She removes her O2 several times per day when she is in bed and when up in her chair. Staff redirects her to put the nasal canula in multiple times a day. Interventions: Administer oxygen as ordered, assess respiratory status: rate, depth, pattern, skin color, head of bed elevated to prevent shortness of breath, monitor 02 saturation if indicated per MD (medical doctor), monitor vital signs and lung sounds. R4's MDS, dated [DATE], documents R4 has a severe cognitive impairment and required substantial/maximal assistance for toileting, and partial/moderate assistance for other ADLs. R4 was frequently incontinent of both bowel and bladder.On 7/13/26 at 2:35 PM, V5, R4's family member, stated she walked in one day and R4 didn't have her O2 on and she is supposed to have it on 24/7 (24 hours a day, 7 days a week) at 3 L/NC. V5 stated she knew R4 would frequently take off her O2, but it wasn't even in the room for her to use, and she would find the tank sitting at the nurse's desk. V5 stated they would put her on a portable tank, and it would be empty. V5 stated she had an O2 machine in her room and all it did was beep one night and no one ever did anything about it. V5 stated she told V1, and V1 blew it off and did nothing. On 7/15/26 at 12:40 PM, V18, Registered Nurse/RN, stated, If a resident is on O2 24/7, then their O2 concentrator will come with them wherever they go, if it is just PRN (as needed), we leave it up to that resident if they need it and if they say yes, then it should be with them and on. The CNAs should let the nurse know if resident is short of breath so they can be assessed. On 7/15/26 at 2:10 PM, V19, CNA, stated, If a resident is on continuous O2 and I have to take them out of the room, I will notify the nurse, and the nurse will take the O2 concentrator out with them. If the resident is on O2 PRN, I will ask the resident if they need it, and if they say they do, then I will tell the nurse to bring the O2 with them. If I find the resident short of breath, I will inform the nurse right away. On 7/15/26 at 2:12 PM, V8, CNA, stated, I ask the resident if they need O2 when getting them out of bed or going to the dining room and if they do, I get the nurse to take the O2 there. The resident will say if they need it or not and I go by what they say. If the resident is short of breath, I will let the nurse know. On 7/15/26 at 10:45 AM, V2, Director of Nursing (DON), stated, I would expect all staff to provide Oxygen to any resident who is on and requesting to use Oxygen and to notify the nurse if a resident is complaining of shortness of breath. Facility Grievance Form, dated 6/11/26, documents V5, R4's family member, complained of, This is on-going problem. I know she takes her hose off, but not in room at all. If you would like to talk call me, I have pictures. Description: Got her a little after 7:00 PM. Mom in bed her O2 machine not in her room & hooked up. They left in the hallway. Bed broke, won't move at all. Steps of investigation: Monitoring resident and talking with staff. Summary/Findings: Resident had just been assisted to bed and staff were bringing her O2 concentrator to her room. Recommendation/Action taken: 1 staff member to push resident w/c (wheelchair) and 1 staff member to push O2 concentrator at the same time. The facility's Oxygen Delivery System Policy, dated 12/1/25, documents, It is the policy of this facility that oxygen will be delivered to the residents based upon physician's orders utilizing the following systems: A. Oxygen concentrators providing> 93% oxygen concentration at flow rates ranging from 1LPMto I0LPM. B. There will always be an adequate number of additional oxygen delivery systems available in the facility to accommodate for new admissions, replacement of concentrators when indicated and for emergency situations. The facility's Oxygen Therapy Policy, dated 12/1/25, documents, It is the policy of this facility that oxygen shall be used in a safe and effective manner in accordance with applicable rules and regulations and the standard of care.

Based on interview, observation, and record review, the facility failed to provide a functional sink for 2 of 10 residents (R1, R4) reviewed for functional equipment to maintain a homelike environment in the sample of 10. The findings include: 1. R1's admission Record, dated 7/15/26, documents R1 was admitted to the facility on [DATE] with diagnosis of Colitis, Clavicle fracture, Myelodysplastic syndrome, Anxiety disorder, Dementia, Attention Deficit Hyperactivity Disorder (ADHD), Opioid dependence, Chronic pain syndrome, Major depressive disorder, Dyskinesia, Osteoporosis, Scoliosis, Dorsalgia, Irritable Bowel Syndrome (IBS), and Falls. R1's Care Plan, dated 2/23/26, documents R1 requires assist with daily care needs related to (r/t) diagnoses of right clavicle fracture, Myelodysplastic Syndrome, Dementia. R1 receives Physical Therapy (PT) and Occupational Therapy (OT) therapy services. R1 is at high risk for falls. R1 is continent of bowel and occasionally incontinent of bladder. 5/29/26: R1 has impaired physical mobility due to diagnoses of drug induced subacute dyskinesia (Tardive dyskinesia), muscle weakness, right clavicle fracture and Scoliosis. R1's Minimum Data Set (MDS), dated [DATE], documents R1 has a moderate cognitive impairment and requires substantial/maximal assistance for toileting and transfers, and requires partial/moderate assistance for other Activities of Daily Living (ADLs). R1 is occasionally incontinent of both bowel and bladder. On 7/14/26 at 8:15 AM, R1 stated, My toilet was broke (sic) for few days and I had to use the shower room. My sink isn't working now; it overflows all over. R1's sink was seen with plastic over it and not in working order. 2. R4's admission Record, dated 7/15/26, documents R4 was admitted to the facility on [DATE] and was discharged on 6/24/26 with diagnosis of Metabolic Encephalopathy, COPD, Chronic Respiratory Failure, Obstructive and Reflux Uropathy, Dementia, Major depressive disorder, Anxiety disorder, Post Traumatic Stress Disorder (PTSD), Hypertension (HTN), Congestive Heart Failure (CHF), Atrial Fibrillation, Diverticulitis, Irritable Bowel Syndrome (IBS), Fibromyalgia, Cardiac Pacemaker, and is Dependent on Oxygen. R4's Care Plan, dated 3/28/26, documents R4 is at high risk for falls r/t history of falling, restlessness and metabolic encephalopathy. R4 needs assistance with toileting hygiene due to occasional incontinence of bowel and bladder. R4 requires assistance with repositioning in bed and also with transferring. 3/30/26: R4 requires assist with daily care needs. 4/15/26: R4 has a self-care deficit in toileting r/t no longer having an indwelling catheter and need for bowel training due to occasional incontinence of bowel. R4's MDS, dated [DATE], documents R4 has a severe cognitive impairment and required substantial/maximal assistance for toileting, and partial/moderate assistance for other ADLs. R4 was frequently incontinent of both bowel and bladder. On 7/13/26 at 2:35 PM, V5, R4's family member, stated, (R4) was in room (#) and her toilet would never flush, the sink didn't work, and they would have these taped off so no one could use them so the residents would have to use another restroom in the facility. I got into it with (V1, Administrator) about these issues and they moved (R4) to another room (room #) and even that toilet didn't flush correctly. On 7/14/26 at 7:50 AM, V6, Maintenance Director, stated, The toilet in (R1's room) was broken for a couple of days, the floater was broken and I had to get the part. The sink was clogged with some sort of a cap, maybe from a toothpaste tube. I got that out and it is draining fine now. I believe the residents in that room had to use the shower room down the hall for a restroom. Right now, all the toilets and sinks on this hall are working fine and I don't have any out of service. When asked if he has a maintenance log to see what is broke or has been fixed, V6 stated, No, I don't keep any kind of maintenance log. On 7/14/26 at 9:10 AM, V9, Housekeeper, stated, The only sink or toilet that I know of that is not working is the sink in room (#). There was a sink in another room that wasn't working, but it just got replaced. On 7/14/26 at 3:32 PM, the sink in room (#) now has the plastic off the sink with a tall trash can full of blackened dirty water seen under the sink, and water seen on the floor by both the sink and toilet. On 7/15/26 at 8:07 AM, R1's restroom still had a tall trash can under the sink with blackened dirty water, a pair of rubber gloves, and other misc. items in it. There was also a pile of folded towels on the floor under the sink. On 7/15/26 at 8:10 AM, V6 stated, I did not know anything about room (#) sink not working. Nobody told me about it, and I found out yesterday and snaked the drain and now it is working fine. I don't keep any logs of what I fix unless it is a life safety issue. I have not received any maintenance requests from staff in a long, long time, they usually call or text me when something is broken and I go fix it. On 7/15/26 at 10:45 AM, V2, Director of Nursing (DON), stated, I would expect the Maintenance Director to take care of any broken items in the facility and to keep some kind of a log of things broken and/or fixed. On 7/15/26 at 3:37 PM, V1, Administrator, stated, I would expect (V6, Maintenance Director) to keep up with broken things and keep everything working well, especially for residents and their rooms. The facility's Grievance Form, dated 6/1/26, documents, (V5, R4's family member) complained of bathroom not flushing in her room (room #). Steps of investigation: (V1, Administrator), and (V6, Maintenance Director) inspected toilet thoroughly. Residents were moved out of room until toilet was fixed and working properly. Summary/Findings: Toilet was not flushing properly. Toilet needed a part. This part was purchased and put on. Grievance confirmed: (V6) fixed toilet. Other resident returned to room. Family updated, but this particular resident (R4) stayed in new room. The facility's Resident Council Meeting minutes, dated 5/28/26, documents two residents (R6 and R10) sinks were broken. The facility's Maintenance Policy, undated, documents, Communication: Non-emergency work orders are managed through the Tel's platform, while emergencies require immediate phone contact with the maintenance director and regional director. Preventive Maintenance: The maintenance team should conduct daily checks of call cords and operations and log these in the life safety binder. Emergency Equipment: Regular testing and regulation compliance are required per IDPH guidelines, with records recorded in the life safety binder. Safety: Monthly safety meetings should be held with key personnel, and any safety issues reported by staff must be addressed immediately by the maintenance director and administrator.

Based on interview and record review, the facility failed to convey within 30 days the resident's funds, and a final accounting of those funds, to the resident for 1 of 3 resident (R3) reviewed for resident funds in the sample of 10. The findings include:R3's admission Record, dated 7/15/26, documents R3 was admitted to the facility on [DATE] and was discharged on 11/24/25. On 7/13/26 at 2:10 PM, R3 stated he was discharged from the facility the last week in November 2025. R3 stated he was supposed to get money back from this facility but never received any. R3 stated when he called the facility, he was told they had already sent the check back in April. R3 stated he volunteered to go to facility to pick up the check and the facility told him no because they already sent it to him. R3 stated someone from his current facility also called this facility to inquire about his money and was told they contacted Social Security and they had sent $720 back to the facility and R3 stated he should have that money too. R3 stated the facility never told him how much they wrote the check for and does not know for sure how much he should receive. When asked about the amount stated in the complaint ($359.75), R3 stated he does not know where that amount came from. R3 stated he has not heard back from this facility since April 2026. On 7/14/26 at 10:34 AM, V10, Business Office Manager (BOM), stated, I just started on June 1st, and I am not aware of (R3) waiting on a check. I just got a check approved to be sent that I just printed and was going to send to him today. It is dated July 1, 2026, and is for $689.08. I have never spoken to (R3) about his money. When asked what the process is for a resident getting discharged to get his money owed, V10 stated, When a resident is discharged and they have money in their trust account, I order a check request, then once it is approved, I print the check off and mail to that individual. V10 stated, My corporate BOM may know more about (R3). On 7/4/26 at 10:40 AM, V11, Corporate BOM, stated, It was brought to my attention about a month ago regarding (R3) still having funds with the facility. I reached out to our billers and there was supposed to be a check issued from out AR (accounts receivable) for an overpayment, however that went to Social Security. Our RFMS Trust, which is the resident's accounts, should have sent the remaining balance directly to him. I see where a check was sent to him on 5/28/26 and was voided because it was never received by the resident. Then a second check was sent out on 6/9/26 and again was returned because it was never received by resident. Now we have a new one dated 7/1/26, that (V10) is sending out today. When asked once a resident is discharged , how long before a resident receives his money, V11 stated, The discharged resident should get his/her money within 30 days of discharge. V10 and V11 were discussing R3's present location and V10 was planning on sending the check to the address listed in his Electronic Medical Record. V11 stated, He does not live there, he resides at (another facility in a different town). V10 stated, I'm glad I saw that because I was going to mail it to the address in the computer. V10 stated she was planning on calling R3 at his current location and letting him know his check is on its way. On 7/14/26 at 11:38 AM, V12, Regional Nurse Consultant (RNC), stated, I was just told about (R3's) money owed and I am having his check delivered to him today. I also told (V10) to run an audit to make sure there is no other residents that is owed money. On 7/15/26 at 3:37 PM, V1, Administrator, stated, I would expect the BOM to keep up with any money due to a resident and to get it to them within 30 days after discharge. The facility's Resident Trust Fund Banking Policy, dated 11/2025, documents, Resident monies shall be held in their facility trust fund (RFMS) which is overseen by the Business Office. Monies shall be made available whenever consumers/residents want to make a withdrawal on their specific banking day(s). All Trust fund accounts will be closed upon permanent discharge or expiration of the resident within 15 calendar days but not to exceed into the next month and a check will be issued to: Resident - if the resident transferred back to community or another facility and the facility was Rep Payee are to be sent to your local Social Security office, marked as Conserved Funds. If facility not Rep Payee a check will be issued in the resident's name for funds left in Trust Fund account.

Based on interview and record review, the facility failed to have a supporting diagnosis for a prescribed antipsychotic for 1 of 6 residents (R6); reviewed for chemical restraints in a sample of 7.Findings include:R6's Facesheet with a print date of 5/4/26, documented she was admitted to the facility on [DATE] and was discharged on 2/5/26. R6's Facesheet also documented she was admitted with the following diagnoses of fracture of right tibia, fracture of upper and lower end of right fibula, alcohol abuse, insomnia, and major depressive disorder.R6's Minimum Data Set (MDS), dated [DATE], documented she was cognitively intact.R6's Medication Order Audit documented V25, Licensed Practical Nurse (LPN), placed an order on 1/16/26 at 9:44 PM for Quetiapine Fumarate oral tablet 50 mg (milligrams) to be given 1 tablet by mouth two times a day for prophylaxis. Additional information on the order documented in red letters Alert? Black Box Warning! R6's Order details on Quetiapine also documented under notes to obtain informed consent. The Order details documented V21 (Medical Director) was the ordering provider.R6's Hospital History and Physical, dated 12/30/26, did not document her being prescribed Quetiapine.R6's Rehabilitation prescriptions, dated 1/14/26, did not document a prescription for Quetiapine.R6's Medication List from previous facility, dated 1/23/26, did not include Quetiapine.R6's Consent for Psychotropic Medications, dated 1/23/26, did not include consent for Quetiapine.R6's Medication Administration Record (MAR) for January 2026 documented R6 was administered Quetiapine from 1/17/26-1/23/26.On 4/22/26 at 10:15 AM, V5 (Hospital Social Worker) stated R6 first came from a different facility that she did not have good experiences at, and had her daughter take her home after only a few days but was sent back to the hospital and discharged to this facility for higher level care. V5 stated R6 reported the facility kept her doped up and took 10 pills at one time but didn't know what they were.On 5/4/26 at 1:40 PM, V2, Director of Nursing (DON), stated she could not find a reason R6 was prescribed Seroquel (Quetiapine); just that the medication is ordered on provider assessments. V2 stated she does not know who originally placed R6 on Seroquel or if she was on it prior to admission.On 5/4/26 at 2:00 PM, V24, Advanced Practice Registered Nurse (APRN), stated she was unable to find a supporting diagnosis for R6 to be on Quetiapine (Seroquel), so she discontinued it. V24 stated she was not sure why R6 was on Seroquel, but it was not appropriate for her. V24 stated she doesn't remember any reports of R6 having side effects from the medication such as slurred speech or being overly tired. V24 stated on 1/20/26, R6 had no mental status change and did not have slurred speech. V24 stated she remembers R6 was admitted to the facility disoriented to begin with and she believed that to be related to DTs (Delirium tremens) from alcohol use, however, she improved throughout her stay, never reported to have any declines. V24 stated for R6 to be on 10 or more pills would be appropriate considering all her treatment needs and supplementation; you can be on 10 or more pills and be medicated appropriately. V24 stated it is a case-by-case situation to be over medicated but having been on 10 or more pills at once does not mean being overmedicated. V24 stated she did not see any harmful effects of Seroquel on R6 and does not believe it to cause any harm for her in particular at her age. V24 stated R6 has recurrent major depressive disorder, alcohol withdrawals and insomnia which is all why she was on Ramelteon, Sertraline, Trazadone, and Fluoxetine and these all had appropriate diagnosis.On 5/5/26 at 8:34 AM, V3 (Assistant DON) stated she had been doing psych (psychological) audits for the facility when she saw R6 was on Quetiapine for prophylaxis, which is not an appropriate diagnosis to be prescribe that medication for. V3 stated they calledV24 (APRN) and came to the conclusion R6 should not be on the medication and discontinued it. V3 stated the expectation for antipsychotics is have an appropriate supporting diagnosis to be prescribed them.The facility's Psychotropic Medication Program Policy, dated 10/2024, documented, The second purpose of this process is to ensure the resident is evaluated and the indication for the medication is documented within the medical record including but not limited to the nursing staff, social services, activities and the physician. Also, the resident and or resident representative are aware of the potential side effects and the facility obtains an informed consent for the use of the psychotropic medication.

Based on interview and record review, the Facility failed to ensure a resident with history of falls was assessed appropriately by nursing staff after a fall. This failure would have resulted in a reasonable person enduring pain for over a day due to a rib and clavicle fracture until nursing staff was notified completed an assessment. Findings include:R2's December 2025 Physician Order Sheet (POS) documents a diagnosis of Parkinson's disease with dyskinesia, with fluctuations, chronic respiratory failure, severe protein calorie malnutrition, traumatic subarachnoid hemorrhage without loss of consciousness, abnormal weight loss, delirium due to physiological condition, and anxiety disorder. R2's Minimum Data Set (MDS), dated [DATE], document R2 was severely impaired for cognition for activities of daily living. R2 uses a wheelchair and requires substantial/maximal assistance-Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. R2's Care Plan: Falls documents, (R2) is at risk for falls. Cognitive deficits, Functional Deficits, Poor Balance, Use of Psychotropic Medication. Date Initiated: 11/27/2023. R2's Progress Notes, dated 11/25/2029 at 1:29 PM, Note Text: CNA'S reported to nurse that resident had a fall yesterday evening 11/24/25, around dinner time, CNA's got resident up without nurses knowledge, ROM (range of motion) and skin assessment provided this shift, resd (resident) does not want staff to touch her arm, Hospice assessed resident with orders to send to ER (emergency room) for eval (evaluation) and tx (treatment). R2's Progress Notes, dated 11/26/2025 at 2:10PM, Note Text: Call received from (Hospice Nurse from Hospital) DX (diagnosis of UTI (urinary tract infection) with new ABT (antibiotic orders), Multiple rib fractures and Fractured clavicle. On call Nurse to have PRN (as needed) Morphine for pain control delivery of pain medication to the facility for resident's comfort and pain control. R2's Hospital Report, with an encounter date of 11/25/2205 at 2:39 PM, documents, I called (Facility) and spoke with nurse. She reported that the patient was found on the floor yesterday around dinner time. She states that somehow, she must have fallen out of her wheelchair. Stated that the medical assistant found her and did not report it to any nursing staff. Nursing staff found out this morning that the patient fell yesterday evening. Nurse stated that the patient had pain to her left shoulder when examined. The patient is nonverbal, bed bound unless in a wheelchair up for food and does not feed herself. Elderly, frail patient observed bed bound in chronic flex/fetal posture, consistent with contractures, Requires full assistance with positioning. The CT scan final results dated 11/25/2025 document, 'the medical portion, right clavicle, the anterior aspect right first, and second ribs are angulated with cortical irregularity could indicate subtle acute fractures. Closed fracture of multiple ribs of right side, initial encounter, closed, nondisplaced fracture of shaft of right clavicle, initial encounter.R2's Initial Report, dated 11/24/2025, documents, Resident had fall with injury. Investigation initiated DON (Director of Nursing), POA (Power of Attorney), MD (Medical Doctor) notified. This is our initial report 5 day to follow. R2's Final Report incident date of 11/24/2025 documents, Resident resides at (Facility) as a long-term care resident. She is alert and oriented x1, she is dependent for mobility throughout the facility as well as a (mechanical lift) transfer. Resident can be impulsive at times; resident sustained a non-witnessed fall in the dining room. After the investigation of the events, the resident was restless in her chair and slid out of her (geriatric) chair. She was sent to the hospital and returned without admission to hospital. Diagnostics show a right clavicle fracture and 1st/2nd ribs with subtle acute fractures and UTI (urinary tract infection) Care plan reviewed and revised to meet resident needs. This is our final report. R2's Progress Notes, dated 11/26/2025 at 12:15 AM, Note Text: Resident returned to the facility. Resident transported to room, staff assisted residents into the bed and call light placed in reach. Resident seen in ER and treated for Un-witnessed fall, Abnormal CT-Scan, Closed FX (fracture) of multiple ribs on right side, Closed non-displaced Fx of right clavicle, Stercoral colitis, constipation and Acute UTI (urinary tract infection). Resident has new orders for ABT (antibiotics) from ER (emergency room). Discoloration noted to UE (upper extremity). Resident tearful during assessment and PRN (as needed ) pain medication given for discomfort. On 12/3/2025 at 6:25 AM, V7, Certified Nursing Assistant (CNA), stated she usually works midnights. R2 fell in the dining room. I did not witness it but heard she had fallen but she passed away yesterday. If a resident falls, we are supposed to get help and tell the nurse. The nurse will then tell us what to do. I am not sure why (R2) was moved. On 12/4/2025 at 1:29 PM, V8, Certified Nursing Assistant (CNA), stated, If a resident falls, we are supposed to get help and tell the nurse before moving them because we could make it worse if we moved them and they were injured. On 12/4/2025 at 4:14 PM, V14, Licensed Practical Nurse (LPN) stated, If a resident falls, staff are to yell for help and wait for nursing to assess them. If we think there may be an injury, we notify the doctor and send them out. Staff are never to get any resident up without them being assessed first. If they try and get someone up they could easily injure them. On 12/8/2025 at 1:11 PM, V2, Director of Nursing (DON), stated, I know the previous DON was walked out of the building, but I am not sure what went down. Today, is my first day. If a resident falls, I would expect staff to yell for help, nursing to assess the resident, and if there are any injuries or possible injuries to notify the physician to send them out to the hospital. I would never expect staff to get them up without assessing them and/or notifying nursing and/or are being monitored by staff. On 12/17/2025 at 3:38 PM, V23, Medical Doctor, stated, If a resident had a fall, I would expect nursing staff to be contacted so they could assess the resident look for possible injury and depending on the nature of the injury that would determine what staff to do next. In this case, (R2) did have a fracture and injury so this is something staff need to know that there was fall. On 12/19/2025 at 12:10 PM, V24, Infection Control Nurse, stated, I did speak with someone from the hospital. We went back and looked at the cameras, and it was not a medical assistant that found (R2), it was actually a CNA (V25). I am not sure what happened and why no management knew (R2) had fallen until the next day. On 12/19/2025 at 12:10 PM, V25, CNA, stated, I was in the dining room feeding another person. When I looked over, I saw a (geriatric chair) sitting at the table with no resident. I thought it was odd and when I stood up (R2) was under the table. I was trying to get staff attention and there was an agency nurse there and I thought she saw her under the table. The Facility Fall Prevention and Management Policy, with a revision date of 9/2025, documents, This facility is committed to maximizing each resident's physical, mental and psychosocial well-being.While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident fallsshall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. Evaluate the resident for any injury and notify the physician and emergency contact. Complete a fall incident report in the (Computer) risk management portal.

Based on interview and record review the Facility failed to ensure the alleged perpetrator of an abuse allegation did not have access to residents when an allegation of abuse occurred, and failed to ensure all abuse allegations were investigated. This has the potential to affect all 50 residents living in the facility. Findings include:R10'S Physician Order Sheet (POS) for December 2025 documents a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Type 2 diabetes mellites with other specified complications, muscle weakness, acquired absence of left leg below knee, major depression disorder, single episode, several without psychotic features, and dependence on wheelchair. R10's Minimum Data Set, dated [DATE], document R10 has an impairment on both his upper and lower extremity on one side. R10 was cognitively intact for decision making of activities of daily living, uses a wheelchair and needs substantial assistance for most ADL's (activities of daily living). R10's Care Plan includes: ADL (Activities of daily living): (R10) requires assist with daily care needs r/t (related to) left sided weakness from a CVA. He has a BKA (below knee amputation) of the left leg and requires assistance with transfers. He prefers to have the open side of the bed to the right side to help facilitate bed mobility as that is his strong side. He was placed on restorative dressing/grooming and Transfer programs. R10's Care Plan does not address abuse or document R10 has a history of cussing out staff.R10's Initial Report, dated 11/27/2025, documents, It was reported on 11/26/2026 there was an alleged verbal abuse altercation between (R10) and (V13). Investigation initiated. Final to follow. R10's Final Report date of incident 11/27/2025, documents, (R10) is a [AGE] year-old male. An alleged verbal altercation was reported to have taken place between (R10) and (V13) on 11/26/2026 at approximately 7:55 PM. This was an unwitnessed conversation. Due to the lack of supporting documentation and statements the alleged altercation cannot be substantiated. Staff were in-serviced on customer service and one on one support was provided to the resident. R10's Progress notes, dated 12/2/2025 at 10:52 AM, documents, Late Entry: Note Text: Writer spoke with residents about the abuse allegation he reported. Resident stated he had no further issues and was happy with the follow-through from staff investigating the situation. I asked the resident if he felt safe and comfortable here at the facility, and he stated that he did. Resident was in good spirits. R10's Progress Notes do not document anything related to the allegation of abuse on 11/27/2025. Statement from V14, Licensed Practical Nurse (LPN), documented (V13) came up to the desk and kept talking and yelling about how (R10) had apparently called her out of her name (sic). She was going on about how she wasn't in the resident room and that another CNA (certified nursing assistant) was told she needed less hours. Upon speaking with resident, he stated he said bc (because) this CNA weeks ago, asked or told him why he can't use the bathroom. Resident stated CNA came into his room and yelled at him asking why he cusses at her. This nurse along with agency nurse told CNA to clock out and go home. CNA went to sit in a coworker's car, after she proceeded to stated it was cold outside and wasn't leaving bc (because) she had a ride. She proceeded to sit at the desk, calling myself and the other nurse fake. The level of disrespect from CNA is crazy, I've dealt with from a few that still work there. I should have sent her home earlier, but I was busy on my hall on top of dealing with that. Statement from V13, CNA documents, I was told by another coworker that (R10) called me out my name (sic) and was saying mean stuff about me while she was changing him. All I wanted to know was what was wrong. I have not had him in a while. Went down to his room to ask him was everything okay. Did I do something to make him mad? He started cussing me out. Tell me to get the fuc* out of his room and that I don't need to work here. I'm not shi* and stuff like that. I never cursed at him. I just asked him what was wrong. That's the only thing I asked him. He tried to record me and everything and not once did I cuss at him I though he hadn't said nothing to me all day yesterday 11/26 I work 16 hours do not even have the set he was on so I was just trying to figure out what was the problem. Had a situation about a month ago and it got handled but why are you bringing up a situation that already got handled by the administration? Telling the aide anything about me? And for him just trying to figure out what was the problem. Had a situation about a month ago and it got handled but why are you talking about me to somebody and why are you bringing up a situation that already got handled by the administration. Telling the aide anything about me. And for him to call me out my name and talk to me that way he did was not right, there needs to be a level of respect when it comes too these residents just like we have to respect them as well. This is not the first time he cussed me out or other staff out, The nurses that were on shift treated me as if I did something wrong and I did nothing wrong the aids can vouch for me as well. Told me to clock out and go stand outside in the cold and I did not have working transportation. I also got told that the was police was going to get called on me. All this for what I do my work the best I can and know how I do not disrespect anybody at work. I actually had a good day until all of this, I am very upset. On 12/8/2025 at 2:36 PM, V17, Licensed Practical Nurse (LPN) stated, I was not working (R10's) hall we had an agency nurse that night and she reported to me that a CNA was giving care to (R10) and he had told her that (V13) had given him care and he did not want her taking care of him anymore because she doesn't like to work and then that CNA told (V13) and (V13) then confronted (R10) and when I reported her and asked her to leave she kept saying she did not have a ride and refused to leave and sat the nurse station cussing. I got her to go outside, and she was sitting in someone's car, but then she came back in and said she didn't do anything, and she wasn't going to leave because it was cold outside. She was calling me names and I told her I was going to have to call the police, and she just refused to leave. I was working but I tried to stay close the nurse's station where she was sitting. On 12/8/2025 at 2:55 PM, V2, Director of Nursing, stated, Today is my first day of working here. I know the previous DON was walked out of the building, but I am not sure what went down. Today is my first day. If a resident made an allegation of abuse against a staff member, I would make sure the resident is safe and the staff member does not have access to them pending the investigation and for the staff to be suspended immediately so we can start an investigation. The staff member must leave the premises, they do not have a choice, it is not optional. This is about keeping the resident safe. They have to leave until we clear them. I would expect all staff that have an allegation of abuse made against them to be escorted out of the building. No staff should still be in the building unless they are in an area away from residents and do not have any access to any residents and/or being monitored for resident interaction. I would not expect the nurse's station to be away from residents because there are a lot of residents that sit near the station and/or are being monitored by staff. Plus, resident can hear and see everything that is going on. On 12/16/2026 at 2:30 PM, V1, Administrator, stated, I expect all staff to be suspended and leave the premises whenever there is an allegation of abuse, and they are not allowed to come back into the Facility until they are cleared. The Abuse was investigated and (V13) is reinstated and working in the building now. On 12/19/2025 at 1:12 PM, V13, Certified Nursing Assistant, stated, I know another CNA came to me and told me (R10) was saying bad stuff about me. I thought we were cool and I had not even provided care for him for while. I went into his room to try and talk to him and he did not want to talk to me. He started cussing me out and trying to record me. I didn't respond or say anything back to him. I just walked away. Then the nurse told me I had to leave so I left. I left when they told me to leave and I was not in the building after that. 2.R9's POS for December 2025 documents a diagnosis of Chronic traumatic brain injury, right hemiplegia, muscle contractures, complex regional pain syndrome, diabetes, hypertension, and significant behavioral dysregulation. R9s' Care Plan, with a revision date of 10/7/2025, documents, Attention Seeking Behavior -Putting self on the floor; BEHAVIOR: False Accusations saying staff hits him, other residents hit him. ADL: [NAME] requires assist with daily care needs r/t (related to) TBI (traumatic brain injury), right sided hemiplegia and Contractures of the right arm and hand. He has impulse control issues and will sporadically try to get out of his wheelchair using his left arm and left leg. R9's MDS, dated [DATE], document Resident is cognately intact for decision making of activities of daily living. Impairment on one side of upper extremity and impairment on both sides. Uses a wheelchair and requires substantial /maximal assistance for most ADL's. On 12/8/2025 at 1:48 PM, V17, Registered Nurse (RN) stated, (R9) was upset with me and made allegation of verbal abuse because he came out in the hallway and was naked except for a pillow this was about a week ago. I said something and he thought I was talking about his penis and got upset. (V1) was in the hospital. I was with my daughter. I did not say anything about his penis, and it was not investigated. I never gave any statements or anything to anybody. On 12/8/2025 at 2:38 PM, R9 stated, (V17, LPN) his nurse is always making comments about my penis being small and I told my mom, and this has been going on and on and nobody does anything about it and it bothers me. On 12/8/2025 at 2:49 PM, V21, Family of R9, stated, (R9) called me because he was very upset because he thinks his nurse is making fun of his penis and telling him it is so small. I know this upsets him. On 12/8/2025 at 3:30 PM, all abuse investigations were requested. On 12/8/2025 at 4:30 PM, no verbal abuse investigation and/or any investigation related to R9 was provided. On 12/8/2025 at 4:35 PM, V1, Administrator, stated she did not have any abuse investigation for R9. On 12/16/2025 at 1:32 PM, V1, Administrator, stated, I was in the hospital, and my DON (Director of Nursing) was in charge. I was very ill and when I came back my DON had not kept up with anything. I did not even know (R9) had made any abuse allegations until (State) brought it to my attention. I would have expected my DON to send the staff home, interview everyone and try and determine if the abuse did and/or did not happen. It's very frustrating because I take abuse seriously and she should have opened an investigation. What can I say it was not done and it should have been done. The Facility Abuse Policy, with a revision date of 9/2017, documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect exploitation, misappropriation of property and mistreatment of residents. This will be done by: identifying occurrences and patterns of potential mistreatment; immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences; filing accurate and timely investigative reports. The CMS 671 Form, dated 12/3/2025, documents there were 50 residents living in the facility.

Based on interview and record review, the facility failed to provide the correct dose of physician prescribed medication (Lantus insulin) in 1 (R2) of 3 residents reviewed for medication errors in the sample of 3. Findings Include:R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] and has medical diagnoses of Type 2 Diabetes Mellitus, Alzheimer's Disease, Dementia, and Anxiety Disorder.R2's Minimum Data Set (MDS), dated [DATE], documents R2 is severely cognitively impaired.R2's Previous Physician Order, dated 8/4/2025 at 9:27 AM ,documents Lantus Solution 100 UNIT/ML (Insulin Glargine) Inject 27 unit subcutaneously at bedtime for diabetes mellitus.R2's Nurses Notes, dated 9/23/2025 at 10:02 PM, documents, The other Nurse stated she gave resident 27 units of Lantus, I told Nurse res (resident) was mine and already had insulin. Telehealth Medical Doctor (MD) aware stated check fasting blood sugar (fsbs) every hour. Res was given snack and glucose gel. Sugar is 231, however res is being sent to local hospital for evaluation of Hypertension (HTN).R2's Nurses Notes, dated 9/23/2025 at 10:18 PM, documents Res transferred to local hospital for eval of HTN 180/90 via Emergency Medical Services (EMS).R2's Local Hospital Records, dated 9/23/2025 at 11:06 PM, documents per Emergency Medical Services (EMS), facility stated they called for Hypertension (HTN) that was caused from giving too much Lantus. R2's Local Hospital Records, dated 9/23/2025 at 11:06 PM, documents, On arrival Blood Pressure 181/101.R2's Local Hospital Records, dated 9/24/2025 at 9:12 AM, documents, She was suppose to (sic) take 27 units nightly according to chart review but apparently was given a double dose of this. She was brought to the ER for evaluation due to this. She did say that she had felt poorly earlier but she is unable to describe any specific symptoms.On 10/14/2025 at 11:13 AM, V6, Nurse Practitioner (NP), stated the on-call physician was notified on 9/23/2025 that R2 had received a double dose of her Lantus insulin. V6 stated with receiving a double dose of insulin R2 could have experienced lethargy, loss of consciousness, pathological events, or hypoglycemia to a dangerous level. V6 stated R2 was sent to the local hospital for elevated blood pressure and evaluation after receiving the extra insulin dosage.On 10/14/2025 at 11:30 AM, V2, Director of Nursing (DON), stated she was called and home and informed R2 had received a double dose of her Lantus, long-acting insulin. V2 stated V10, Licensed Practical Nurse (LPN), had given R2 a dose of her insulin after V9, LPN, had already administered R2 the insulin. V2 stated there was a computer issue and V10 did not see that V9 had already administered R2's insulin. V2 stated she informed staff to give R2 glucose gel, graham crackers, and juice in case R2's blood sugars dropped. V2 stated R2's blood pressure appeared to be elevated, and the facility decided to send R2 to the local hospital for evaluation.On 10/14/2025 at 12:03 PM, V10, LPN, stated she accidently gave R2 her insulin after V9, LPN, administered the insulin. V10 stated she was confused on which resident's she was taking care of and thought R2 was her resident and did not see on the Medication Administration Record (MAR) that the insulin was already administered to R2. V10 stated R2 was sent to the local hospital due to her blood pressure being elevated after receiving the insulin.On 10/14/2025 at 3:10 PM, V14, R2's family, stated he received a phone call from the facility stating R2 had received a double dose of one of her insulin. V14 stated he was informed there was a mix up with which nurse was taking care of which resident and R2 was given more insulin than she should have been given. V14 stated he was informed R2 was being taken to the local hospital for high blood pressure. V14 states R2 can get anxious and does not always understand what is going on.On 10/15/2025 at 1:15 PM, V9, LPN, stated she was R2's nurse the night that R2 received a double dose of insulin. V9 stated she went to do R2's accu- check and bedtime medications and gave R2 her Lantus. V9 stated the nurse she was working with stated she also gave R2 the dosage of Lantus about an hour after V9 administered the insulin to R2. V9 stated V10 informed her V10 thought R2 was V10's resident to pass medications to. V9 stated the facility has frequent internet and computer issues and when she gave R2 the insulin, she had the MAR pulled up and could not click off that the medication was administered due to internet issues. V9 stated R2's blood pressure was taken a little while later and R2's blood pressure was elevated. V9 stated R2 was sent to the hospital for evaluation.The Facility's Medication Administration Policy, reviewed 4/2025, documents, All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Guideline #6 documents Check medication administration record prior to administering medication for the right medication, dose, route, patient/resident and time.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and interventions to prevent falls for 1 of 3 residents (R2) reviewed for falls. Findings include:R2's undated face sheet documented she was admitted to the facility on [DATE], with diagnoses including anxiety, hyperlipidemia, hypertension, altered mental status, and dementia.R2's Minimum Data Set (MDS), dated [DATE], documented she has memory problems and is moderately cognitively impaired. The MDS documented R2 requires set-up assistance for eating and requires staff supervision for all other activities of daily living (ADL's). R2's care plan, dated 7/15/25, documented R2 is a currently at a high risk for falls with a goal that she will remain free of falls. Her interventions for this care plan include: encourage appropriate use of wheelchair, evaluate multiple falls to determine any patter, fall risk assessment quarterly and as needed, keep bed in lowest position, keep frequently used items within reach, monitor for changes in gait or ability to ambulate, move resident to room with optimal visual access from nurses station, notify medical doctor (MD) and family of any new fall, promote placement of call light within reach, provide proper, well maintained footwear, provide resident with night light, restorative care as appropriate, rounding at a minimum of every two hours, staff to assist as needed and therapy to evaluate and treat as indicated.R2's care plan, updated on 7/31/25, documented bed to be placed in lowest position when in bed. R2's care plan was updated 8/4/25 after a fall with the interventions including therapy to screen for strengthening and position and send to local hospital emergency room (ER) for evaluation. On 8/5/25 at 1:48 am, after another fall, the only intervention added to the care plan was to send to local hospital ER. There was no other intervention added for this fall. On 8/5/25 at 9:47 pm, R2 had a third fall with the intervention added to send to local hospital ER for evaluation and floor mat to open side of the bed. On 8/2/25 at 9:45 am, V1 (administrator) and V13 (MDS director) stated R2's only intervention for her second fall on 8/5/25 at 1:48 am was to send R2 to hospital ER. There was not an intervention added that would keep her safe from falling again. On 8/4/25 at 8:19 pm, R2's progress note documented R2 was observed lying supine on floor in front of the nurse's station. A small skin tear to the outer right elbow is noted, no other visible injuries. R2 was transported to local hospital via emergency medical services (EMS).On 8/18/25 at 3:55 pm, V8, Licensed Practical Nurse (LPN), stated on 8/4/25 in the evening, R2 had been sitting in front of the nurse's desk in her wheelchair for close observation, when V8 went to assist another resident urgently. When V8 came back up to the nurse's station, R2 was lying on the floor. V8 stated that the cameras were reviewed and looked like she had slid out of the wheelchair on her buttocks. V8 saw no injuries, but due to her receiving blood thinners, R2 was sent out to the hospital. V8 stated prior to R2 falling, she was on fall precautions and staff were checking on her frequently. On 8/20/25 at 9:10 am, V1 stated the timing of frequent monitoring varies depends on each situation and could be every 15 minutes, every hour, or every two hours.R2's fall investigation, undated, or the fall on 8/4/24 at 8:09 pm, documented interdisciplinary team (IDT) met and documented upon investigation, it was found the fall is the result of R2 attempting to get up from the wheelchair without help. The interventions include sending R2 to evaluation and treatment. Upon return physical therapy is to screen for strengthening and positioning. On 8/18/25 at 11:15 am, V3, Registered Nurse, (RN) stated R2 returned to the facility on 8/5/35 at 12:49 am, and the EMS attendant placed R2 in bed. V3 stated she was at the facility about an hour and fell out of bed again. V3 stated V4, Certified Nursing Assistant (CNA) was the CNA working that night and was sitting in the hallway across from R2's room to keep a close eye on her. When V4 went into her room, R2 was lying on the floor. V3 stated she assessed R2 had a laceration in the back of her head, and due to R2 receiving blood thinners, V3 sent R2 out to the hospital again. V3 stated R2 was alert to self and described her as impulsive.On 8/5/25 at 12:49 am, R2's progress notes by V3 documented R2 returned to the facility per EMS, who assisted R2 in bed and call light placed in reach. No new orders received from local ER at time of return to the facility. V3 documented range of motion (ROM) and Neuro checks within normal limits (WNL) for R2. CNA staff aware of the need to frequently to monitor resident post-fall. On 8/20/25 at 9:21 am, V4 stated on 8/5/25 during her night shift, she was sitting in the hallway outside of R2's room, a little to the right of the doorway across the hall. She stated from that vantage point she could not directly visualize R2, but was able to get up often and check on R2, along with all of her other residents on the hallway. V4 stated she kept going back and forth checking on R2 frequently. V4 stated she didn't think about sitting at her doorway because she was also thinking of being available for all her other residents on the hall. V4 stated she did not see or hear her fall, but on one of her checks, R2 was lying on the ground.On 8/5/25 at 1:48 am, progress note by V3 documented she called to R2's room by CNA staff and R2 observed laying on floor next to bed with head towards wall and bilateral lower extremities (BLE) extended outward toward bathroom. Call light not activated at time of fall. V3 noted blood on the floor under R2's head. Raised hematoma noted to back of head with laceration noted to area. CNA staff remained with resident. At 1:52 am, V3 documented call placed to 911 for transfer back to local hospital ER for another assessment due to second fall.On 8/5/25 at 2:08 am, V3 documented EMS arrived at the facility and R2 assisted on the stretcher by EMS staff and transported to local hospital ER. R2's fall investigation undated fall investigation for the fall on 8/5/24 at 1:48 am documented Interdisciplinary Team (IDT) met and documented upon investigation, it was found that the fall was the result of R2 rolling out of bed. The intervention is sending R2 to evaluation and treatment. On 8/5/25 at 2:26 pm, R2's progress notes documented she returned from local hospital via EMS and was transferred from stretcher to bed.On 8/5/25 at 9:47 pm, R2's progress note documented CNA alerted nurse at 9:15 pm that R2 was on the floor. When nurse arrived at R2's room, she was on the floor on her left side with blood noted around her head. Nurse controlled the bleeding to R2's head and then contacted 911 for transfer to local hospital ER for further observation. On 8/19/25 at 12:33 pm, V12, LPN, stated R2 was already in the facility when she arrived for her evening shift on 8/5/25. V12 added all the staff were aware a close eye needed to be kept on R2. V12 stated R2's bed was in the lowest position, and her call light was in reach when R2 returned to her room. V12 stated the CNA had just left the room about ten minutes prior to R4, (R2's roommate) coming out and stating R2 was trying to get up. V12 stated she went into the room, R2 was lying on the floor.On 8/18/25 at 12:08 pm, V5, ER supervisor, stated R2 was in the ER on [DATE] from 8:51 pm until 8/5/25 12:24 am, due to an unwitnessed ground level fall. V5 stated R2 then returned to the ER again on 8/5/25 at 2:32 am for a fall, was admitted for observation, and was discharged at 2:54 am. V5 stated R2 was once again admitted to ER on [DATE] at 10:05 pm for an unwitnessed fall and then discharged on 8/6/25 at 3:51 pm to a different facility.Fall Prevention and Management policy, dated 5/2015, with last revision date of 1/2024, documented the facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventative strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. Facility guideline following a fall incident are to evaluate the resident for any injury and notify the physician and resident responsible party. Complete a fall incident report in the EMR risk management portal. A fall risk evaluation is completed by the nurse. A score of 10 or greater indicates the resident is at high risk for fall. Care plan to updated with a new intervention based on root cause analysis after each fall occurrence.

Based on observation, interview, and record review, the Facility failed to ensure each resident had a closet with shelf space for 1 of 6 residents (R2) reviewed for closet space in the sample of 6. Findings include: On 6/5/2025 at 12:48 PM, V8, Family of R2, stated, (R2)'s room was at the end of the hall. There was a small space, but no actual closet, and from the ceiling the facility had a PVC pipe running from one end to the other then forming a box, that I guess that was where my mom was supposed to hang her clothes. There was no shelving, and we went out and bought her a curtain and put it on tension rod, so it would be more homelike for her. It was not homelike before that, trust me on that one. (R2) had a single room but there was no closet, just this space with the PVC pipe. There was no portable wardobe just the PVC pipe for the clothes. On 6/5/2025 at 1:14 PM, R2's former room did not contain a built in wardrobe. There was a small space boxed in a square, with white PVC pipe running all the way across the ceiling. At one end of the PVC pipe was a square made out of additional pieces of PVC pipe. Behind the PVC pipe was a metal stand consisting of two upright metal bars and two metal bars running across with wheels on the bottom of it. The metal clothes hanging rack was portable. There were no shelves present. On 6/5/2025 at 1:18 PM, V1, Administrator, stated, (R2) was located on the 100 halls at the end of the hall, but the room is empty now. There used to be a clothing wardrobe in the room, but it was removed. When (R2) was at the facility there was no wardrobe, and maintenance had hung the PVC pipe. There were no shelves. The Resident Right Policy, dated 10/2003, documents, The objective of the accommodation of resident needs and preferences is to create an individualized, home-like environment to maintain and/or achieve independent functioning, dignity, and well-being to the extent possible in accord ance with the resident's own needs and preference. Facility will provide sufficient individual closet space for each resident.

Based on interview and record review, the facility failed to prevent a significant medication error in 1 of 6 residents (R3) when reviewed for medication administration in the sample of 6. This failure resulted in R3 being admitted to the hospital with a principal problem of Accidental Drug Overdose. Findings Include: R3's Progress Note, dated 4/17/25 at 6:59 PM, documents the following: This Nurse recognized that I administered a wrong medication to the resident. Res. (Resident) has NKA (No Known Allergies). Res sent to ER (emergency room ) for evaluation. NP (Nurse Practitioner, Administrator, and D.O.N (Director of Nurses) all made aware. ER MD (Medical Doctor) aware. R3's Progress Note, dated 4/18/25 at 5:50 PM, documents the following: Update resident admitted with hypoglycemia and medication error. Resident stable and alert at this time. R3's Progress Note, dated 4/20/25 15:02 PM, documents the following: Resident returned to facility via ambulance at 14:55 (2:55 PM). R3's Medication Error Report, dated, 4/17/25, documents the following: Occurred on 4/17/25 at 6:50 PM, discovered 4/21/25 at 6:50 PM by V8, RN (Registered Nurse). Medication Involved: Clozaril (Clonzipine) 150 mg (milligrams). Description: resident came to nurse requesting meds while nurse was preparing meds for another resident and accidentally gave R3 the other resident's (R5) medication. Medication Error Type: wrong resident, wrong drug. Contributing factors: lack of staff concentration. Symptoms experienced: lethargy, sent to ER and admitted for observation. MD, pharmacy and family notified. Results of investigation: Sent to ER for further evaluation. ER admitted for 24 hours and returned to facility with no other adverse effects. Interventions: DON completed medication administration competency with V8, RN, and completed medication administration in-services with the nurses. R3's ED (Emergency Department: Provider Notes, dated 4/17/25, document the following: Patient here for lethargy, somnolence, history of diabetes. Nursing home called and said he was given a medication in error at 4:30 PM, 150 mg of Clozaril. Nursing home staff gave 22 units for his sugar of 330. Final diagnosis: Accidental drug overdose, Hypoglycemia, AMS (Altered Mental Status). Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Hypo/Hyper Glycemic Control, Acute Ingestion. Poison control was contacted, unfortunately there is no reversal agent, recommended supportive measures, monitor for dystonia and seizures (control with benzos if needed), treat Hypotension with fluids and pressors as needed to protect the airway and admit for observation. R3's blood sugar in the emergency room was 85. R3's Post-Acute Transfer Report, dated 4/20/25, document R3's Principal Problem was an accidental drug overdose. R3's Physician Order Sheets (POS) were reviewed with no orders for Clozaril. R5's POS was reviewed with an order for Clozapine (Clozaril) 100 mg, give 1.5 tablets by mouth twice daily. On 4/22/25 at 1:23 PM, V8, RN, stated she was at the medication cart, getting medications ready for another resident (R5) when R3 came up to her and asked for his medication, and she accidentally gave R3 R5's medication, Clozaril, and about 15 - 20 minutes later, she realized what she had done. V8 stated R3 was very lethargic, the Nurse Practitioner was notified, and R3 was sent to the hospital. V8 stated R3 was admitted to the hospital for a few days. On 4/22/25 at 1:30 PM, V10, Pharmacist, stated she reviewed R3's medication, and there were none of his medications that would have interacted with the Clozaril/Clozapine. V10 stated receiving one dose of this medication, would not have made R3 fatigued or lethargic. V10 stated when it is given regularly some common side effects can be lethargy, blurred vision, etc. from it building in their system with multiple doses, it would not normally be caused by just one dose. On 4/22/25 at 2:45 PM, V2, DON, stated she was not here when the medication error with R3 took place, she was called at home by V8, RN, and V8 had already notified R3's physician and called EMS, and R3 was sent to the hospital. R2 stated, (R3) did not have any adverse reaction from the medication; he is a severe brittle diabetic, his blood sugars quickly go high to low. V2 stated she was told by the hospital R3 was hypoglycemic upon arrival to the ER and was admitted . V2 stated prior to R3 going to the hospital, R3's blood sugar was 300 and he was given 22 units of insulin, and depending on when the insulin was given and he ate, could have caused his blood sugar to drop quickly, which is normal for R3. V2 stated they have changed his insulin and accu-check times to make sure when he is high and needs insulin, that he eats right then and doesn't wait. V2 stated R3 knows when his blood sugar is low and will get peanut butter cups and juice. V2 stated she is a diabetic and hypoglycemia can cause lethargy. V2 stated when a nurse is administering medications, she would expect them to follow the rights of medication administration, right medication, right person, right time, right frequency, etc. On 4/22/25 at 2:55 PM, R3 stated he doesn't remember anything about the incident on 4/17/25, or for a couple of days after. R3 stated he woke up in the hospital and was told they thought he had been given the wrong medication, but that is all he was told. R3 stated his blood sugar goes up and down quickly, and now he doesn't take his insulin until he eats so it won't drop. R3 stated he knows when his blood sugar is low and he will get some candy to raise it. R3 stated when his blood sugar is low, he feels bad and sometimes will black out. The Clozaril Information from Drugs.com documents the following: It is an anti-psychotic used to treat Schizophrenia after other treatments have failed, works by changing chemical reactions in the brain. Also used for reduce the risk of suicidal behavior in adults with Schizophrenia or similar disorders. Clozaril can affect your immune system, can cause seizures when given in high doses, cause heart problems. Overdose symptoms may include drowsiness, confusion, fast heartbeats, feeling light-headed, weak or shallow breathing, drooling, choking, or seizure. The Medication Administration Policy, dated 6/2015, documents the following: All medications are administered safely and appropriately to aid in residents to overcome illness, relieve and prevent symptoms, and help in diagnosis. Check medication administration record prior to administering medication for the right medication, dose, route, patient/resident, and time.

Based on interview and record review, the facility failed to administer medications as ordered by the physician in 2 of 4 residents (R2, R3) reviewed for pharmacy services in the sample of 4. Findings include: 1. On 4/8/25 at 11:55 AM, V5, R2's Daughter, stated R2 had not been receiving her daily medications. R2's Face sheet, undated, documents R2 has the following diagnoses: Three Part Fracture of the Left Humerus, COPD (Chronic Obstructive Pulmonary Disease), Neuropathy, MDD (Major Depressive Disorder), CHF (Congestive Heart Failure), Cardiac Pacemaker and Defibrillator, History of Falling, Arthropathy, Gout, HTN (Hypertension), Low Back Pain, and Chronic A. Fib (Atrial Fibrillation). R2's MAR (Medication Administration Record), dated 4/1/25 through 4/30/25, documents the following physician orders, dated 4/1/25: Spironolactone Oral Tablet 25 MG (Milligrams) give 0.5 tablets by mouth one time a day for High Blood Pressure; Sertraline HCl (Hydrochloride) Oral Tablet 25 MG give 1 tablet by mouth one time a day for Depression; Furosemide Oral Tablet 40 MG give 1 tablet by mouth one time a day for Cardiac Failure; Empagliflozin Oral Tablet 10 MG give 1 tablet by mouth one time a day for Heart Failure; Neurontin Oral Capsule 100 MG give 1 capsule by mouth one time a day for Neuropathy; Protonix Tablet Delayed Release 40 MG give 1 tablet by mouth one time a day for GERD; Clopidogrel Bisulfate Tablet 75 MG give 1 tablet by mouth one time a day for blood clot prevention; - Atorvastatin Calcium Oral Tablet 40 MG give 1 tablet by mouth one time a day; and Amiodarone HCl Oral Tablet 200 MG give 1 tablet by mouth one time a day for Atrial Fibrillation. The MAR goes on to document those medications were not administered on 4/2/25 or 4/3/25. R2's Progress Notes, dated 4/2/25 and 4/3/25, document these medications were not administered due to not on hand. 2. On 4/8/25 at 8:00 AM, R3 stated she is supposed to get 4 calcium carbonates after meals, and they were out for a while, so she wasn't getting them. R3's Face sheet, undated, documents R3 has a diagnosis of GERD (Gastro-Esophageal Reflux Disease). R3's MAR, documents an order, dated 3/22/25, for Calcium Carbonate Oral Tablet Chewable 500 MG (Antacid) give 4 tablets by mouth three times a day for supplement. R3's MAR goes on to document that R3 did not receive her medication as ordered on 3/22/25, 3/23/25, 3/24/25, 3/25/25, 3/26/25, and 3/27/25; therefore, missing a total of 8 doses. R3's MDS (Minimum Data Set), dated 3/29/25, documents R3 has a BIMS (Brief Interview of Mental Status) score of 14, indicating R3 is cognitively intact. R3's Care plan, dated 3/24/25, documents R3 has a diagnosis of GERD and is at risk for complications related to hyperacidity with an intervention to administer medications as ordered. On 4/8/25 at 4:44 PM, V2, Director of Nurses, stated medications are to be given as ordered by the physician. The Medication Administration Policy, dated 6/2015, documents all medications are to be administered safely and appropriately to aid the residents to overcome illness, relieve and prevent symptoms and help in diagnosis.

Based on interview and record review, the facility failed to ensure a resident's discharge was complete, including housing, Durable Medical Equipment (DME), and medications needed prior to discharging the resident to the hospital, and then failing to accept the resident back to the facility upon hospital discharge for 1 of 4 residents (R2) reviewed for transfer and discharge requirements. This failure resulted in R2 having to find a place to live, not having appropriate DME, and not having medications available as needed. The findings include: R2's Admission Record, dated 3/26/25, documents R2 was admitted to the facility on [DATE], and was discharged to the hospital on 3/5/25. R2's diagnosis include: Spinal stenosis cervicothoracic region, Type 2 Diabetes Mellitus (DM), nicotine dependence, rhabdomyolysis, suicidal behavior, major depressive disorder, alcohol use, hypothyroidism, hypertension (HTN), bipolar disorder, mood affective disorder, encephalopathy, spondylosis with myelopathy, and osteoarthritis. R2's Care Plan, dated 12/27/24, documents R2 requires assist with daily care needs, R2 has alteration in comfort, R2 requires the use of Psychotropic medication to assist with managing mood and behavior, R2 has a self-care deficit in dressing and grooming, R2 is a high risk for falls, R2 is a high risk for skin complications related to dependence on staff for toileting, transfers, and repositioning activities of daily living (ADL). R2's Minimum Data Set (MDS), dated [DATE], documents R2 was cognitively intact, and was dependent on staff for transfers and toileting. R2 required substantial/maximal assistance for bathing. On 3/24/25 at 2:38 PM, V12, Registered Nurse (RN), stated I am an emergency room (ER) nurse at the (local hospital) and was working when (R2) came to our ER from the facility due to behaviors. The facility assumed that (R2) was going to be admitted , but once he was evaluated by the physician, (R2) did not meet criteria for admission, and when we tried sending (R2) back to the facility, the facility refused, and stated that (R2) was discharged and not allowed to return. I know that (R2) was a difficulty patient and I was told that (R2) was to be discharged to an apartment, but that apartment was not ready, and we needed to send (R2) back to the facility because he had no place to go. On 3/25/25 at 3:55 PM, R2's Community Social Worker, stated, I worked with (R2) in getting senior housing, or an apartment. (R2's) apartment lease was signed, and it was ready on 2/28/25 for him, however, his daughter was supposed to coordinate with a moving crew to get all his belongings from his original home to his apartment, and she did not do that. (R2) did not have any furniture or belongings in his apartment when the facility discharged him. Also, the facility sent the DME request to a medical supply store, and did not do it correctly, and (R2) did not have any DME set up at his apartment. I called the store, and they said it was an incomplete referral form that they could not approve or fill. I was contacted by the Social Worker from the hospital (R2) was in because (R2) was supposed to be discharged , but did not have any place to go, because the facility refused to take him back. It just so happened that I am neighbors with (R2's) daughter and friends of his family, and I have a B&B (Bed and Breakfast) that was open for the weekend, so I let (R2) stay there until Monday (3/10/25). (R2's) daughter had everything ready for him on that Monday, so he moved into his apartment that day. (R2) didn't even have any of his medications from the facility, so he is working with his physician to get his medications. On 3/25/25 at 12:45 PM, V1, Administrator, stated, I was called on 3/5/25 for (R2) being loud, throwing things, screaming, pinning staff against wall, and threatening suicide-- at times indicating he was going to hurt himself. (R2) was putting all the staff and other residents at risk for harm because he was going everywhere in the facility doing these things. (R2) had other residents scared. We contacted the Psych Nurse Practitioner (NP) who gave the order to put in an Involuntary Admission to (local regional hospital). The staff had the Police and Emergency Medical Service (EMS) trying to help them. (R2) had a discharge order, dated 2/27/25, to discharge home. On 3/25/25 at 12:50 PM, V3, Social Service Director, stated, (R2) was scheduled to be discharged from the facility to his home the next day. I worked almost daily with (V7, R3's community Social Worker) about (R2's) discharge and plans. I had follow-up appointments, DME, and Home Health set up for (R2) and he was to go to his physician appointments where (local home health) would get their orders. I thought (R2) had an apartment ready to go once he was discharged from the facility, but when he had his episode, (R2) was sent to the hospital and should have been discharged to his home from there. I was not aware of (R2's) apartment was not ready for him. I have many emails regarding (R2's) DME, and I was never told that it was not filled or that it was declined. An email from V7 to V3, dated 3/5/25 at 9:10 AM, documents some confusion as to if the DME has been ordered or approved. R2's Social Service Note, dated 3/7/25 at 2:12 PM, documents, Writer sent DME signed notes from nurse prac (Nurse Practitioner) and patient, to continue with getting (R2) the equipment he needs for home. This was two days after R2 was discharged . On 3/25/25 at 2:50 PM, V3 stated, I spoke with (V7) who helped (R2) get his apartment set up, and according to (V7), (R2's) apartment move-in date was on 2/28/25. I was sent (R2's) apartment lease indicating his apartment move-in date was 2/28/25. On 3/25/25 at 3:25 PM, V1, Administrator, stated, (R2) was supposed to be discharged on [DATE], and when that date came, (R2) decided he didn't want to go and wanted to stay for more therapy. Then when therapy tried to work with him, he declined, and refused to work with them. Each time he was scheduled to leave, he changed his mind. When he had the incident, we had to do the involuntary psych admit/eval and we all thought, and I was even told, that the hospital would admit (R2) and then get treated and be discharged home from there. I assumed that (R2) would be admitted , and did not even think he would be discharged that same day. I called my boss and was told to go ahead and discharge him from the facility, and let the hospital discharge him to his home. Everyone from the EMS guys to my boss told me that (R2) would be admitted for a psych eval due to the involuntary form that we filled out. I was not aware until now that (R2) was not admitted , and I assumed that he was discharged to his apartment from the hospital after his stay. I would never put anyone out on the streets with nowhere to live, and would have absolutely let (R2) come back to the facility if I would have known that. I did not even think of (R2's) psychiatric status that day and his ability to go home by himself, because I assumed he was going to be admitted , and the hospital would treat him and help him with his discharge home. Normally on a Resident Initiated Discharge, the resident signs a discharge packet and the nurse will go over all their medications with them and they sign it off together. Then each interdisciplinary department signs off on what is recommended for that resident. Since (R2) was discharged to the hospital and not home, the nurse did not go over his medications with (R2) because they thought the hospital would do that. (R2) has hard scripts for his medications that were sent with his paperwork. I guess I learned something today, that an involuntary psych eval does not necessarily mean that person would be admitted . We probably should have waited until we found out his status, and then discharged him. R2's NP Psych Note, dated 2/28/25, documents, Findings in Patient ' s Room: Upon entry, it was discovered that the patient was in possession of a vape containing THC (tetrahydrocannabinol). The administrator addressed this issue with the patient, explaining that this is a violation of facility regulations. The patient became rude and demanding, insisting that he needed a day pass. Discussion and Facility Policy Violation: The patient was informed that his actions violated facility policies, potentially endangering both himself and other residents. Despite this, he continued to debate the issue and demonstrated a lack of insight into the consequences of his actions. I explained to him that a day pass is not an urgent or emergency matter and that further evaluation of his safety and the well-being of other residents is necessary. Discharge Planning and Additional Concerns: Discussed discharge planning with the patient, but he does not appear to have a clear or definitive plan for placement at this time. Given the situation, I am ordering a urine drug screen (UDS) to further assess for substance use. If the patient experiences a significant change in condition that poses a risk to himself or others, I recommend sending him to the ER for further evaluation. R2's Social Service Note, dated 2/27/25 at 12:30 PM, documents, (3/5/25) Late Entry: Note Text: Discharge Plan: Resident signed lease for d/c (discharge) with daughter/his own social services (V7). Resident plans to leave facility Tuesday 3/4/25 to discharge home. R2's Nurses Note, dated 3/3/25 at 1:52 PM, documents This nurse presented (R2) with a NOMNC (Notice of Medicare Non-Coverage) for last covered Medicare-A day as of 3/5/25. He doesn't wish to appeal at this time, and still plans on returning home with community care giver assistance. He is aware he is able to appeal the decision and has to do so before noon on 3/4/25. He did sign the NOMNC at this time. R2's NOMNC, dated 3/3/25, documents R2's last day covered was 3/5/25. R3 signed this document on 3/3/25. R2's Nurses Note, dated 3/5/25 at 12:10 PM, documents, Note Text: at 1130 (11:30 AM) resident came out of room being aggressive combative and screaming threats to staff demanding meds. He has already been informed by the night nurse and me that the Oxy (Oxycodone) he is requesting is on order with pharmacy and that they will deliver tonight or tomorrow morning. he was given his last dose of Oxy last night at 2100 (9:00 PM) and educated by night nurse that was his last dose until the other is delivered via pharmacy. All morning meds were given to resident this morning except for the Oxy which was explained to him numerous times as to why it wasn't given to him. 911 called. When the police arrived resident yelled at them also stating that is the only way to get things done around here. He also stated he didn't care if he was getting sent out for a psych eval regarding his actions. Police and EMS are currently with resident while he is talking to his daughter on the phone. Resident's daughter is currently his POA (power of attorney). EMS refused to take resident stating it is non-medical. Resident is currently in room screaming in an uproar. This nurse has spoken with resident's daughter regarding situation and has referred her to speak to management r/t (related to) her having multiple questions for management. This nurse has relayed message to contact her regarding her concerns. R2's Nurses Note, dated 3/5/25 at 1:08 PM, documents, At this time I received an order as follows due to resident spitting on others, stating he wanted to harm himself, assaulting staff members and refusing to go to the hospital for evaluation. Send resident as an Involuntary Admission to (Local Regional Hospital) via Psychiatric Nurse Practitioner, related to diagnoses of personal history of suicidal behavior, bipolar disorder and major depressive disorder for a psychiatric evaluation. Order noted. R2's Nurses Note, dated 3/5/25 at 2:37 PM, documents, After sheriff and EMS left they were called back to facility for resident r/t him becoming suicidal. He threw glass across room causing it to break. Resident taken to (local regional hospital) at 1345 (1:45 PM). NP called for involuntary discharge to be initiated per Admin. Resident is not to be accepted back to facility per Admin. POA has been made aware regarding situation. R2's Nurses Note, dated 3/5/25 at 6:28 PM, documents, (V12), RN from (local regional hospital) was asking why we won't take resident back, This Nurse gave (V12), RN, (V1, Administrator's) phone number. Explained to not yell at this writer and to get a hold of the Administrator regarding this issue. R2's Administrator's Note, dated 3/5/25 at 6:31 PM, documents, Writer was called around 12:30 (12:30 PM) by the Social Services Director (SSD) to inform me that this resident came out of his room being combative, yelling, threatening staff, spitting on staff, throwing glass and breaking it in his room, going to the dining room where other residents were just to yell and curse which made many residents uncomfortable. (R2) also cornered a staff member on the hall causing her not to be able to get around him. I was told this resident stated he was suicidal but when asked if he was suicidal or if he had a plan he would laugh at the police and EMT and say he was just playing. Because of this, I asked that (R2) be added to 1:1 to ensure the safety of him and other residents. Resident continued to yell and show aggressive behavior so I then called (local hospital) EMT (Emergency Medical Technician) department to ask why they would not transport this resident out. I made the EMT manager at (local hospital) aware of all that was going on and he asked to call me back. When he did, he stated that we needed to have an involuntary admission form filled out. I then called psych NP for guidance and approval to have this form filled out and signed. She agreed. I was informed that any RN could sign this form since she was not in the facility. I then called the Social Services Director and the Nurse Manager to assist them in filling this form out. While speaking to them the EMT Manager had come to the facility to see exactly what was going on. He again stated that they needed the involuntary admission form because he was witnessing how this resident was acting but because this resident was A&OX4 (alert and oriented to person, place, time, and event) and refusing to go and had not broken the law his team could not take him without the form. I told him they were in the process of filling it out. To my knowledge this form was given to (EMS manager) along with (R2's) discharge order and documents. Shortly after this resident was taken by EMT. I called his POA and daughter to update her on everything and that her father had been sent out to (local regional hospital) in (area town) with an involuntary admission form and his discharge order. This resident planned to be discharged from this facility on 3/4 or 3/5 of this week to his home. It was discussed that (R2) was discharged from our facility and would return home after his hospital stay at (local regional hospital). POA was at work and not happy that her father was unhappy and having these behaviors. She wasn't happy that she was being called numerous times concerning this. She stated that nobody ever called her before this to update her on her father's care. I reminded her that she requested a care plan meeting, and a date and time were set and agreed to, and she never showed up or called us. I also told her our SSD had tried to reach her but (R2) had given the wrong number for his daughter and then asked that she not be called by anyone other than him. R2's Administrator Note, dated 3/5/25 at 7:17 PM, documents, Writer was called by the facility nurse to update me that she had spoken with (local regional hospital) Nurse and was told they were sending this resident back to (this facility). I informed this nurse that we were not to readmit this resident because he was discharged to the hospital, and after he is discharged from the hospital, he will then go to his home. She asked if she could have this nurse call me and I agreed. Shortly after I spoke with the (local regional hospital) nurse she stated that (R2) did not have an IVD (involuntary discharge) form. I told her he did not need one. He was to be admitted to them with the involuntary admission form and he has discharge orders. That after his visit with them, he will return to him home. His Social Worker who he has had out in the community is aware of this discharge to his home as they have been working on this for weeks. This community social worker has also updated his daughter on his plan to be discharged . R2's Social Service Note, dated 3/5/25 at 12:30 PM, documents, (R2) was in the hall 300 today being disruptive screaming very loudly and being aggressive, in staffs face spitting on staff while yelling, saying verbal threats along with calling staff disrespectful names. (R2) was asked to quiet down he was informed that he was being disruptive towards other residents living in the facility and staff working. (R2) responded screaming back towards staff saying F**k you B**ch, I'm going to cause hell today. Resident was asked to not use profanity multiple times. Staff began to redirect (R2) multiple times back to his room to talk quietly, he then began cornering a staff member up against the wall grabbing onto the hall rail blocking her against the wall screaming in her face. Nurse called police. (R2) was then asked to calm down and was informed that police have been called he then started to scream at the residents in the dining room very loudly saying Hey everybody, this is a F**king sh*t hole, hey everybody I'm going to scream all day if I have to. Police then arrived to facility, writer walked them down to his hall (R2) was sitting in the hall with staff still screaming when police arrived, he was then asked by police to calm down he refused he then stated that if police took him he would love to see it because he will kick, push, and throw his hands and put up a fight. Police then got him to his room EMT arrived they placed him in his bed they began asking him what his concerns and issues was he screamed This is a sh*t hole. EMT then mentioned resident made a suicidal remark but quickly laughed about it and said he was joking he knows the game and he will play it EMT mentioned to writer if it is not medical emergency they cannot take him. EMT left the facility stating that police deal with the situation since it is not medical. Police told writer resident is A&Ox4 and they cannot take him if he is not willing to consent to go to hospital for a psych eval, stated he was refusing to go. I then began to call POA of Healthcare for (local) County police there was no answer, voicemail was full. At this time Police did take resident out of facility, police sat outside of facility before they could leave, they were aware of a 911 call from (R2) calling inside the facility off his own personal cell phone. (local) County Police stated they were going to let residents know that if he calls 911 giving false accusations over 4 times he will then be charged with a felony. While resident was speaking with police and under 1:1 observation by CNA, supervisor writer then was told to assist in completing an Involuntary Admissions Form to (local regional) Hospital for a psych eval by the administrator per her conversation with NP. This form was giving to the Manager of (local) Hospital EMT along with d/c orders and proper documentation. R2's Physician Order, dated 2/27/25, documents May discharge patient to Home. R2's Physician Order, dated 2/28/25, documents May discharge home with all medications and continue as ordered, standard measure wheelchair of 18x16 with swing away footrest and swing back arm rests, PT (physical therapy)/OT (occupational therapy) and home health nursing services. R2's Physician Order, dated 3/5/25, documents Send resident as an Involuntary Admission to (Local Regional Hospital) via Psychiatric Nurse practitioner related to diagnoses of personal history of suicidal behavior, bipolar disorder and major depressive disorder for a psychiatric evaluation. R2's Discharge Plan Assessment located in Forms in his Electronic Medical Record (EMR), dated 2/27/25, is blank and has not been completed. R2's Discharge Instructions located in Forms in his EMR, dated 2/27/25, is blank and has not been completed. There was no Bed Hold located for R2's discharge to the hospital on 3/5/25. On 3/31/25 at 1:25 PM, V1 stated, I will be going over the discharge policy with those people and departments involved to reeducate them on their part of the discharge process. The policy clearly states what should be done and to follow-up to make sure things have been done. I'm using this as a learning process for all of us and going forward, I will expect the staff involved to ensure things have been set up prior to a resident's discharge. The Facility's Discharges Policy, dated 9/2017, documents, Guideline: Discharge to Home: 1. Discharge potential is assessed by Social Service on admission. 2. When the IDT, in conjunction with the resident/patient and family determine that a resident/patient is ready to be discharged , the physician is contacted for an order. 3. Social Services will meet with the resident/patient and/or family to set up outside services and equipment. 4. A Discharge Instruction Form is initiated by Social Services or Discharge Planner and finished by the IDT. 5. If medication is to be sent with the resident, a physician order is necessary. 6. Teaching will be done with the resident/patient/family on any dressings or special tasks. This will be documented in the medical record. 7. If necessary, dietary will provide any special diet instructions. 8. If necessary, Therapy will provide any necessary instructions. 9. On the day of discharge, the nurse will review the discharge instruction form, as well as the medications with the resident/patient and/or representative. 10. The patient/resident and/or representative must sign the Discharge Instruction form. A copy of the signed form is given to the family and a copy of the signature sheet is scanned into the EMR. 11. The nurse will have the patient/resident or responsible party sign the current Medication Summary Sheet/Discharge Medication form or the designated pharmacy form for the facility. A Signed copy will be given to the patient/resident or representative. A Signed copy will be scanned into the patient's EMR. 15. The Social Service Department will enter a Discharge Summary Progress Note into the patient's EMR upon planned discharge from the facility. 16. The Discharge Summary Progress Note is to include a summary of the patient/resident stay while in the facility. The Discharge Summary Progress Note should include where the patient/resident was admitted from, reason patient/resident was admitted , services received during patient's/resident's stay, patient's/resident's goals during facility stay, whether the goals were met during the facility stay, and discharge disposition. Hospital Transfer: 1. Notify the physician regarding a change in resident/patient status and obtain an order for transfer to the hospital. This may be a direct admit or an emergency room admission. 2. If attending physician is not available, contact the medical director. 3. Arrange transportation, either paramedics or ambulance depending on the status of the resident/patient. 4. Inform the resident/patient and the resident's/patient's responsible party of the transfer. 5. Prepare an eINTERACT transfer form. 6. Document in the progress notes the condition of the resident/patient, who was notified of the transfer, where the resident/patient is going, mode of transportation, disposition of resident/patient belongings and medications, notification to all parties of the discharge.

Based on observation, interview, and record review, the facility failed to ensure enteral gastrointestinal feedings and care were provided as ordered for 3 of 3 (R2, R1, R3) residents reviewed for enteral feeding management. This failure resulted in R2 requiring hospitalization for treatment of aspiration pneumonia related to food regurgitation. Findings include: 1. R2 was admitted to the facility on [DATE], with diagnoses of diffuse traumatic brain injury with loss of consciousness, severe protein-calorie malnutrition, dysphagia, and acute respiratory failure. R2's Minimum Data Set (MDS), dated [DATE], documented he is severely cognitively impaired and dependent on staff to assist with all mobility. R2's Care Plan, dated 5/30/24, documented R2 is at risk for complications related to tube feeding with a goal to remain free of aspiration pneumonia throughout next review. Interventions for this care plan are documented to be, in part, administer tube feedings as ordered. R2's Progress notes on 2/20/25 at 7:33 PM documented, (R2) returned from hospital via ambulance with 2 attendants. (R2) is alert per his baseline. G-tube (gastrostomy tube) was replaced, BS (bowel sounds) in all 4 quadrants, abdomen is soft. A surgical incision is present to the midline of the lower abdomen. A drain is present to the left lower quadrant. Urinary catheter is patent. LCTA (lungs clear to auscultation). Edema is noted to the RUE (right upper extremity), including the hand. Some shearing is noted to the buttock. Feedings are 1.5 at 45mL/hr (milliliters per hour) with 120 mL water flushes every 4 hours. R2's hospital discharge orders, dated 2/20/25, documented to start tube feedings at 10mL/hr, advance by 10mL/hr q(every) 6hr to goal of 45mL/hr. An additional hospital discharge order listed included, Scopolamine 1 mg over 3 days patch 3 day place 1 patch on the skin every third day. This is documented as last given on 2/17/25 at 4:01 PM at hospital. R2's facility orders, dated 2/20/25 at 6:30 PM, documented every 24 hours Enteral Feeding Formula 1.5 Rate 45 mL/hr. R2's Medication Administration Record documented V7 started administration of R2's Enteral Feeding at a rate of 45mL/hr at 9:34 PM. R2's Progress note, dated 2/20/2025 at 9:45 PM, documented, Scopolamine Transdermal Patch 72 Hour Apply 1 mg (milligram) transdermally every 72 hours for nausea unavailable. R2's Progress Note, dated 2/21/25 at 8:30 AM, documented, (R2) has what appears to be tube feeding coming from his trach (tracheostomy) and having large emesis that appears to be tube feeding. (R2) being transferred to the hospital for evaluation. The phone numbers listed for the resident's emergency contact are not in service. The documenter unable to reach POA (Power of Attorney) via telephone to update her on the resident's status. R2's Progress note, dated 2/21/25 at 3:54 PM, documented, This Nurse called local hospital. (R2) is being admitted with aspiration pneumonia r/t (related to) food regurgitation. On 3/4/25 at 11:49 AM, V7, Licensed Practical Nurse (LPN), stated R2 was doing okay when he returned from the hospital on 2/20/25, but she remembers he had swelling to his right arm and hand. V7 stated she put in R2's orders as written in his hospital discharge paperwork. V7 stated she started R2 at 45mL of tube feeding not too long after he returned back from the hospital. V7 stated R2 was also having mucus coming from his tracheostomy that was thick and tan. V7 stated Scopolamine patches were ordered and can help with secretions and with nausea, but it wasn't available. V7 stated she did not call for the doctor for alternative orders. V7 stated R2 was not aspirating while she was at the facility, it happened after she left, and she doesn't know exactly what happened. On 3/4/25 at 9:10 AM, V6, Certified Nursing Assistant (CNA), stated R2 did not verbalize how he was feeling while he was in the facility. V6 stated she was not sure what happened, but he was having trach issues on 2/21/25 before R2 went back to the hospital, although she did not specify what the occurrance was which made her say he was having issues. On 3/4/25 at 11:05 AM, V3, CNA, stated R2 had something coming out of his tracheostomy the morning of 2/21/25 when he was sent back out to the hospital. On 3/4/25 at 12:27 PM, V8, Nurse Practitioner, stated R2 could have had abdominal distention, nausea, and vomiting if his tube feedings were not titrated as recommended. V8 stated starting R2's tube feedings at 45mL/hr could have been too much for him, causing him to aspirate. V8 stated if the Scopolamine patches weren't available, an alternative medication could have been requested to help prevent nausea and vomiting. The patch is also used to help with secretions in patients with tracheostomies. V8 stated she would recommend keeping a resident elevation for at least 30-60 minutes after a tube feeding to prevent aspiration. 2. R1 admitted to the facility on [DATE], with diagnoses of female intestinal-genital tract fistulae, Methicillin resistant staphylococcus aureus infection, and dysphagia. R1's MDS, dated [DATE], documented she is severely cognitively impaired and dependent on assistance with feeding and all mobility tasks. R1's Care Plan, dated 1/15/25, documented R1 is at risk for complications related to presence of a feeding tube. R1 is allowed to have a regular mechanical soft diet and regular liquids for pleasure feedings as ordered; keep HOB (head of bed) raised 30 degrees; elevate the head of the bed 30-45 degrees during feeding, check tube placement by auscultating air injection every shift; check placement of G-tube (gastrointestinal tube) using auscultation before administering food/medications/fluids, check feeding tube residual as ordered; cleanse stoma site daily with soap and water during routine care; may be done by nursing assistant if no open areas; keep HOB raised 30 degrees; and elevate the head of the bed 30-45 degrees during feeding. R1's orders, dated 1/14/25, documented check placement of Gtube using auscultation before administering food/medications/fluids. R1's orders, dated 1/14/25, also documented cleanse stoma site daily with soap and water during routine care; may be done by nursing assistant if no open areas. R1's orders, dated 1/14/25, continued to document monitor enteral tube site for signs and symptoms of infection every shift for skin. On 3/3/25 at 11:03 AM, R1 stated, Sometimes the nurses will give me tube feedings while I'm flat. R1 stated the staff clean her stoma every once in a while. On 3/3/25 at 12:33 PM, V3, CNA, assisted R1 with her fruit cup for lunch. R1 stated she did not like the main dish and would like a substitute, if available. V3 placed an order for grilled cheese as a substitute, mechanically soft. On 3/3/25 at 2:03 PM, R1 stated she would like her tube feeding bolus because she didn't have a large meal. V4, Registered Nurse, provided R1 her tube feeding bolus and water flush, without checking for residual or auscultating to check for placement of the feeding tube. The dressing on R1's G-tube site was dated 2/27/25. R1's G-tube stoma site had tender reddened skin surrounding it. As V4 cleansed R1's G-tube stoma site, R1 stated oww every time it was touched. V4 applied skin prep to the stoma before covering it with split gauze. R1's tube feeding was completed at 2:35 PM. V4 stated she would need to notify the provider to see if they would like to add any new treatment to it. On 3/4/25 at 2:19 PM, R1 was observed as having same dressing from day prior, dated 3/3/25 in place. V9, Licensed Practical Nurse, stated she was not told in report that there were any concerns seen yesterday for R1's stoma site, and did not look at it today since R1 did not require a bolus feeding. V9 left the soiled dressing in place and did not remove it to assess the skin, despite R1 reported it being tender. 3. R3 was admitted to the facility on [DATE], with diagnoses of spastic quadriplegic cerebral palsy, unspecified severe protein-calorie malnutrition, and chronic hepatic failure. R3's MDS, dated [DATE], documented she is rarely/never understood, is dependent on assistance with eating and requires substantial/maximal assistance with rolling left and right on the bed, sitting to lying on the bed and lying to sitting on the bed. R3's Care Plan, dated 1/24/25, documented tube feeding: R3 is at risk for complications related to gastrostomy tube placement due to history of BMI (body mass index) of 9.0, recent weight loss and diagnosis of severe malnutrition; check feeding tube residual as ordered; check tube placement by auscultating air injection every shift; keep HOB (Head of Bed) raised 30 degrees. R3's active orders, dated 10/23/2024 at 10:00 PM, documented, Cleanse stoma site daily with soap and water during routine care. May be done by nursing assistant if no open areas. Apply antibacterial cleanser to a 2x2 drain sponge. Allow to set for 10 minutes or longer. Using a cotton tip applicator, apply cream twice daily and PRN (as needed). R3's active orders, dated 10/23/24 at 8:58 PM, documented: check placement of G-tube using auscultation before administering food/medication/fluids. On 3/3/25 at 3:31 PM, V5, LPN, went to R3's room to administer her enteral tube feeding that was due at 2:00 PM. V2, Director of Nursing (DON) was present during the treatment. V5 did not gown up while administering R3's tube feeding. V5 did not auscultate to check for placement of R3's Gtube prior to administering her bolus. V2 stated R3 is on Enhanced Barrier Precautions (EBP) for having a G-tube. R3 did not have a dressing on her G-tube stoma site. At 3:40 PM, V2 stated the day shift nurse didn't have time to apply another dressing to R3's site while they were here. V5 is supposed to do that during her shift, at some point. V2 stated she expects a dressing to be in place on R3's stoma site. V2 stated she expects any staff with direct contact to a resident on EBP to be gowned and gloved up while providing care. On 3/4/25 at 2:05 PM, V9, LPN, administered a bolus of tube feeding to R3 without auscultating to check for placement. On 3/4/25 at 2:30 PM, V1, Administrator, stated, (R2) was admitted to the hospital with pneumonia, and he will not be returning to the facility. I saw firsthand, (R2) had tube feeding coming out of his trach (tracheostomy) and mouth the morning of 2/21/25. I expect the nurses to follow discharge orders as recommended, and absolutely notify a provider if a prescription isn't available to see if an alternative medication can be given. V1 stated she expects her nurses to check for placement of G-tubes prior to administering anything, either by auscultation or checking for residual, but always to find a way. V1 stated she expects staff to be following EBP while providing tube feeding care and to be providing care as ordered/written in their charts and per facility policy. The facility's Tube Feeding Policy, dated 9/2024, documented the following guidelines: check tube placement by aspiration or air insertion, head of the bed should be elevated 30-45 degrees unless ordered differently, check for placement using auscultation prior to flushing, the site is cleansed with soap and water during daily care, turn on pump, set prescribed rate and start feeding, and the CNA will clean the tube site during routine care; should there be any issues with the site, the CNA will notify the nurse who will communicate with the health care provider. The facility's Enhanced Barrier Precautions Policy dated 10/16/23, documented, Our facility employs the use of Enhanced Barrier Precautions (EBP) to reduce transmission of MDROs (multi-drug resistant organisms) to staff hands and clothing that employs targeted gown and glove use during high-contact resident care activities. Staff utilize gown and gloves for high-contact resident care activities when residents require EBP; high contact activities may include Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator.

Based on observation, interview, and record review, the facility failed to have physician prescribed narcotic pain medication for 1 of 3 residents (R2) reviewed for pain. This failure resulted in the resident experiencing severe pain, becoming incontinent of bowel and bladder, and displaying agressive behaviors. Findings include: R2's Undated Face Sheet documents he was admitted to the facility on [DATE], with diagnoses including spinal stenosis, pain thoracic spine, low back pain, and chronic pain syndrome. R2's Care Plan documents, focus pain alteration in comfort related to the advanced disease process, chronic physical or psychological disability, musculoskeletal, neurological issues due to diabetic neuropathy and osteoarthritis of the right hip. Goal: resident will not experience a decline in overall function r/t (related to) pain through next review. Will maintain adequate levels of comfort as evidence by no s/s (signs or symptoms) of unrelieved pain or distress, verbalizing satisfaction or expressing with relief and comfort throughout next review. Interventions: administer pain meds, assess effectiveness of pain medication, assess pain characteristics: duration, location, quality. R2's Admission Pain Evaluation, dated 12/26/2024, documents pain diagnoses spinal stenosis, myelopathy and right hip pain. Hurts a whole lot describes pain as radiating, stabbing, tightness and tingling. Other comments: has a history of threatening suicide when experiencing pain. R2's Quarterly Minimal Data Set (MDS) documents he is alert and had pain. R2's Physician's Order Sheet (POS), dated 1/2025, documents 1/6/2025 Oxycodone 20 mg every eight hours. R2's Medication Administration Record (MAR), dated 1/2025, documents 9 other see nurse's note for the following dates and times: 1/30/2025 at 2:00 PM and 10:00 PM and on 1/31/2025 at 6:00 AM. R2's Nurse Progress Note, dated 1/30/2025, had no documentation regarding narcotic pain medication for 2:00 PM and 10:00 PM. R2's Nurse Progress Note, dated 1/31/2025 at 1:31 PM, V3, Registered Nurse (RN), documented, resident c/o nausea and several stools today. He has not had his pain medicine-prob side effect of that. Explained to resident with understanding verbalized. R2's Nurse Progress Note, dated 1/31/2025 at 3:40 PM, V3 documented, 2:30 PM Resident up to desk yelling, demanding his pain medicine which we did not have but were ordered. He could not be redirected or calmed regarding situation becoming louder and throwing things. 911 called however resident refused to go to hospital. DON (Director of Nursing) trying to get his pain medicine sooner. On 2/28/2025 at 9:33 AM, V5, Certified Nurse Aide (CNA), stated, (R2) uses a urinal and a bed side commode for bowel movements; he is not incontinent, and he is up in his wheelchair self-propelling about the facility most of the day. On 2/28/2025 at 9:50 AM, V6, CNA, stated R2 is continent of bowel and bladder and is usually up in his wheelchair, but at the end of January 2025, she was working and was assigned to (R2), and he was very upset that he didn't have his pain medication. He was incontinent of bowel and bladder and was curled up in bed at that time. On 2/28/2025 at 9:58 AM, V7, CNA, stated, (R2) is continent of bowel and bladder and he is usually up in his wheelchair. On 2/27/2025 at 2:45 PM V3, RN stated she recalled R2's narcotic pain medication wasn't available at the end of January 2025, but it was on the way to the facility, and she told him. He was really mad and was having side effects from not having the medication, which was incontinent loose stools that day due to the pain he was experiencing. On 2/27/2025 at 11:48 AM, R2 stated he uses the urinal for bladder, and a bed side commode for bowel moments and is up in his wheelchair self-propelling about the facility. (R2) stated he went several days without his narcotic pain medication at the end of January 2025. Because he didn't have it, he was curled up in the fetal position s****ing all over himself all day. The nurse (name unknown) came in and told him he was feeling so bad because the facility didn't have his narcotic pain medication, and it was on the way from the pharmacy in (city). He was very upset he didn't have his narcotic pain medication available at that time. He stated he went through h*** those two days because he was in such pain; his body was breaking down, and it takes what feels like forever to get out of that severe pain because the pain is so severe it takes several doses of his narcotic pain medication to catch up in his body to start to relive the pain again. On 2/27/2025 at 1:10 PM, V2, Director of Nurses (DON), stated she wasn't aware any residents, including (R2), missed three consecutive doses of narcotic pain medication because it wasn't available at the facility. She expected staff to call her so she could work on getting the narcotic pain medication delivered to the facility as soon as possible. The nurse should have notified the pharmacy, and if the facility had a signed prescription on file, then the pharmacy would have sent a code and the facility staff could have accessed the medication in the emergency kit. On 2/27/2025 at 3:30 PM, V2 stated R2 is alert and is usually continent of bowel and bladder. V2 recalled the day R2 missed a few doses of his narcotic pain medication because he was up at the nurse's station calling her a f****** b**** and everything but a white woman. At that time, she wasn't aware R2 missed three doses of his narcotic pain medication and he was out of control. Facility staff called the police because R2 was so upset, cursing and yelling at everyone. R2 usually contacts her when he is out of his narcotic pain medication, and she was shocked he didn't come to her sooner and let her know he was out of it. V2 stated when staff realized he was out of narcotic pain medication on 1/30/2025, they printed a prescription and put it in the folder for the Nurse Practitioner to sign on 1/31/2025, but she didn't come to the facility that day, so the prescription wasn't signed. 1/31/2025 was the day R2 snapped on the staff and she got the pharmacy to send her a code, and she got a dose of R2's narcotic pain medication from the emergency medication kit. R2 calmed down after receiving the pain medication. On 2/27/2025 at 12:20 PM, V4, Nurse Practitioner, stated she expected all physician ordered medication to be available at the facility, and she expected staff to follow facility policies on medication administration. On 2/28/2025 at 9:00 AM, V4, Nurse Practitioner, stated she wasn't aware R2 went without narcotic pain medication for three doses at the end of January 2025. Although he has a lot of comorbidities including spinal stenosis, which is very painful, if he was usually continent of bowel and bladder and up in his wheelchair propelling about the facility then became incontinent of bowel and bladder and in the fetal position in bed due to not having pain medication, that could potentially cause these side effects due to not having the narcotic pain medication. The Facility's Medication Administration Policy, revised 5/2017, documents, if medication is not given as ordered, document the reason on the MAR and notify the Health Care Provider if required. if medication is ordered, but not present, check to see if it was misplaced and then call the pharmacy to obtain the medication. If available, obtain it from the contingency or convenience box.

Based on interview and record review, the facility failed to assess 4 of 4 residents (R2, R3, R11, R12) for risks of self-harm upon their admission to the facility. This failure has the potential to affect those residents from self- harm. Findings include: 1.R2's Face Sheet undated documents he was admitted to the facility 7/26/24, with diagnoses of Major Depressive Disorder, Cerebral, Infarction, Unspecified, Restless and Agitation, Vascular Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood disturbance and Anxiety, and Vascular Dementia, Unspecified Severity, with Agitation. R2's Minimum Data Set (MDS), dated [DATE], documents R2 has moderate cognitive impairment, reports 12-14 days (nearly every day) of feeling bad about himself or that he is a failure or that he has let his family down; is feeling down, depressed, or hopeless. R2's Psychiatric Progress note, dated 8/27/24, from the area psychiatric services documents R2's family reported R2 threatens family and threatens suicide when upset. R2's electronic nursing home records do not document a suicide assessment risk upon admission. On 11/7/24 at 2:45 PM, V4, niece of R2, stated he (R2) wanted to die, twice. 2. R3's Face Sheet undated documents he was admitted to the facility 9/11/2020, with diagnoses of Other Schizophrenia, Major Depressive Disorder, Post-traumatic Stress Disorder (PTSD), Unspecified, and Insomnia, Unspecified. R3's Minimum Data Set (MDS), dated [DATE], documents R3 has moderate cognitive impairment, reports 7-11 days (half or more of the days) of feeling down, depressed or hopeless; Never or 1 day of thoughts that he would be better off dead or of hurting himself. R3's medical records for nursing home placement, dated 7/4/2019, documents a past medical history of Suicidal Ideation (5/16/2019). R3's electronic nursing home records do not document a suicide assessment risk upon admission. 3. R11's Face Sheet undated documents she was admitted to the facility 1/20/24, with diagnoses of Cerebral Palsy, Chronic Obstructive Pulmonary Disease (COPD), Anxiety Disorder, Epilepsy Unspecified, Not intractable without Status Epilepticus, Malignant Neoplasm of Unspecified Site of Left Female breast, Schizoaffective Disorder, Bipolar Type, Major Depressive Disorder, Recurrent Severe without Psychotic features, Suicidal Ideations (6/19/24) Vascular Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood disturbance, and Anxiety. R11's Minimum Data Set (MDS), dated [DATE], documents R11 has moderate cognitive impairment, reports 12-14 days (nearly every day) of feeling bad about herself or that she is a failure or that she has let her family down; is feeling down, depressed or hopeless; Has never or 1 day of thoughts that you would be be better off dead, or of hurting yourself in some way. R11's electronic nursing home records do not document a suicide assessment risk upon admission. 4.R12's Face Sheet undated documents she was admitted to the facility 12/8/22, with diagnoses of Hydrocephalus, Anxiety Disorder, Major Depressive Disorder, Recurrent Unspecified, Non-Suicidal Self-Harm (12/7/22), Factitious Disorder Imposed on Self with Predominantly Physical signs and Symptoms. R12's Minimum Data Set (MDS), dated [DATE], documents R12 is cognitively intact, reports 7-11 days (half or more of the days) feeling down, depressed or hopeless. 12-14 days (nearly every day) of feeling bad about herself or that she is a failure or that she has let her family down; is feeling down, depressed or hopeless; Has never or 1 day of thoughts that you would be be better off dead, or of hurting yourself in some way. R13's electronic nursing home records do not document a suicide assessment risk upon admission. On 11/12/24 at 2:45 PM, V1, Administrator, stated, The facility's protocol is to assess residents upon admission if we are aware of a diagnosis or history of suicidal ideation or suicide attempts. That assessment can be done by the nurse or the Social Worker. The facility's policy Suicide Assessment with a review date of 8/2024 documents, The facility social worker or designee will conduct a medical record review of the resident to identify any risk factors that have been identified. Trauma Assessment and Suicide Assessment will be completed. Protective factors will be explored with the resident as well. a. Risk factors include, but are not limited to: i. History of prior suicide attempts or self-injurious behaviors. ii. Current or past psychiatric disorder(s) and/or recent change in psychiatric treatment (change in medication/treatment/provider or recent discharge from inpatient psychiatric setting). iii. Symptoms such as hopelessness, helplessness, anxiety/panic, and impulsivity.

Based on interview and record review, the facility failed to administer 4 of 4 residents ( R2, R3, R5, R13) medications as prescribed and according to the facility's policy and procedures. This failure resulted in residents receiving their medications two hours or more after the scheduled times. Findings include: 1. R2's Face Sheet undated documents he was admitted to the facility 7/26/24, with pertinent diagnoses of Major Depressive Disorder, Cerebral, Infarction, Unspecified, Restless and Agitation, Vascular Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood disturbance and Anxiety, and Vascular Dementia, Unspecified Severity, with Agitation. R2's Minimum Data Set (MDS), dated [DATE], documents R2 has moderate cognitive impairment, reports 12-14 days (nearly every day) of feeling bad about himself or that he is a failure or that he has let his family down; is feeling down, depressed or hopeless. R2's Physician Order Summary, dated October 2024, documents R2's m/edications as Donzepril (Aricept) 10 mg 1 tablet at bedtime related to Vascular Dementia , Unspecified, Start date: 8/1/24 R2's Medication Audit Report, dated 11/12/24, documents R2 received 5 doses out of 31 doses of Aricept 10 mg greater than 2 hours after the scheduled time of 9:00 PM. R2's Physician Order Summary, dated October 2024, documents R2's medications as Seroquel 25 mg 1 tablet every 12 hours related to Delirium due to known physiological condition. Start date: 10/21/24 R2's Medication Audit Report, dated 11/12/24, documents R2 received 5 doses out of 21 doses of Seroquel 25 mg greater than 2 hours after the scheduled times of 8:00 AM and 8:00 PM. R2's Physician Order Summary, dated October 2024, documents R2's medications as Depakote 125 mg Delayed Release (DR) BID related to Major Depressive Disorder. Start date: 9/12/24. R2's Medication Audit Report, dated 11/12/24, documents R2 received 19 doses out of 62 doses of Depakote 125 mg Delayed Release (DR) greater than 2 hours after the scheduled times of 8:00 AM and 9:00 PM. R2's Physician Order Summary, dated October 2024, documents R2's medications as Synthroid 150 mcg 1 tablet in the morning. Start date: 7/27/24. R2's Medication Audit Report, dated 11/12/24, documents R2 received 3 doses out of 31 doses of Synthroid 150 mcg greater than 2 hours after the scheduled time of 8:00 AM R2's Physician Order Summary, dated October 2024, documents R2's medications as Xarelto 15 mg 1 tablet in the morning for Prophylaxis. Start date 7/27/24. R2's Medication Audit Report, dated 11/12/24, documents R2 received 5 doses out of 31 doses of Xarelto 15 mg greater than 2 hours after the scheduled time of 8:00 AM. R2's Physician Order Summary, dated October 2024, documents R2's medications as Metoprolol Extended Release (ER) 25 mg 1 capsule in the morning related to Essential (Primary Hypertension). Start date: 7/27/24. R2's Medication Audit Report, dated 11/12/24, documents R2 received 9 doses out of 31 doses of Metoprolol ER 25 mg greater than 2 hours after the scheduled time of 8:00 AM R2's Physician Order Summary, dated October 2024, documents R2's medications as Paroxetine 40 mg 1 tablet for Major Depressive Disorder. Start date: 8/28/24. R2's Medication Audit Report dated 11/12/24 documents R2 received 6 doses out of 31 doses of Paroxetine 40 mg greater than 2 hours after the scheduled time of 8:00 AM. R2's Physician Order Summary, dated October 2024, documents R2's medications as Losartan Potassium 75 mg 1 tablet related to Essential (Primary Hypertension) Start date: 8/14/24. R2's Medication Audit Report, dated 11/12/24, documents R2 received 6 doses out of 31 doses of Losartan Potassium 75 mg greater than 2 hours after the scheduled time of 8:00 AM. R2's Medication Audit Report, dated 11/12/24, documents R2 received 17 doses out of 122 doses of Hydroxyzine greater than 2 hours after the scheduled time of 8:00 AM. On 11/7/24 at 2:45 PM, V4, niece of R2, stated R2 did not get his 8:00 AM meds on 10/30/24 until after 10: 45 AM. On 11/12/24 at 2:45 PM, V1, Administrator, stated, My night nurse stayed over because the day nurse called off. To my understanding, she was completing a med pass. Medications can be administered 1 hour before and up to 1 hour after the scheduled administration time. On 11/13/24 at 1:15 PM, V16, Licensed Practical Nurse (LPN), stated she was the night shift nurse that stayed over until the agency nurse arrived. V16 stated she was instructed by V1, Administrator, to just do the blood fingersticks to help out. V16, LPN, stated she did pass medications to residents on the 200 Hall, but could not recall who they were. 2. R3's Face Sheet undated documents an admittance date of 9/11/2020, with pertinent diagnoses as Other Schizophrenia, Post Traumatic Stress Disorder (PTSD), Chronic Obstructive Pulmonary Disorder (COPD), Essential (Primary) Hypertension, and Major Depressive Disorder, Recurrent, unspecified. R3's Physician Order Summary, dated October 2024, documents R3's medications as Lidoderm Patch 5% for pain. Start date: 4/23/22 R3's Medication Audit Report, dated 11/12/24, documents R3 received 12 doses out of 31 doses of Lidoderm Patch 5% 2 hours or more after the scheduled time of 8:00 AM. R3's Physician Order Summary, dated October 2024, documents R3's medication Acetaminophen 500 mg TID related to pain. Start date: 5/27/24 R3's Medication Audit Report, dated 11/12/24, documents R3 received 13 doses out of 93 doses of Acetaminophen 500 mg 2 hours or more after the scheduled time of 8:00 AM, 12:00 PM and 5:00 PM. R3's Physician Order Summary, dated October 2024, documents R3's medication Aspirin 81 mg for Heart Health. Start date: 1/6/22. R3's Medication Audit Report, dated 11/12/24, documents R3 received 8 doses out of 31 doses of Aspirin 2 hours or more after the scheduled time of 8:00 AM. R3's Physician Order Summary, dated October 2024, documents R3's medication Metoprolol ER 50 mg for Essential (Primary) Hypertension. Start date: 2/20/22 R3's Medication Audit Report, dated 11/12/24, documents R3 received 14 doses out of 31 doses of Metoprolol 50 mg 2 hours or more after the scheduled time of 8:00 AM. R3's Physician Order Summary, dated October 2024, documents R3's medication Bupropion ER 300 mg-dose 450 mg for Major Depressive Disorder. Start date: 9/6/24 R3's Medication Audit Report, dated 11/12/24, documents R3 received 9 doses out of 31 doses of Bupropion ER 300 mg 2 hours or more after the scheduled time of 8:00 AM. R3's Physician Order Summary, dated October 2024, document's R3's medication Clozapine 100 mg (1.5 tab) BID for Other Schizophrenia. Start date:7/15/24. R3's Medication Audit Report, dated 11/12/24, documents R3 received 28 doses out of 62 doses of Clozapine 100 mg (1.5 tablets) 2 hours or more after the scheduled time of 8:00 AM and 9:00 PM. R3's Physician Order Summary, dated October 2024, documents R3's medication Fluoxetine 40 mg (take 2 tabs) Daily for Major Depression Start date: 10/24/24 R3's Medication Audit Report, dated 11/12/24, documents R3 received 8 doses out of 8 doses of Fluxoetine 60 mg 2 hours or more after the scheduled time of 8:00 AM. R3's Physician Order Summary, dated October 2024, documents R3's medication for Lisinopril 40 mg Daily for Hypertension. Start date: 2/20/22 R3's Medication Audit Report, dated 11/12/24, documents R3 received 12 doses out of 31 doses of Lisinopril 25 mg 2 hours or more after the scheduled time of 8:00 AM. R3's Physician Order Summary, dated October 2024, documents R3's medication Amlodipine 5 mg (2 tabs) for Hypertension. Start date: 2/20/22. R3's Medication Audit Report, dated 11/12/24, documents R3 received 15 doses out of 31 doses of Amlodipine 5 mg 2 hours or more after the scheduled time of 8:00 AM. R3's Physician Order Summary, dated October 2024, documents R3's medication Vraylar capsule 4.5 mg related to Other Schizophrenia. Start date: 1/30/22 R3's Medication Audit Report, dated 11/12/24, documents R3 received 11 doses out of 31 doses of Vraylar capsule 4.5 mg 2 hours or more after the scheduled time of 8:00 AM. R3's Physician Order Summary, dated October 2024, documents R3's medication Olanzapine 5 mg 1 tab at bedtime for Schizophrenia. Start date: 8/28/24. R3's Medication Audit Report, dated 11/12/24, documents R3 received 10 doses out of 31 doses of Olanzaprine 25 mg 2 hours or more after the scheduled time of 8:00 AM. R3's Physician Order Summary, dated October 2024, documents R3's medication Donepezil 10 mg 1 tab at bedtime for cognition. Start date: 2/19/12. R3's Medication Audit Report, dated 11/12/24, documents R3 received 16 doses out of 31 doses of Donzepril 2 hours or more after the scheduled time of 8:00 AM. 3. R5's Face Sheet undated documents his admittance date as 4/7/23, with pertinent diagnoses as Unspecified Nondisplaced Fracture of Fifth Cervical Vertebrae, subsequent encounter for Fracture with routine healing, Hypokalemia, Fusion of Spine, Cervical Region, Wedge Compression Fracture of the Fourth Thoracic Vertebrae, subsequent encounter for fracture with routine healing. Major Depressive Disorder, single episode, unspecified other low back pain, and Neuromuscular Dysfunction of Bladder, unspecified. R5's Physician Order Summary, dated October 2024, documents R5's medications as Norco 10/325 mg BID related to Low back pain. Start date: 5/27/24 R5's Medication Audit Report, dated 11/12/24, documents R5 received 7 doses out of 62 doses of Norco 10/325 mg 2 hours or more after the scheduled time of 8:00 AM and 9:00 PM. R5's Physician Order Summary, dated October 2024, documents R5's medications as Morphine Extended Release (ER) 15 mg BID related to Unspecified Nondisplaced Fracture of Fifth Cervical Vertebrae, subsequent encounter for Fracture with routine healing. Start date: 5/27/24. R5's Medication Audit Report, dated 11/12/24, documents R5 received 22 doses out of 62 doses of Morphine Sulfate Extended Release (ER) 2 hours or more after the scheduled times of 8:00 AM and 9:00 PM. R5's Physician Order Summary, dated October 2024, documents R5's medications as Lyrica 25 mg 1 tablet every 12 hours related to Central Cord Start Date: 4/18/24. R5's Medication Audit Report, dated 11/12/24, documents R5 received 15 doses out of 62 doses of Lyrica 25 mg 2 hours or more after the scheduled time of 8:00 AM and 8:00 PM. R5's Physician Order Summary, dated October 2024, documents R5's medications as Gabapentin 400 mg TID related to Low back pain. Start date: 4/18/24. R5's Medication Audit Report, dated 11/12/24, documents R5 received 28 doses out of 93 doses of Gabapentin 2 hours or more after the scheduled time of 8:00 AM, 12:00 PM and 9:00 PM. R5's Physician Order Summary, dated October 2024, documents R5's medications as Lasix 20mg 40 mg Daily - Diuretic. Start date: 4/18/24. R5's Medication Audit Report, dated 11/12/24, documents R5 received 2 doses out of 31 doses of Lasix 20 mg 2 hours or more after the scheduled time of 8:00 AM. R5's Physician Order Summary, dated October 2024, documents R5's medications as Duloxetine 40 mg 1 capsule BID related to Major Depressive Disorder. Start date: 4/10/24. R5's Medication Audit Report, dated 11/12/24, documents R5 received 6 doses out of 31 doses of Duloxetine 40 mg 2 hours or more after the scheduled time of 8:00 AM. R5's Physician Order Summary, dated October 2024, documents R5's medications as Lopressor 50 mg BID for Hypertension. Start date: 4/15/23. R5's Medication Audit Repor,t dated 11/12/24, documents R5 received 25 doses out of 62 doses of Lopressor 2 hours or more after the scheduled time of 8:00 AM and 9:00 PM. 4. R13's undated Face Sheet documents her admittance date as 4/10/23, with the pertinent diagnoses as Unspecified Sequelae of Cerebral Infarction, Dementia in other disease classified elsewhere Unspecified Severity, without Behavioral Disturbances, Psychotic Disturbances, Mood Disturbance and Anxiety, Bipolar Disorder, current episode, Manic Severe with Psychotic features, Anxiety Disorder, Post Traumatic Stress Disorder (PTSD), and Major Depressive Disorder, Unspecified. R13's Physician Order Summary, dated October 2024, documents R13's medications as Mirtazapine 30 mg 1 tablet a bedtime related to Major Depressive Disorder. Start date: 11/2/24. R13's Medication Audit Report, dated 11/12/24, documents R13 received 3 doses out 31 doses of Mirtazapine 30 mg 2 hours or more after the scheduled time of 9:00 PM. R13's Physician Order Summary, dated October 2024, documents R13's medications as Prozac Capsules 3 Capsules in the morning related to Major Depressive Disorder. Start date: 11/12/24. R13's Medication Audit Report, dated 11/12/24, documents R13 received 8 doses out 31 doses of Prozac 10 mg 2 hours or more after the scheduled time of 8:00 AM. R13's Physician Order Summary, dated October 2024, documents R13's medications as Hydroxyzine 25 mg BID related to Bipolar Disorder. Start date: 9/12/24. R13's Medication Audit Report, dated 11/12/24, documents R13 received 26 doses out 62 doses of Hydroxyzine 25 mg 2 hours or more after the scheduled times of 8:00 AM and 9:00 PM. R13's Physician Order Summary, dated October 2024, documents R13's medications as Metoprolol 50 mg BID related to Essential (Primary) Hypertension. Start date: 9/5/24. R13's Medication Audit Report, dated 11/12/24, documents R13 received 17 doses out of 29 doses of Metoprolol 50 mg 2 hours or more after the scheduled time of 8:00 AM and 9:00 PM. R13's Physician Order Summary, dated October 2024, documents R13's medications as Glucophage (Metformin)1000 mg tablet BID related to Diabetes Mellitus Type 2. Start date: 6/30/24. R13's Medication Audit Report, dated 11/12/24, documents R13 received 25 doses out of 62 doses of Metformin 1000 mg 2 hours or more after the scheduled times of 8:00 AM and 9:00 PM. R13's Physician Order Summary, dated October 2024, documents R13's medications as Trulicity 1.5 mg Subcutaneous 1 a day every 7 days related to Diabetes Mellitus with Diabetic Polyneuropathy. Start date: 5/10/24. R13's Medication Audit Report, dated 11/12/24, documents R13 received 1 doses out of 4 doses of Trulicity 1.5 mg 2 hours or more after the scheduled time of 8:00 AM. R13's Physician Order Summary, dated October 2024, documents R13's medications as Gabapentin 100 mg tablet TID for Prophylaxis. Start date: 1/22/24 R13's Medication Audit Report, dated 11/12/24, documents R13 received 27 doses out of 86 doses of Gabapentin 100 mg 2 hours or more after the scheduled times, of 8:00 AM 12:00 PM and 9:00 PM R13's Physician Order Summary, dated October 2024, documents R13's medications as Lisinopril 20 mg tablet Daily for Prophylaxis. Start date: 1/22/24. R13's Medication Audit Report, dated 11/12/24, documents R13 received 10 doses out of 31 doses of Lisinopril 20 mg 2 hours or more after the scheduled time of 8:00 AM. On 11/13/24 at 1:15 PM, V12, Nurse Practitioner, stated she had not been notified medications were not being administered in a timely manner, and does not believe it has caused harm, but it could affect the prescrbing of medications, especially if the provider thought an increase is warranted. The facility's policy Medication Administration, with a review date of 4/2024, documents verify that the medication is being administered at the proper time, in the prescribed dose and by the correct route; document as each medication is prepared on the MAR; if the physician's order cannot be followed for any reason, the physician should be notified in a timely manner (depending on the situation), and a note should reflect the situation in the resident's medical records.

Based on interview, observation, and record review, the facility failed to utilize physician ordered pressure relieving devices and or treatments for two of three residents (R3, R35) reviewed for pressure ulcers in the sample of 31. Findings Include: 1. R3's Minimum Data Set (MDS), dated [DATE], documents R3 is severely cognitively impaired. R3's MDS also documents need substantial to maximum assistance in rolling from left to right. R3's Braden Scale, dated 6/28/24, documents R3 has a moderate risk of developing pressure ulcers. R3's Physician Order Sheet (POS), dated 7/28/24, documents, (pressure Relieving boots) to bil (bilateral) feet when in bed, for sore heels. R3's Skin Care Plan intervention documents protect heels initiated on 2/28/24. On 08/13/24 at 2:20 PM, R3 was laying in bed and her heels were directly on the bed. On 8/15/24 at 2:20 PM while watching catheter care, R3 did not have on pressure relieving boots and her bilateral heels were red. R3's heels were lying flat on the bed. On 8/15/24 at 3:15 PM, V2, Director of Nursing, stated, She usually has the boots on, and they are in her room on her chair. V2 stated a standing order for skin prep would be initiated to R3's heels. 34964 2. R35's Face Sheet documents her diagnoses to include Multiple Sclerosis, Contractures of Bilateral Knees and Pressure Ulcer of Left Buttock. R35's Care Plan, dated 10/9/23, documents: SKIN: (R35) was admitted to the facility with actual skin complications r/t (related to) pressure injuries of the left buttock, left heel and right heel. She often refuses staff to turn and reposition her or will say she was already repositioned. She has a history of refusal of repositioning in another facility. The goal for this care plan documents: Will remain free of further skin complications throughout next review. Interventions for this care plan include: Treatment as ordered to left buttock wound (admitted with) as per POS/TAR (Physician Order Sheet/Treatment Administration Record) until resolved. R35's Physician Order Summary Report, dated 8/15/24, documents the order dated 8/14/24: Cleanse area to left buttock with wound cleanser, apply collagen, calcium alginate, and bordered foam daily and prn (as needed). R35's Minimum Data Set (MDS), dated [DATE], documents R35 is alert and oriented. The assessment documents R35 has one unhealed unstageable pressure ulcer that was present on admission. R35's Wound Consultant report, dated 8/1/24, documents the measurements of her Stage 4 pressure ulcer as 3 cm by 2.5 cm by 0.2 cm with 100 % granulation. R35's Wound Consultant report, dated 8/8/24, documents her wound as a Stage 4 Pressure Ulcer that is improving with delayed wound closure. It documents the wound measurements as 1.6 centimeters (cm) by 2.5 cm by 0.2 cm. It documents there is 100% granulation with periwound intact. On 8/13/24 at 3:24 PM, R35 stated she has a pressure ulcer on her upper right thigh that they have been treating for a while and stated it is getting better. On 8/15/24 at 4:40 AM, observed V17, Certified Nursing Assistant (CNA), and V19, CNA, provide incontinent care for R35. When turning R35 to her right side, there was a quarter sized pressure ulcer on her left ischium with no dressing on it. V17 checked the wet adult diaper that she had just removed and there was no old dressing in the diaper. V17 stated she was not sure if there was a treatment on the pressure ulcer when she changed R35 at about 2:45 AM. She stated she did not let the nurse know that there was not a treatment on R35's pressure ulcer. On 8/15/24 at 8:15 AM, V2, Director of Nursing (DON), V3, Registered Nurse /Minimum Data Set (MDS) Coordinator, and V22, Wound Nurse, provided pressure ulcer treatment for R35. V2 stated she did not know if the nurse was informed by the CNAs who took care of R35 this morning that her pressure ulcer dressing was not in place as ordered. She stated she did not know if the nurse did the treatment after R35 was changed. V2 stated if a CNA notices a treatment has fallen off of a resident's pressure ulcer they should inform the nurse so the treatment can be replaced so pressure ulcer is not exposed to urine and feces. When they rolled R35 to her side, there was still no dressing on her pressure ulcer on her left ischial pressure ulcer. V22 hand sanitized and donned gloves and cleansed the wound with wound cleanser. V22 then hand sanitized and donned gloves and applied a new treatment of collagen powder, calcium alginate, and bordered gauze to the wound. The wound was dry with dry edges with granulation and a large area of scar tissue noted around the wound. V3 stated the wound had gotten much smaller than when R35 was first admitted . The facility's Skin Management: Pressure Injury Treatment/General Wound Treatment policy, dated 4/2024, documents All Nursing Staff Responsible. Implement prevention protocol according to residents needs. Treatment Guidelines for stage 1 pressure injuries Do Not massage over bony prominence, Avoid the use of donut-type devices, consider applying a moisture barrier consider applying a transparent film or hydrocolloid dressing to protect fragile skin. Perform the Treatment as ordered using proper techniques of infection prevention and control.

Based on observation, interview, and record review, the facility failed to ensure progressive fall interventions were implemented for 2 of 6 residents (R1, R4) reviewed for falls in the sample of 31. Findings include: 1-R1's Face Sheet documents R1 was admitted to the facility on [DATE], with diagnoses including bipolar disorder, weakness, unsteadiness on feet, other abnormalities of gait and mobility, and tremor. R1's Minimum Data Set (MDS), dated [DATE], documented R1 was moderately cognitively impaired and ambulated with supervision. R1's Care Plan, initiated 7/17/20, documents R1 is at risk for falls related to balance issues, tremors, marching gait, osteoporosis, and psychoactive drug use. R1's Fall Risk Assessment, dated 6/27/24, documents R1 is at high risk for falls. The Facility's Incident Log documents R1 had falls on 11/20/23, 1/1/24, 2/19/24, 2/20/24, 2/21/24, 3/1/24, and 6/19/24. R1's 2/19/24 Fall Investigation documents R1 lost her balance and fell when trying to use the restroom. The fall intervention added was therapy evaluation. On 8/15/24 at 1:00 PM, V4, Administrator in Training (AIT), stated she checked with the Therapy Department, and no evaluation was completed for R1's 2/19/24 fall intervention. 2-R4's Face Sheet documents R4 was admitted to the facility on [DATE], with diagnoses including respiratory failure, type 2 diabetes mellitus, unsteadiness on feet, and weakness. R4's MDS, dated [DATE], documented R4 was severely cognitively impaired and dependent for transfers. R4's Care Plan, initiated 7/20/20, documents R4 is at high risk for falls due to needing extensive assistance with ADL's (Activities of Daily Living), having a history of falls, and taking medications that could have adverse reactions after falls. R4's Fall Risk Evaluation, dated 7/9/24, documents R4 is at high risk for falls. The Facility's Incident Log documents R4 had falls on 4/6/24 and 6/9/24. R4's 4/6/24 Fall Investigation documents V28, Licensed Practical Nurse (LPN), was called to R4's room where V27, CNA, was attempting to transfer R4 from the bed to wheelchair by herself. V27 stated R4 was not pivoting and was unable to hold her up, so she had to lower her to the floor. The Root Cause was determined to be V27 was attempting a one person transfer that should have been a mechanical lift transfer. (R4's MDS dated [DATE] documents R4 was dependent for transfer.) R4's 6/9/24 Fall Report documents R4 was yelling for help and was found sitting on her buttocks in her room. R4 was sent to the emergency room (ER) for evaluation and was found to have a fracture. The Root Cause was determined to be R4 self-transferred when she should be a mechanical lift transfer with maximal assistance. The progressive fall interventions added included keeping R4's bed in the lowest position and adding a floor mat to the open side of her bed. On 8/14/24 at 4:00 PM, R4 was sleeping in bed in her room. The right side of R4's bed was pushed against the wall, and there was a bedside table to R4's left side. There was no floor mat on the open (left) side of her bed, and the bed was raised to standard height. On 8/14/24 at 4:13 PM, V21, Licensed Practical Nurse/LPN, stated R4 is a fall risk, but was unsure of her specific fall interventions. V21 reviewed R4's Care Plan, then entered R4's room, lowered her bed, and stated she would place a floor mat in her room right away. On 8/14/24 at 4:17 PM, V20, CNA, stated she has been working with R4 in the facility for a few months and was not aware she was a fall risk. V20 stated she had never seen any floor mats in R4's room. On 8/16/24 at 12:15 PM, V4, Administrator in Training (AIT), stated she expects progressive fall interventions to remain in place unless discontinued. The Facility's Fall Prevention and Management Policy, reviewed 9/2023, documents, This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventative strategies, and facilitate as safe and environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. Facility Guideline following a fall incident: Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence.

Based on interview and record review, the facility failed to assure appropriate fall interventions were in place and supervise 1 of 4 (R3) residents reviewed for falls and safety in the sample of 4. This failure resulted in R28 sustaining multiple falls, bruising of varies stages of healing, and a laceration to R3's head. Finding includes: 1. R3's Admission Record, not dated, documents R3's admitted [DATE]. It also documents Hemiplegia and Hemiparesis following Cerebral Infarction Affecting left non-dominant side, Type 1 Diabetes Mellitus with other specified complication, Dysphagia following cerebral infarction, Cerebral Infarction, unspecified, Chronic Obstructive Pulmonary Disease, unspecified, Difficulty in walking, not elsewhere classified, weakness, unsteadiness on feet, Displaced Intertrochanteric Fracture of Right femur, Chronic pain syndrome, Unspecified History of falling, and polyneuropathy, unspecified, listed as diagnoses. R3's Baseline Care Plan, dated 5/30/2024, documents R3 is at high risk for falls. It continues, Interventions: A. Call light within reach B. Provide clutter-free environment C. Encourage use of assistive device D. Provide proper, well-maintained footwear. It also documents, Fracture 1. Focus: A. Resident (res) has limited mobility related to fracture 2. GOAL: A. Resident's mobility status will return to pre-fracture status 3. INTERVENTIONS: A. Assist with repositioning as needed B. Do not lay resident on affected side C. Do not allow resident to cross legs if he/she has a hip fracture 4.Comments: right hip fracture, recent surgical repair. R3's Fall Risk Assessment, dated 5/30/2024, documents R3 has decreased mobility (stiffness, limitation in ROM (range of motion), contractures, amputation). R3 has Predisposing HTN (hypertension), CVA (cerebral vascular accident), Parkinson's, Hypotension, Seizure, Osteoporosis. R3 has Impaired memory or judgement, History of falls in the past 1-6 months, S/P Fall and/or Fracture in past 6 months and Drugs that have a diuretic effect or increase GI (gastro instestinal) motility. Drugs that affect the thought process (i.e. sedatives, hypnotics, narcotics, analgesics). Drugs that create a hypotensive effect (newly ordered or dosage adjustment). R3's Nurses Notes, dated 5/30/2024 2:35 PM, documents, Note Text: Patient admitted (Facility) from (Regional Hospital) transported by EMS (emergency medical service). Patient arrived by stretcher and patient is alert and oriented times three. Patient is able to make her needs known. Patient is a one assist while transferring and requires a wheelchair. Patient had no complaints of pain and abdomen was non distended. Bowel sounds were heard in all four quadrants. Patient is a regular diet with regular liquids. Patient last BM (bowel movement) was 5/30/24. No complaints of SOB (shortness of breath) and no oxygen required. Lungs clear. Patient is a smoker and wanted to smoke while getting off the stretcher, but Nurse educated patient that she had to be evaluated by therapy first. Skin is warm and dry, no bruises or injuries. Nurse has educated patient on how to use call light and bed remote. Patient is now in bedroom with hydration available and call light accessible. R3's Progress notes, dated 5/30/2024 7:19 PM, documents, Nurses Notes Note Text: Res (resident) fell in room and hit head. Res alert no visible injuries. Blood pressure is 161/88, pulse 89 resp 20 non labored blood sugar 277. Res (resident ) c/o (complain of) right hip pain r/t (related to) post op (operation). Res transferred via ambulance to (local hospital) eval and treatment. Attempted to notify POA (power of attorney) ,wrong number. Attempted to notify POA (Power of Attorney) #2 no answer. Report called to (local hospital). R3's Incident report, dated 5/30/24 10:49 PM, documents R3 was found on back in her room on floor no visible injuries. Oriented to person, place, time and situation. Predisposing Factors: gait imbalance, impaired memory , admitted within last 72 hours, during transfer. It also documents that R3 had recently fracture of right femur, resident newly admitted to facility. No root cause analysis was identified. R3's Physician Order Sheet, dated 6/1/24-6/30/24, documents Resident is placed on enhanced supervision. Every shift for safety. R3's Care Plan, dated 6/4/2024, documents, FALL: (R3) is at high risk for falls r/t (related to) having a history of repeated falls, diagnoses of CVA (stroke), right hemiparesis, schizoaffective disorder, bipolar disorder, psychosis, and anemia. She takes blood thinners, antidepressants, and seizure medications. She has poor short-term memory and poor safety awareness. It continues, 5/30/24-Was sent to (Local Hospital emergency room ) for evaluation due to use of blood thinners. 6/2/24-Placed on enhanced supervision with 15 minute checks. 6/4/24-Residents room moved closer to the nurse's station upon return from hospital. 6/4/24-send to (local hospital emergency room ) for evaluation due to use of a blood thinner. FSBS (fingerstick blood sugars), Vitals, Head to toe assessment with neuro checks and Resident not moved, and staff remained by her side until EMTs (emergency technician) arrived to transport to hospital. Educate resident on the importance of complying with safety measures. Document residents understanding of education and instances of noncompliance. Evaluate multiple falls to determine commonalities or patterns. R3's Progress Notes, dated 6/4/2024 at 7:38 PM, documents, Nurses Notes, Note Text: During shift change resident had a fall. Went down to assess the resident she states she was trying to get from her wheelchair to the bathroom and she fell . per assessing the resident, she did have a laceration to the back of her head and the right side of her leg. Resident was sent to (local Hospital) a x-ray and ct (computed tomography) scan everything was negative. Resident was sent back with no new order besides pain, Which was set to NP (nurse practitioner) and pharmacy. R3's Progress Notes, dated 6/6/2024 at 7:30 PM, documents, Nurses Notes, Note Text: visitor came to desk and said he seen a resident on the floor as he was walking past. this nurse and CNA (Certified Nursing Assistant) went to room and noted resident inside door of her room. resident in w/c, w/c laying on its side with resident in it. her head resting against the bathroom door. Resident able to move all extremities and denied any injury. this nurse and CNA assisted resident to standing position and back into upright w/c (wheelchair). (V10) N.P. (Nurse Practitioner) and DON (Director of Nursing) notified. (local Hospital) ambulance notified of need for transport. report called to (local hospital emergency room ) nurse for eval post fall. resident left at this time per (local hospital) ambulance. resident alert and oriented x2. skin w/d (warm and dry). resp nonlabored on room air. R3's Incident report, dated 6/6/2024 at 7:00pm, documents the nurse was alerted by visitor that the resident on floor. Upon the nurse and CNA entering room noted resident on floor inside door of room. Resident in wheelchair laying on side with resident in it. head resting against bathroom door. Resident able to move all extremities and denied any injury. Resident stated that she was trying to go in the bathroom. It also documents that R3 is confused/forgetful. Oriented to person and place. Redisposing factors noncompliant with safety guidance, gait imbalance, impaired memory. No root cause analysis provided. On 6/11/2024 4:00 PM, requested R3's Enhanced Supervision Monitoring Tool every 15minutes documentation. As of 6/18/2024 at 3:00 PM, the facility has not provided the Enhanced Supervision 15-minute documentation for 6/4/2024. On 6/11/2024 at 4:20 PM, observed V7, CNA, and V11, RN, assist R3 with applying the lift pad. R3's pant legs were raised revealing large discolorations in various stages of healing ranging from yellow, green, blue, purple, and black in color. On 6/12/2024, a review of R3's Electronic Health Record revealed there was not a Fall Risk Assessment performed on 6/4/2024. On 6/12/2024 at 11:00 AM, requested R3's fall investigations. The facility was unable to provide R3's investigation for 6/4/2024. At 4:40 PM, V2, Director of Nursing, provided R3's incident report for 6/4/2024 incident that was completed 6/12/2024. No root cause analysis identified. On 6/12/2024 at 3:00 PM, V2, Director of Nursing, stated she completed the incident report for 6/4/2024, today, (6/12/2024), and used the nurses note in the computer. As of 6/12/2024 at 4:00 PM, R3's medical record does not document bruising to R3's legs, and arms. On 6/11/2024 at 4:50 PM, R3 stated she has fallen at the facility. R3 stated she fell and broke her leg prior to being at the facility. R3 stated she was trying to go to the bathroom. R3 stated she likes to do things herself. R3 stated it takes so long for them to come and help. R3 stated she doesn't want to go on herself. R3 stated she pulls the cord, but they never come. On 6/13/2024 at approximately 1:30 PM, V13, Wound Nurse/LPN, stated she was at the facility when R3 fell on [DATE]. V13 stated she was notified that R3 fell . V13 stated she went to the room and saw R3 lying on floor with blood coming from her head. V13 stated the nurse was an agency nurse. V13 stated because R3 was bleeding, R3 was sent to the hospital. V13 stated R3 is at high risk for falls. V13 stated R3 requires increased supervision and was placed on enhanced supervision because R3 was trying to transfer self. V13 stated R3 is alert and able to verbalize her needs and have an alert conversation. V13 stated she was aware of R3's bruises and scratches. R3 stated on the day of the fall, it was not clear as to where the blood was coming from, and R3 was sent to the hospital. V13 stated ]she completed the documentation in the computer yesterday (6/12/2024). On 6/12/2024 at 3:10 PM, V4, Registered Nurse (RN), stated she has cared for R3. V4 stated R3 requires supervision and should not be in her room unattended, unless in bed. V4 stated R3 has had multiple falls, a fracture and multiple comorbidities that would put her at risk for falls. V4 stated R3 makes multiple attempts to transfer herself. V4 stated they try to keep R3 out front by the nurse's station. V4 stated R3 can move the chair and move around in the facility. V4 stated she was the nurse on 6/6/24 when R3 fell . V4 stated R3 was in her room in her wheelchair prior to the fall. V4 stated a visitor informed her R3 was on the floor. V4 stated she went to the room and R3 was lying on the floor inside her wheelchair, with her head against the bathroom. V4 stated the chair was folded on its side with R3 inside. V4 stated she was worried R3 would have hit her head because she may have not been able to brace herself. On 6/12/2024 at 3:15 PM V5, Licensed Practical Nurse (LPN), stated she is familiar with R3. V5 stated R3 is at high risk for falls. V5 stated R3 has had multiple falls since being at the facility. V5 stated she was present for 2 of R3's falls. V5 stated R3 was in her room alone at time of falls. V5 stated R3 was responding to toileting. V5 stated they try to keep R3 out of her room and near the nurse's station or in activities because R3 will try to transfer herself. V5 stated R3 is alert and able to express herself. V5 stated R3 has not had any injuries. V5 stated R3 was placed on 15-minute checks. The facility's Fall Prevention and Management policy, dated 9/2023, documents, The facility Is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the residents existing plan of care shall be evaluated and modified as needed. Upon admission a fall risk evaluation will be completed on admission, readmission and quarterly, significant change and after each fall. Residents at risk for fall will have fall risk identified on the interim plan of care ant the ISP with interventions implemented to minimize fall risk. the facility guidelines following a fall incident are listed 1. Evaluate for injury and notify physician and emergency contact. 2. Complete a fall incident report in PCC risk management portal. 3. a fall risk evaluation is completed by the nurse. A score of 10 or greater indicates the resident is at high risk for falls; a score of less that 10 indicates at risk for falls. 4. Care plan to be updated with new intervention based on root cause analysis after each fall occurrence. 5. Complete follow up monitoring form every shift for 72 hours.

Based on interview and record review, the facility failed to assess and treat pressure wounds for 1 of 3 residents (R2) reviewed for pressures ulcers in the sample of 5. Findings include: 1. R2's ELH (electronic health record) encounter for orthopedic aftercare for surgical amputation; type 2 diabetes mellitus without complications; unspecified severe protein calorie malnutrition; elevated white blood cells; major depressive disorder; vitamin d deficiency; anxiety; vitamin b12 deficiency, anemias; adult failure to thrive; acquired above the left knee amputation; personal history of diseases of the skin and subcutaneous tissue; pulmonary hypertension unspecified; peripheral vascular disease; hyperlipidemia. R2's ELH dated 05/06/24 documents that the resident was admitted into the facility. R2's MDS (Minimum Data Set), dated 515/2024, documents alert and oriented to self and place. BIMS (Brief Interview for Mental Status) indicates a score of 3; severe cognitive impairment. Dependent upon assistance of ADLs (activities of daily living), has bilateral AKA (above the knee amputation), atrial fibrillation and other dysrhythmias, and congestive heart failure, and indwelling urinary catheter. R2's Braden scale, dated 5/6/2024, documents a high risk for pressure ulcers and requires assistance with turning and repositioning. R2's care plan, dated 5/7/2024, documents dietary supplements as indicated. Monitor areas for s/s(signs/symptoms) of infection: odor, drainage, color, or size. 2)use pressure redistribution surface if bed/chair bound. 3)skin assessment weekly. 4)treatment as ordered. R2's POS (physician order sheet) ordered 5/14/2024 to start 5/15/2024; Santyl ointment (collagenase) apply to verbal per additional directions topically every day shift for wound care, wound cleanser, then apply Santyl and calcium alginate to coccyx wound daily, cover with Opti foam. R2's Nurses Note dated 05/06/24 at 5:15 PM documents The resident arrived via Ems (Emergency Medical Services), placed in room [ROOM NUMBER]. Vitals were obtained, body assessment completed, order from 2L of oxygen. The resident has pressure wound to coccyx, bruising to left groin, left forearm, and surgical site from left above the knee amputation. (R2) a&o (Alert and Oriented) 1-2, regular diet, and (mechanical lift). She's now in bed with call in reach, bed in low position. The hospital records, dated on 5/18/2020 through 5/22/2024, documents from US (Ultrasound) right AKA (above the knee amputation) soft tissue edema throughout without hypervascularity. There is a hypoechoic fluid collection along the medial aspect of the night lower extremity stump, inferior to the skin staples measuring at 0.9 x 0.8 x 4.8 cm. Pictures show yellow drainage from the incision site of the stapled area. The CT (Computed Tomography) sacral area soft tissues overlying the sacrum are slightly thickened. Decubitus sacral ulcer necrotic tissue noted. Started on empiric antibiotics due to Sepsis of the decubitus sacral ulcer. Please correlate clinically for decubitus ulcer reported in history. TAR (treatment administration record) documents wound care on 5/15,5/16, and 5/18; no documentation of wound care from admission 5/6/2024 to 5/14/2024, nor 5/17/2024. No indwelling catheter care documented on the TAR. On 5/22/2024 at 11:25 AM, V4, Registered Nurse/RN stated R2 arrived at the ER (emergency room ) via stretcher 5/18/24 late night until Sunday, then transferred from the ER to the ICU (intensive care unit). V4 stated R2 was alert to self and place. V4 stated R2 came because the facility said she had an elevated WBCs (white blood cells) urine catheter looked nasty and filthy. The catheter looked like (R2) had no catheter care, and it was removed and replaced upon arrival in the ER. Upon her arrival, (R2) had two wounds stage 3/4; pictures were taken of the sacral area. V4 stated R2 was in the hospital around the beginning of May, about the 3rd. She had pictures taken at that time of the sacrum with a barely stage 1 of the left gluteal; Stage 3, and stage 1/2 bilateral aka (above knee amputation). V4 stated right AKA (above the knee amputation) dressing was crusted and dried on that it had to be wet down to remove. (R2) had an infection in the surgcial site, had to be drained by doctor. V4 stated R2's dressings were not being changed and she can't do it herself. V4 stated R2 is alert to self only. V4 stated blood cultures, wound cultures and labs were obtained with urine culture in the ER. On 5/28/2024 at 9:00 AM, V11, Nurse Practitioner/NP, stated, The notification of any resident admitted with a wound (pressure wound) should occur within the shift of the nurse on duty that has admitted the resident. It also depends on the orders. Facility's Policy SKIN MANAGEGMNT: Pressure Injury Treatment/General Wound Treatment, revised 4/2024, documents: General: The following treatment guidelines have been developed to serve as a general protocol for selecting the type of treatment or dressing to be used. However, the facility recognizes that the selection of treatment protocols is individualized based on the resident condition and Health Care Provider practice patterns. Therefore, these are only guidelines and not all inclusive. An order is required for all treatment orders. Responsible Party: All Nursing Staff General Treatment Guidelines: 1. Review the physicians order in the EHR and place all necessary supplies in treatment cart. 2. Perform the treatment as ordered using proper techniques of infection prevention. 3. Document routine and PRN treatments in the treatment administration record of the EHR. Document all significant observations in the Nursing Progress Notes. 4. Mobility turn and reposition every 2 hours and PRN using a person centered approach.

Based on observation, interview, and record review, the facility failed to provide timely and complete incontinence and catheter care for 5 of 5 (R23, R41, R42, R45, 150) residents reviewed for incontinent care in a sample of 34. This failure resulted in R42 feeling angry, sad, alone, and like no one wants to take care of her. Findings include: 1. R42's Care Plan, dated 5/25/23, documents, skin: (R42) has potential for skin integrity issues such as pressure ulcers/injuries as she always is incontinent of bowel and bladder and requires limited assistance with the bed mobility ADL. She has diagnoses of DM type 2, anemia, and morbid obesity due to excess calories. R42's Minimum Data Set, (MDS), dated [DATE], documents R42 is cognitively intact, always incontinent of bowel and bladder, and is totally dependent on 1 staff for toileting. On 7/18/2023 at 12:50 PM, V2, Director of Nursing, and V5, Restorative Aide, assisted R42 with incontinent care. R42 was incontinent of urine and bowel. V5 opened R42's incontinent brief and revealed a large amount of loose stool. Using premoistened wipes, V5 wiped each side of R42's groin. V5 did not cleanse R42's inner and outer labia. V2 and V5 then assisted R42 onto her right side and partially cleansed R42's left buttock and anal area. V2 and V5 turned R42 over to her right side, and V2 partially cleansed R42's left buttock. V2 and V5 then turned R42 onto her back. V2 then left the room, and V5 wiped R42's inner thighs leaving stool on legs. V2 and V5 did not cleanse R42 entire buttocks, leaving bowel on the upper left buttock. On 7/18/2023 at 12:45 PM, R42 stated she has been wet since last night. R42 stated the staff do not come in and check on her every 2 hours. She has been wet for hours. R42 stated she pulls her call light, but it takes a long time to answer her light, if it is answered at all. They are supposed to check every 2 hours, but they don't. R42 stated it makes her angry. R42 stated she does not have family and friends in the area. R42 stated it makes her feel sad, alone, and like no one wants to take care of her. 2. R150's Care Plan, dated 7/14/23, documents (Indwelling catheter): (R150) requires use of an indwelling catheter size 16/30ml, (milliliters), r/t, (related to), Obstructive uropathy, wounds and bladder retention and is at risk for infection of the bladder. R150's Interim Baseline Care Plan, dated 7/10/2023, documents, Catheter Care per orders. R150's Admission Observation, dated 7/7/2023, documents R150 is Responding to environment, oriented to person, place, time, and frequently incontinent of bowel. On 7/17/2023 at 10:50 AM, V13, Certified Nurse Assistant (CNA), and V12, CNA, assisted R150 with incontinent care. R150 was incontinent of urine and bowel. V13, using premoistened wipes, wiped R150's groin. V13 cleansed R150's penis and wiped R150's urinary catheter. V13's catheter had dark brown drainage on it that remained after V13 wiped the catheter. V13 and V12 then rolled R150 over onto his left side. V13 then, using a premoistened wipe, cleansed bowel from R150's anal area, and right buttock. V13 and V12 assisted R150 onto his right side and removed the soiled incontinent undergarment and incontinent pad from beneath R150. V13 and V12 then assisted R150 onto his back. V12 stated they were finished with incontinent care, and covered R150 with a sheet. V12 and V13 did not retract R150s skin and cleanse penis, did not cleanse R150's scrotum, and did not cleanse R150's left buttock. On 7/17/2023 at 11:10 AM, V13 stated she was not going to put an incontinent brief on R150 because he needed to air out. The facility's Foley Catheter Care Policy, dated 04/2019, documents, Policy: Daily and PRN catheter care will be done to promote comfort and cleanliness. Responsible Party: RN, LPN, C.N.A. It further documents Procedure: 1. Wash your hands before beginning the procedure. 2. Assemble all equipment and supplies that will be necessary to perform the procedure. 3. Knock before entering the room. 4. Arrange the supplies so they can be easily reached. 5. Identify yourself. Explain procedure to resident. 6. If visitors are present, ask them to wait outside unless the resident allows visitor (s) to remain in the room. 7. Close the door. 8. Pull the cubicle curtain around the bed for privacy. 9. Position resident in semi-fowlers position if tolerated. 10. Put gloves on. 11. Cleanse area of catheter insertion site, using soap and water or pre-moistened wipes. Being careful not to pull on catheter or advance further into urethra. 12. Wash catheter itself by holding on to catheter at insertion site, wash with one stroke downward, suing same procedure for rinsing. 13. Secure and anchor the catheter by utilizing a leg strap or other device. 14. Position resident for comfort. 15. Remove and discard gloves. Wash hands. 16. Catheter bag to be emptied at the end of every shift, and PRN. Make sure to record output. 44967 3. R23's Admission Record, undated, documents R23 was admitted to the facility on [DATE]. R23's Electronic Medical Record, documents, R23's Diagnosis include; Chronic Obstructive Pulmonary Disease, (COPD), Emphysema, Type 2 DM (Diabetes Mellitus), Cerebral Infarction, Lumbago with Sciatica, Gastrostomy, Convulsions, Major Depressive Disorder, Malignant Neoplasm of lung, Atherosclerotic Heart Disease, (ASHD), Anemia, Adult Failure to Thrive, Myocardial Infarction, (MI), Hypertension, (HTN), Hyperlipidemia, and Malignant Neoplasm of Pelvic Bones, Sacrum and Coccyx. R23's Care Plan, dated 6/5/23, documents, (R23) requires assist with daily care needs r/t, (related to), weakness from Lung Cancer, Sacral Cancer, Lumbago, and Emphysema. Interventions: Assist resident with ADLs, (Activities of Daily Living), Encourage/Assist with turning and repositioning every two hours and as needed, keep clean and dry after each incontinent episode, monitor skin integrity during routine care and report abnormal findings. It continues, (R23) has a self-care deficit in dressing and grooming r/t weakness/pain. It continues, (R23) is at risk for skin complications r/t dx, (diagnosis), of type 2 DM, protein-calorie malnutrition, malignant lung neoplasm. Interventions: Assess and document of progress of areas weekly, assist and encourage resident to turn and reposition every one to two hours and PRN, (as needed) Educate resident on MD, (Medical Doctor), orders for wound care, monitor area for s/s, (signs/symptoms), of infection: odor, drainage, color, size, Observe and assess regularly, Skin assessment weekly. It continues, (R23) is at risk for skin complications r/t dx of type 2 DM, protein-calorie malnutrition, malignant lung neoplasm. R23's Minimum Data Set (MDS), dated [DATE], documents R23 has a moderate cognitive impairment with a BIMS (Basic Interview for Mental Status) of 11. R23 requires extensive assistance from one staff member for personal hygiene and dressing, total dependence of one staff member for toileting, and limited assistance from one to two staff members for all other ADLs. R23 is always incontinent of both bowel and bladder. On 7/17/23 at 9:12 AM, R23 was lying in bed, appeared very unkempt, hair messy, unshaven with long facial hair; smell of body odor and/or urine odor noted. On 7/17/23 at 9:15 AM, R23 stated, I don't get out of bed because my legs don't work. I just go in my bed. I can't tell them when I'm wet or need cleaned up, because I can't find my call light, so I just have to sit in it for a long time. I don't remember if someone came in this morning to clean me up or not. On 7/18/23 at 9:13 AM, R23 was lying in bed, remained unkempt appearance, with body odor and/or urine odor. R23's facial hair had been cut, but he still has long facial stubbles. On 7/18/23 at 9:15 AM, R23 stated, I think the last time I was cleaned up down there was around 3:00 AM or 4:00 AM this morning. I think I am wet now but, I can't reach my call light. R23's call light was seen still hanging on the bottom of the left side rail, with cord dangling on the floor and out of R23's reach. On 7/18/23 at 11:00 AM, R23 was still lying in bed. R23 stated he has not been checked yet. R23's call light is still out of his reach. On 7/18/23 at 11:40 AM, R23 was still lying in bed. No staff member has checked on him. R23 stated he's still wet. On 7/18/23 at 11:58 AM, V2, DON (Director of Nursing) was notified of R23 still waiting to be cleaned up. V2 was told of R23's call light being out of his reach. V2 found R23's call light tangled with the remote cord to the bed and was not within reach and not usable. V2 stated she would send CNAs, (Certified Nursing Assistants), in to clean him up immediately. On 7/18/23 at 12:10 PM, R23 stated, They were just in and cleaned me up. On 7/19/23 at 8:18 AM, R23 was lying in bed, with very messy hair with dry flakes, appeared unshaven, with a body odor and/or urine odor. R23 stated he had incontinence care done by the night shift, and has not been check yet this morning. R23 stated he is wet already this am, and is waiting for someone to clean him up. On 7/19/23 at 10:56 AM, V13, CNA, stated, I check on my residents probably less than every two hours. On 7/19/23 at 12:35 PM, R23 stated, Someone came in around 10:30 or so and cleaned me up. I think I am dry right now. On 7/19/23 at 10:41 AM, V2, DON, stated, I expect the staff to be checking on the residents for incontinence every two hours and providing timely and complete incontinent care to the residents. 4. R41's Admission Record, undated, documents R41 was admitted to the facility on [DATE]. R41's Electronic Medical Record, documents R41's Diagnoses include: Type 2 DM, Morbid Obesity, Fracture of fifth cervical vertebra, Displaced fracture of fourth vertebra, Compression fracture of thoracic vertebra, Central Cord Syndrome, Rhabdomyolysis, HTN, Major Depressive Disorder, Obstructive and Reflux Uropathy, and neuromuscular Dysfunction of bladder. R41's Care Plan, dated 5/8/23, documents, (R41) requires assist with daily care needs r/t recent fracture of the cervical and thoracic spine and requires the use of a cervical collar at all times. He receives PT, (Physical Therapy), and OT, (Occupational Therapy), therapy services and requires assistance with all ADLs. He has an indwelling catheter that the nursing staff/CNAs care for. Interventions: Assist resident with ADLs, Encourage/Assist with turning and repositioning every two hours and as needed, He prefers his call light cord be tied to the bed rail per his choice, (full body mechanical lift) lift with two assist for transfers, Keep clean and dry after each incontinent episode, Monitor skin integrity during routine care, Two person assist for transfers with a full body mechanical lift. It continues, (R41) has a self-care deficit in bed mobility r/t Decreased ability to position or reposition self in bed. Interventions: Position and reposition resident in bed for comfort, joint support and skin integrity. It continues (R41) has a self-care deficit in dressing and grooming r/t cervical fx. It continues, (R41) requires use of an indwelling catheter r/t neurogenic bladder from central cord syndrome and obstructive uropathy and is at risk for of infection. Intervention: Keep draining bag covered to promote privacy. It continues, (R41) is at risk for skin complications r/t being admitted with multiple open areas to the skin. He is to see our (wound company) wound specialist and has DX of Type 2 DM, morbid obesity, Fracture of 5th cervical vertebrae and thoracic vertebrae. He requires assistance with the transfers. Interventions: Low air loss mattress in place, assist and encourage resident to turn and reposition every one to two hours and PRN, ensure proper body alignment, Resident education on risk of not turning and repositioning approximately every two hours. It continues, (R41) risk for skin complications r/t dx of type 2 DM, morbid obesity, fracture of 5th cervical vertebra and thoracic vertebra, requires assists with transfers and is non-compliant. Interventions: Assess and document of progress of areas weekly, Observe and assess regularly, protect elbows and heels if being exposed to friction, Protect heels, Skin assessment weekly. R41's MDS, dated [DATE], documents R41 is cognitively intact with a BIMS of 14. R41 requires extensive assistance from one staff member for all ADLs. R41 has a urinary catheter in place and is always incontinent of bowel. On 7/17/23 at 1:45 PM, V5, CNA, entered to provide incontinence care to R41. V5 carried in one pack of disposable wipes and one incontinent brief. V5 donned gloves and emptied urine from catheter. V5 donned new gloves. V5 unfastened R41's incontinence brief, and a very large amount of liquid stool was seen, covering R41's entire groin and suprapubic area, including R41's penis and urinary catheter. V5 sprayed peri-wash onto R41's penis/groin area and began wiping. V5 noticed she forgot a trash can, and went to R41's roommate's side and took his, and threw soiled wipes in that trash can. V5 wiped R41's left groin and doffed her soiled gloves, then donned clean gloves with no hand hygiene. V5 then wiped R41's left groin again, and had visible feces on her gloves and on her wrist (skin). V5 used the same soiled gloves to get the peri-wash spray bottle and again spray R41's groin area. After wiping several times with the same soiled gloves, V5 doffed her gloves, and did not perform hand hygiene before donning new gloves. V5 then began wiping R41's right groin, and with feces all over her gloves, continued to get more wipes out of the container and began to wipe R41's penis and pubic area. V5 left the room twice to obtain more wipes and incontinence briefs, with no hand hygiene after doffing her gloves, before leaving the room, or again before resident care. V5 continued wiping feces and using the soiled gloves, then performed catheter care by wiping the urinary catheter and penis. V5 did not dry R41 at any time during incontinence care. V5 doffed her gloves and used her bare hands to push the soiled linen under R41, and apply a new pad onto the bed. V5 then, without gloves on, pushed the soiled wipes and trash down into the trash can and tied the bag up and left the room, with no hand hygiene completed. On 7/18/23 at 9:16 AM, R41 seen lying in bed and stated he was last cleaned up late last night, and no one has checked him this am. R41 stated when (V10, Wound Care Nurse) changed his dressings this morning, all she did was unfasten his brief to get to his penis wound, and did not check him or clean him up. On 7/18/23 at 9:19 AM, V27, CNA, entered R41's room with one incontinence brief, and placed it on R41's bedside table and stated she would be back. On 7/18/23 at 9:58 AM, V27, CNA, entered R41's room and dropped off an incontinence pad on R41's bedside table and left the room without checking R41. On 7/18/23 at 11:15 AM, R41 was lying in bed and stated the CNA brought the stuff in twice to clean him up, and she said she would be right back, but hasn't come back in yet. On 7/18/23 at 11:58 AM, V2, DON, was notified of R41 still waiting to be cleaned up, and has been waiting all morning. V2 went into R41's room with the clean incontinent brief and pad still lying on the bedside table. R41 stated the CNA said she would come back and did not. V2 stated she would send CNAs in to clean him up immediately. On 7/18/23 at 12:15 PM, R41 stated, They just left here and cleaned me up. I was dirty and didn't even know it. I guess she should have checked me earlier. On 7/19/23 at 8:25 AM, R41, lying in bed, stated he gets a shower on Wednesdays and should be getting one today, but will see. R41 stated he was last checked and cleaned for incontinence from the night shift before they left, and no one has checked him yet today. The Wound Nurse changed his bandages this am, but they did not check him or clean him up. R41 is unsure if he is soiled or not. 5. R45's Admission Record, undated, documents R45 was admitted to the facility on [DATE]. R45's Care Plan, dated 6/5/23, documents, (R45) requires assist with daily care needs r/t weakness from Lung Cancer, Sacral Cancer Lumbago and Emphysema. Interventions: Assist resident with ADLs, Encourage/ Assist with turning and repositioning every two hours and as needed, keep clean and dry after each incontinent episode, monitor skin integrity during routine care and report abnormal findings, One Person Assist for transfers. It continues (R45) has a self-care deficit in dressing and grooming r/t weakness/pain. R45's MDS, dated [DATE], documents R45 is cognitively intact with a BIMS of 14. R45 requires extensive assistance from one to two staff members for all ADLs. R45 is always incontinent of bladder and frequently incontinent of bowel. 7/17/23 at 9:06 AM, R45 stated, I just go to bathroom in my bed and the staff will check me at some point. On 7/18/23 at 9:07 AM, R45 stated, I was cleaned up, (incontinent care), early this morning by the night shift. On 7/18/23 at 10:05 AM, R45 remains as he was earlier. There has not been any staff member check on him and/or provide incontinent care. On 7/18/23 at 11:35 AM, V14, Licensed Practical Nurse/LPN, entered R45's room to give R45 a medication via G-Tube, and when she finished, V14 started to walk out of the door, when this surveyor asked her to check R45 for incontinence. When she did, R45's incontinence brief was saturated in urine. V14 stated she will have a CNA come and clean him up. On 7/18/23 at 11:47 AM, V15, CNA, came in to do peri-care for R45. V15 donned gloves and used bleach wipes to clean bedside table. V15 changed her gloves, with no hand hygiene completed. V15 only donned one glove, as that was all she had with her, when V10, Wound Nurse, walked in and brought V15 a box of gloves. V15 donned a pair of gloves, with no hand hygiene completed. V15 unfastened R45's brief, which appeared to be soaked in urine, with a small amount of feces noted. V15 wiped R45's anal area, and using the same soiled gloves wiped R45's groins, briefly around R45's penis, and did not wipe R45's scrotum. V15 did not dry R45 at any point during incontinence care. V15 fastened the clean incontinence brief, pulled R45 up in bed, and covered R45 up, all while using the same soiled gloves. V15 doffed her gloves and left the room with no hand hygiene completed. The Facility's Incontinence Care Policy, dated 3/2022, documents Incontinence care is provided to keep residents as dry, comfortable and odor free as possible. It also helps in preventing skin breakdown. Guideline: 1. Incontinent residents are evaluated for a bowel and bladder program and placed on one if appropriate. 2. Perform hand hygiene and don gloves. 3. Provide privacy for resident. 4. Remove soiled clothing and linen. 5. Clean peri area with appropriate cleanser and dry. Appropriate cleanser can mean soap and water, peri-wash, etc. Cleansing should always be from front to back. 6. If resident needs more cleansing, then above, a bath or shower may be given. 7. Apply barrier cream if appropriate. 8. Apply clean clothing and linen. 9. Notify housekeeping if floor is wet. 10. Dispose of soiled clothes and linen in appropriate areas. 11. Perform hand hygiene. 12. Notify nurse if areas of red skin or breakdown so that the Health Care Provider may be notified for further orders.

Based on observation, interview, and record review, the facility failed to provide safe transfers and progressive interventions for 3 of 4 residents (R30, R32, and R35) reviewed for falls in the sample of 34. This failure resulted in R32 falling and fracturing his right hip requiring surgical repair. Findings include: 1. R35's electronic medical record documents R35 has had 5 falls from 2/1/2023-6/25/2023. Fall report, dated 2/1/2023, documents, At 18:15 PM, (R35) was getting off the toilet and had pulled up his (incontinence brief), pants still down to knee, he fell and was lying on right side in doorway of bathroom. He stated he did not hit his head. No injury noted. Interdisciplinary Team (IDT) meeting, 2/9/202, documents, RCA (root cause analysis) resident on toilet and fell pulling up pants, all previously care planned intervention in place and adding education staff to stay with resident while using restroom. Care plan reviewed and updated. R35's record documents R35 had a fall 3/10/232023 at 21:52 PM, Notified on floor in dining room. Fall report documents, IDT met and discussed incident. IDT meeting to discuss and update (R35's) care plan. Fall report, dated 5/1/2023 at 12:55PM, documents, (R35) ground level fall during lunch. Resident was positioned on the floor on his buttocks directly in front of his chair. (R35) stated he was eating his lunch in his recliner and slid off the front edge landing on buttocks in a seated position on the floor, direct in front of the recliner. No head trauma. Report documents, 5/2/2023 IDT meeting to discuss incident on 5/1, staff reapplied a new (anti-slip pad), no skid surface refer to therapy PT (physical therapy), OT (occupational therapy), all other Care Plan interventions to remain in place Care Plan reviewed and updated. Fall report, dated 5/31/2023 at 12:21 PM, documents, While passing medication, Therapy informed the nurse, that the resident was on the floor in the bathroom. Nurse went to resident bathroom and witnessed R35 laying on right side, body halfway in hallway, in the bathroom and other resident room. Nurse went to get Certified Nursing Assistants (CNAs) for assistance and resident was assessed from head to toe, no visible injuries noted. Resident was assisted into chair. (R35) c/o (complaining of) pain to right hip and leg pain at this time. Resident stated he slipped but did not hit anything. Guardian notified, and (R35) sent to the emergency room for evaluation. R35's x-ray report, dated 5/31/2023 at 15:14 PM, documents minimally displaced intertrochanteric right femur fracture. Fall report, dated 6/23/2023 at 22:30 PM, documents, CNA came to the Nurse and said while she was cleaning him up, he rolled off the bed. The fall report documents, Nurse entered (R35's) room and resident was laying on the floor, on right side between the bed and the wall, the bed was in high position, nurse put pillow under resident head, resident moaning out 911 called. Report documents, IDT meeting to discuss incident on 6/23/23. Staff will ensure bed is in low position, bed against the wall, fall mat on the floor next to the bed. All other Care Plan interventions to remain in place. Care Plan reviewed an updated. Fall report, dated 6/25/2023 at 10:51AM, documents, Resident had legs hanging off bed, physically observed no injuries noted, resident denies pain. 6/26/2023, IDT meeting to discuss incident 6/25/23. Staff provided low air loss mattress and staff to offer bedpan/toileting when repositioning. All other Care Plan intervention to remain in place. Care Plan reviewed and updated. On 7/19/2023 at 10:40 AM V2, Director of Nursing/DON stated, The reason report documents reapply (anti-slip pad) is because the (anti-slip pad) becomes soiled and then does not provide no skid surface. The facility is trying to do something different because (anti-slip pad) is not effective. The investigation of R35's fall did not include witness statement or last time R35 was toileted, and fall occured in bathroom. R35's fall out of bed, did not document any type of staff training. V2 stated, There should always be staff education. V2 was asked, Would you have expected staff to be providing more assistance since (R35) fractured his right hip on 5/31? V2 stated, The CNA should have requested additional assistance. 2. R32's Minimum Data Set, (MDS), dated [DATE], documents R32 requires extensive assistance for bed mobility and transfer and one-person physical assistance. R32's Care Plan, dated 12/14/2021, documents, is at high risk for fall r/t confusion, gait, balance problems poor communicating and comprehension. Psychoactive drug use, unaware of safety need, history of falling at his home, history of intentionally lowering himself to the floor from his wheelchair, from the bed to mattress on floor. Intervention dated, 12/16/2021, documents, keep water pitcher in reach when in bed. 12/14/2021 documents, be sure resident call light in reach and encourage the resident to use it to call for assistance as needed. The resident needs prompt response to all requested assistance. On 07/17/23 at 10:50 AM during transfer from chair to bed, V11, Certified Nursing Assistant (CNA), and V5, CNA, both placed an arm under R32's armpit and transfered from chair to bed. No gait belt was utilized. R32 had pressure relieving boots on from foot to below knee; they were removed prior to transfer. V11 and V5, CNAs, stood R32 up, and R32 was unable to pivot. V11 and V5 did a complete lift from the chair to bed. V11, CNA, also lifted R32 by grasping pants around R32's waist. On 7/19/2023 at 10:40AM, V2, DON, stated, (R32) is a (Mechanical lift) transfer and up lift to be toileted. He does not like to use fracture pan. (R32) needs to be up during the day. V2 verified R32 was not up all day yesterday, as she worked on that hall. On 7/19/23 at 11:03 AM, V2 stated she would expect staff to use gait belt during transfers. V2 stated R32 should have had the boots removed prior to transferring to chair. 44967 3. R30's Admission Record, undated, documents R30 was originally admitted to the facility on [DATE]. R30's Care Plan, dated 6/2/23, documents, (R30) requires extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene and supervision with eating and locomotion. She has weakness and has cognitive issues. Interventions: Assist resident with ADLs, (Activities of Daily Living), Encourage/Assist with turning and repositioning every two hours and as needed, keep clean and dry after each incontinent episode, provide wheelchair for mobility, two person assist for transfers. It continues, (R30) is at high risk for falls r/t, (related to), poor cognitive status, she requires assistance with ADLs and has a propensity to wander about the facility. She has dementia and is unable to express her needs appropriately. Interventions: 1/12/23 brightly colored visual cue reminding to call for assistance with transfers or ambulation, 2/2/23-Mat on floor on open side of bed when in bed, 5/1/23-Environmental survey performed and we applied non-skid strips on floor in front of recliner chair, sink and toilet, encourage appropriate use of wheelchair, encourage use of and provide a reacher as needed to assist resident with getting items from hard reach areas, keep bed in lowest position, promote placement of call light within reach and assess residents ability to use. R30's MDS, dated [DATE], documents R30 has a severe cognitive impairment with a Basic Interview for Mental Status (BIMS) of 3. R30 requires limited assistance of one staff member for transfers and extensive assistance of one staff member for toileting, dressing, and personal hygiene. R30 is occasionally incontinent of urine and always continent of bowel. R30's Nurses Note, dated 5/5/23 at 12:03 PM, documents, Resident was observed as being on her floor next to her bed. She states that she was attempting to get into her wheelchair. Resident states that she did hit her head on her left side. DON, (Director of Nursing)/Management, notified. Neuro checks are initiated. Nurse called POA, (Power of Attorney), and left a message to return the Nurses phone call. Medical Provider called and message left. Resident has no complaints of acute pain or distress noted at this time. Will make 2nd call to notify POA. Vital signs are 118/74, 18, 72, 97.2, 97% on RA, (room air). Resident is now at the Nurse's Station on close observation to keep safety intact. R30's Nurses Note, dated 5/1/23 at 5:00 PM, documents, Resident found in floor of bathroom by (V8, MDS Nurse). Resident was seen lying on her left lateral side. Resident states, she walked from her recliner to the bathroom then lost her balance standing up from the toilet and fell on to the floor. Resident denies known head trauma or LOC, (loss of consciousness). Reports only her back is uncomfortable from her position on the cold floor. Resident VS, (vital signs), taken and WNL, (within normal limit), (BP 142/88, HR 87, T 97.5, RR 16, SPO2 (oxygen saturation) 97% on RA/room air.) history obtained, and full head to toe physical assessment performed. Resident assisted to wheelchair and neuro checks initiated due to poor historian and unwitnessed fall. Physical exam as follows: Pt (patient) is CAO, (conscious, alert oriented), x1 per baseline. Normocephalic without lesions or tenderness. Trachea midline, Airway clear, handling own secretions, Respirations even non labored, Lungs CTA, (clear to auscultate), throughout anteriorly and posteriorly. No JVD, (jugular vein distention), noted. GCS, (Glasgow coma score), 15. Pupils PEARRL, (pupils equal and round, reactive to light). No focal deficits noted. Skin PWD, (pink warm dry), no abnormalities, lesions, or rashes noted. Abdomen SNT, (soft non-tender), non-distended. No obvious injuries or bony deformities. No midline spinal tenderness. No cervical step offs palpated. [NAME], (moves all extremities). NAD, (no acute distress), noted. On 7/1723 at 10:18 AM, R30 was sitting in her wheelchair talking with her family. A fall mat was seen by her bed, and a sign Don't forget to use your call light for assist. seen on the wall. On /17/23 at 10:22 AM, V28, R30's daughter, stated, Mom fell when she first got here, she was confused and tried to get up on her own to her wheelchair from her bed and fell . She broke some ribs and spent some time at (Regional Hospital). On 7/17/23 at 11:18 AM, R30 was seen being assisted to her wheelchair by V5, CNA, who was holding onto R30's pants, and had R30 stand up and pivot to her wheelchair. There was no gait belt used. On 7/17/23 at 11:20 AM, R30's Daughter, stated, They usually just hold onto her pants, so she doesn't fall and get her up. They don't usually use a belt around her. The facility policy Gait Belts, dated 6/2015 and reviewed 9/2017, documents gait belts are used to help prevent injury of staff or residents during transfers and ambulation. The policy documents gait belts should be used by all staff when ambulating or transferring a resident. The facility Fall prevention and management policy, dated reviewed 7/2022, documents the facility is committed to maximizing each resident's physical and psychosocial wellbeing. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventative strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. The policy documents care plan to be updated with a new intervention based on root cause analysis after each fall occurrence.

Based on interview, observation, and record review, the facility failed to provide wound care, including changing dressings, and failed to perform skin and wound assessments for 3 of 6 residents (R23, R32, R150) reviewed for pressure ulcers in the sample of 34. This failure caused R23 to develop an unstageable pressure sore on his left heel, that went unnoticed by the staff, with no Physician Orders or treatment. Findings include: 1. R23's Admission Record, undated, documents R23 was admitted to the facility on [DATE]. R23's Electronic Medical Record, documents R23's Diagnosis include: COPD (Chronic Obstructive Pulmonary Disease), Emphysema, Type 2 DM (Diabetes Mellitus), Cerebral Infarction, Lumbago with Sciatica, Gastrostomy, Convulsions, Major Depressive Disorder, Malignant Neoplasm of lung, ASHD (Atherosclerotic Heart Disease), Anemia, Adult Failure to Thrive, MI (Myocardial Infarction), HTN (Hypertension), Hyperlipidemia, and Malignant Neoplasm of Pelvic Bones, Sacrum, and Coccyx. R23's Care Plan, dated 6/5/23, documents, (R23) requires assist with daily care needs r/t, (related to), weakness from Lung Cancer, Sacral Cancer, Lumbago, and Emphysema. Interventions: Assist resident with ADLs, (Activities of Daily Living), Encourage/Assist with turning and repositioning every two hours and as needed, keep clean and dry after each incontinent episode, monitor skin integrity during routine care and report abnormal findings. It continues, (R23) has a self-care deficit in dressing and grooming r/t weakness/pain. It continues, (R23) is at risk for skin complications r/t dx, (diagnosis), of type 2 DM, protein-calorie malnutrition, malignant lung neoplasm. Interventions: Assess and document of progress of areas weekly, assist and encourage resident to turn and reposition every one to two hours and PRN, (as needed) Educate resident on MD, (Medical Doctor), orders for wound care, monitor area for s/s, (signs/symptoms), of infection: odor, drainage, color, size, Observe and assess regularly, Skin assessment weekly. It continues, (R23) is at risk for skin complications r/t dx of type 2 DM, protein-calorie malnutrition, malignant lung neoplasm. R23's Minimum Data Set (MDS), dated [DATE], documents R23 has a moderate cognitive impairment, with a BIMS (Basic Interview for Mental Status) of 11. R23 requires extensive assistance from one staff member for personal hygiene and dressing, total dependence of one staff member for toileting, and limited assistance from one to two staff members for all other ADLs. R23 is always incontinent of both bowel and bladder. R23's Braden Scale for Predicting Pressure Sore Risk, dated 6/2/23, documents R23 is a Moderate Risk for Pressure Sores, with a score of 14. A score of 15-18 is At Risk, 13-14 is Moderate Risk, 10-12 is High Risk, and 9 or below is Very High Risk. R23's Physician order, dated 11/25/22, and discontinued, on 3/24/23, documents, Left heel: Apply betadine and leave OTA. Prevlon boots when in bed, every day and evening shift for prophylaxis; Skin care. R23's Physician Order, dated 3/24/23, and discontinued on 4/19/23, documents, Betadine External Solution 10 %, Apply to Left heel topically every day and evening shift for wound Cleanse Left heel with NS, (Normal Saline), or WC, (Wound Cleanser), apply Betadine and leave OTA, (open to air), monitor for s/s of infection and notify MD if present. R23's Wound Evaluation and Management Summary, dated 4/11/23, documents, Wound of the left heel: Resolved on 4/11/23. R23's Progress Note, dated 4/19/23, documents, (V18) in facility to see resident on 4/18/23, area to LLE, (left lower extremity), resolved. R23's only Skin and Wound Assessment, dated 5/5/23, documents R23 had a wound to his left heel. The wound is slow to heal or stalled but stable, little/no deterioration. In-House Acquired. Size of wound: Area: 0.2 CM, (centimeters), X Length: 0.7 CM, X Width: 0.5 CM. There were no other weekly skin and wound assessments completed until 7/19/23, when (V10 Wound Nurse) was informed of the wound. R23's Physician Order, dated 6/7/23, documents, Weekly Skin Check, everyday shift, every Wednesday for skin integrity. On 7/17/23 at 9:12 AM, R23 was lying in bed and stated he doesn't get out of bed because his legs don't work. R23 stated he has a sore on his left heel. On 7/18/23 at 9:13 AM, R23's legs continued to be elevated with a pillow. No dressing or wound care was done. On 7/19/23 at 8:18 AM, R23's legs were seen elevated with a pillow. No dressing or wound care was done. On 7/19/23 at 10:05 AM, V10, Wound Nurse, stated, I don't know anything about (R23's) wounds. He was not on my list to see. The staff are supposed to do skin assessments and if a wound is found, they let me know and I get an order to treat it. I see that there are no skin assessments completed on (R23) in the computer. On 7/19/23 at 10:06 AM, V10, Wound Nurse, assessed R23's left heel, which showed a small wound that has not been treated or addressed. V10 stated, I will contact the Physician to get an order to treat the wound. At a minimum, we should be putting Betadine on it. On 7/19/23, V10, Wound Nurse, documented R23's Skin and Wound Assessment, Pressure Wound, Unstageable, Slough and/or eschar, In-House Acquired, Wound Size: Area 0.7 CM, Length 2.3 CM, Width 0.5 CM. R23's Nurses Note, dated 7/19/23 at 11:18 AM, documents, New orders to residents left heel to cleanse left heel, apply betadine BID, (twice a day), and PRN, monitor for s/s of infection and notify MD if present. POA, (Power of Attorney), and Physician notified. On 7/19/23 at 10:56 AM, V13, CNA, (Certified Nursing Assistant), stated, I check on my residents probably less than every two hours. I try to get in and turn them when I check on them. I do skin assessments when I do a shower/bath. I circle on the picture of a person if I find anything on their skin and will tell the nurse. On 7/19/23 at 10:42 AM, V2 DON (Director of Nursing), stated I would expect the staff to be turning and repositioning the residents at least every two hours. I would expect the staff to perform skin assessments weekly. The nurses need to do their own skin assessment each week and document it in the medical record. The CNAs need to be doing a skin assessment while giving the resident a shower or bath. 42108 2. R150's Care Plan, dated 7/19/2023, documents, skin: (R150) requires extensive assistance with the bed mobility is always incontinent, of bowel and has multiple stage 3 and 4 pressure injuries and several unstageable pressure injuries he was admitted with. He has diagnoses of Type 2 DM, MRSA (Methycillin-Resistant Staphylococcus Aureus) of wound, Peripheral vascular disease and morbid obesity with a BMI of 40. He often puts off getting his treatments done and needs much education as to not refuse treatment. R150's MDS, dated [DATE], documents R150 is cognitively intact. R150's Treatment Administration Record, dated 7/1/23 to 7/31/23, documents: 1. Start Date: 7/15/2023 6AM Ca (Calicium) Alginate everyday shift for wound cleanse wound to right inner thigh, left proximal and distal thigh with NS (normal saline) or WC (Wound cleanser), apply [NAME] and calcium alginate cover with a dry dressing daily. monitor for s/s of infection and notify md if present. 7/15, 7/16 were blank. 2. wet to dry dressing every day and evening shift for wound Cleanse right glute/hip wounds with NS or WC, pack with moistened gauze and cover with ABD (abdominal) pads and secure with tape BID (twice daily) and prn (as needed) when wound vac not in place awaiting supplies. Monitor for s/s of infection and notify md (medical doctor) if present. -Start Date- 07/15/2023 0600. 7/15 and 7/16 blank. On 7/17/2023 at 10:50 AM, V13, Certified Nursing Assistant (CNA), and V12, CNA, assisted R150 with incontinent care. During incontinent care, V13 and V12 assisted R150 over onto his left side, revealing a pressure ulcer to R150's back, with a large amount of dark brown foul-smelling drainage to R150's back and fitted sheet. R150's pressure ulcer did not have a dressing in place. R150's dressings to right leg were detached, and a large amount of foul-smelling brown, red drainage observed on R150's right hip and right buttocks. On 7/17/2023 at 11:00 AM, V4, LPN, stated there should be a dressing in place to the pressure ulcer on R150's back. On 7/17/2023 at 12:30 PM, V10, Wound Nurse, stated she works at this facility helping to train the new wound nurse. V10 stated she worked last Thursday and Friday, and did wounds. V14 stated when R150 came from the hospital he had an order for a wound vac. V14 stated the hospital did not send the correct supplies to perform the treatment. V14 stated the cord for the machine was correct, and the supplies were not enough to perform the treatment. She notified V18, Wound Doctor, and received orders for wet to dry dressings on the 14th until the supplies came in. V14 stated the supplies had not came in as of yet, but she was following up on it today. 32874 3. R32's care plan, dated 12/14/2021, documents has actual impairment to skin integrity related to fragile skin, cognitive deficits, history of falling and anemic. Intervention dated 12/14/2021 documents follow treatment protocols for treatment of injury. R32's MDS, dated [DATE], documents R32 requires extensive assistance and one plus physical assistance for bed mobility. R32's Physician Orders, dated 7/14/2023, documents, apply to Coccyx topically every day and evening shift for Wound Cleanse coccyx with NS or WC. Apply Silvadene, Ca Alginate, collagen and silicone foam bordered gauze bid and PRN. Betadine External Solution, (Povidone-Iodine), apply to affected areas topically every day and evening shift for wound Cleanse right glute, R heel, L heel, R hip with NS or WC, apply Betadine BID and prn, monitor for s/s of infection and notify md if present. On 7/17/2023 at 1:45PM, V10, Wound Nurse, stated R32 gets betadine to bilateral heel and right hip, and left open to air. V10 stated treatment to sacral area was calcium alginate, Silvadene, and collagen powder, and cover with border dressing. Prior to treatment, R32 had dressing present to right hip, and dressing to sacral wound, dated 7/15/2023. V10 removed dressings and treated wounds as ordered. Wound Nurse cleansed wounds and provided treatment. V10 stated, Since wound on right hip is now open, it will need a change in treatment. (R32's) treatments are to be done twice daily. Treatments are to be done as ordered by Physician. Wound to right hip was noted with layer of skin missing and bloody. Bilateral heel eschar, sacral wound stage 2, no drainage or foul odor. On 7/19/23 at 10:41AM, V2, Director of Nursing/DON, stated she would expect staff to provide treatments for wound as ordered. The Facility's Skin Management: Pressure Injury Treatment Policy, dated 9/2017, documents, Implement prevention protocol according to resident needs. Activity: turn at least every two hours, reposition in chair, provide appropriate pressure redistribution devices.

Based on observation, interview, and record review, the facility failed to meet the residents' need for assistance with personal care, bathing, showers, and oral care, and failed to ensure residents were provide an effective way to call for help for 5 of 7 (R23, R41, R45, R150, R151) residents reviewed for ADLs (Activities of Daily Living) in the sample of 34. This failure resulted in R151 feeling frightened and scared. Findings include: 1. R151's Admission Record, not dated, documents R151 was admitted on [DATE], and lists Type 2 Diabetes with diabetic Polyneuropathy, Hemiplegia, and Hemi paresis following Cerebral Infarction affecting Left Non-Dominant Side as diagnoses. R151's Interim Baseline Care Plan, effective date 7/12/23, documents, B. Falls, 3. Intervention Call light within reach. R151's Admission Observation, effective date 7/12/23, documents R151 is responding to environment, alert to person, place, and time. R151's Call light Ability Screen, effective date 7/12/2023, documents R151 is able to use the call light. On 7/18/2023 at 11:23 AM, R151 was sitting in a wheelchair at the foot of the bed. Call light was tied to the handrail at the head of the bed. R151 stated he could not reach his call light. R151 stated he is unable to use the call light system at the facility, and is unable to call for help. R151 stated he yells out at his roommate, and his roommate pulls the call light. R151 stated his hands are numb and that he can't feel anything with his hands. R151 stated, It is scary not being able to call for help. If my roommate is not in the room, I can't get help and I must wait. I am concerned and not sure what to. I don't want to get anyone in trouble, but I worry if I need help will anyone be there? That this is frightening. On 7/18/2023 at 11:28 AM, R13 stated he has to call for help for his roommate. R13 stated R151 tells him, and he pulls it. R13 stated his roommate needs help. 2. R150's Admission Record, not dated, documents R150 was admitted [DATE], and lists Methicillin Resistant Staphylococcus Aureus Infection, Diabetes Mellitus, Morbid (Severe) Obesity, Local infection of Skin, Open wound, Right Thigh, Elevated [NAME] blood Cell Count, Hypokalemia, Leg with Necrosis of the bone, Left Leg Above the Knee Absence as diagnoses. R150's MDS, dated [DATE], documents R150 is dependent for showers/bath. The facility's 24-hour Shift Report Form documents R150 is scheduled for a shower/Skin Checks on Monday and Thursday. R150's Electronic Health Records does not document R150 received or refused showers and or baths. On 7/17/2023 at 10:50 AM, R150 was lying in bed on his back. Multiple gnats were on R150's face and chest. A fly was on R150's chest and flying around R150. R150's hair was greasy, face with stubble, not shaven. R150 had a strong foul smelling body odor. R150 stated he is new to the facility, and has been there for about a week and a half. R150 stated he has not had a shower since being at the facility. R150 stated he knows he is big, and it may be a problem with him getting into the shower. R150 stated he doesn't get a bed bath either. R150 stated he would like a bath because he is large, and has multiple wounds that smell. R150 stated the staff come in and clean him when he has an accident. On 7/20/23 at 9:00 AM, V2 stated she was not aware of the residents not getting showers or baths. V2 stated she has a form the staff utilize with the shower dates listed. V2 stated when the staff complete the showers they document on the Skin Monitoring: Comprehensive, CNA Shower Review for showers and refusals, and place them in the shower binder. V2 stated the documentation for the showers given and refused would be in that binder. As of 7/20/23 at 1:00 PM, the facility was unable to provide documentation of R150's shower or bath, or refusals on 7/10/2023, and 7/13/2023. 44967 3. R23's Admission Record, undated, documents R23 was admitted to the facility on [DATE]. R23's Electronic Medical Record, documents R23's Diagnoses include: Chronic Obstructive Pulmonary Disorder, (COPD), Emphysema, Type 2 DM, (Diabetes Mellitus), Cerebral Infarction, Lumbago with Sciatica, Gastrostomy, Convulsions, Major Depressive Disorder, Malignant Neoplasm of lung, Atherosclerotic Heart Disease, (ASHD), Anemia, Adult Failure to Thrive, Myocardial Infarction, (MI), Hypertension, (HTN), Hyperlipidemia, and Malignant Neoplasm of Pelvic Bones, Sacrum, and Coccyx. R23's Care Plan, dated 6/5/23, documents, (R23) requires assist with daily care needs r/t, (related to), weakness from Lung Cancer, Sacral Cancer Lumbago and Emphysema. Interventions: Assist resident with ADLs, (Activities of Daily Living), encourage/Assist with turning and repositioning every two hours and as needed. Keep clean and dry after each incontinent episode, monitor skin integrity during routine care and report abnormal findings. It continues, (R23) has a self-care deficit in dressing and grooming r/t weakness/pain. It continues, (R23) is at risk for skin complications r/t dx, (diagnosis), of type 2 DM, protein-calorie malnutrition, malignant lung neoplasm. Interventions: Assess and document of progress of areas weekly, Assist and encourage resident to turn and reposition every one to two hours and PRN, (as needed), educate resident on MD, (Medical Doctor), orders for wound care, monitor area for s/s, (signs/symptoms), of infection: odor, drainage, color, size, observe and assess regularly, skin assessment weekly. It continues, (R23) is at risk for skin complications r/t dx of type 2 DM, protein-calorie malnutrition, malignant lung neoplasm. R23's MDS, dated [DATE], documents R23 has a moderate cognitive impairment, with a Basic Interview for Mental Status, (BIMS) of 11. R23 requires extensive assistance from one staff member for personal hygiene and dressing, total dependence of one staff member for toileting, and limited assistance from one to two staff members for all other ADLs. R23 is always incontinent of both bowel and bladder. R23's Skin Monitoring: Comprehensive CNA (Certified Nursing Assistant) Shower Review only documents one shower being done on 7/5/23. The Facility's Shower Schedule, undated, documents, R23 was scheduled for a shower/skin checks on Wednesday and Saturday Days. On 7/17/23 at 9:13 AM, R23 was lying in bed, appeared very unkempt with his hair messy, unshaven with long facial hair, and has a smell of body and/or urine odor. R23 stated, I haven't had a shower lately, it's been a long time ago. They don't give me a bed bath either. On 7/18/23 at 9:13 AM, R23 was lying in bed, remained with an unkempt appearance with body odor; facial hair had been cut, but he still had long facial hair stubbles. R23 stated, They shaved me with an electric shaver that did not do a very good job. I was not bathed yesterday, and have not been cleaned up today yet. On 7/19/23 at 8:18 AM, R23 was lying in bed with very messy hair with dry flakes seen in hair, remains unshaven, with body and/or urine odor. R23 stated, I have not been bathed or showered in a while. Can't remember the last time. On 7/19/23 at 10:56 AM, V13, CNA, stated, My residents get bathed when they are scheduled. I actually have residents come to me after my day off and ask me to give them a bath because they did not get theirs while I was off. On 7/19/23 at 2:15 PM, V31, CNA, stated, When we do a shower or bed bath, we are supposed to document it on the shower sheets, along with a skin assessment, and not anything with the skin on that sheet. 4. R41's Admission Record, undated, documents, R41 was admitted to the facility on [DATE]. R41's Electronic Medical Record, documents R41's Diagnoses include: Type 2 DM, Morbid Obesity, Fracture of fifth cervical vertebra, Displaced fracture of fourth vertebra, Compression fracture of thoracic vertebra, Central Cord Syndrome, Rhabdomyolysis, HTN, Major Depressive Disorder, Obstructive and Reflux Uropathy, and neuromuscular Dysfunction of bladder. R41's Care Plan, dated 5/8/23, documents, (R41) requires assist with daily care needs r/t recent fracture of the cervical and thoracic spine and requires the use of a cervical collar at all times. He receives PT, (physical therapy), and OT, (occupational therapy), therapy services and requires assistance with all ADLs. He has an indwelling catheter that the nursing staff/CNAs care for. Interventions: Assist resident with ADLs, Encourage/Assist with turning and repositioning every two hours and as needed. He prefers his call light cord be tied to the bed rail per his choice, (full body mechanical lift) with two assists for transfers. Keep clean and dry after each incontinent episode, monitor skin integrity during routine care, two person assist for transfers with a (full body mechanical lift). It continues, (R41) has a self-care deficit in bed mobility r/t decreased ability to position or reposition self in bed. Interventions: Position and reposition resident in bed for comfort, joint support and skin integrity. It continues, (R41) has a self-care deficit in dressing and grooming r/t cervical fx, (fracture). It continues, (R41) requires use of an indwelling catheter r/t neurogenic bladder from central cord syndrome and obstructive uropathy and is at risk for of infection. Intervention: Keep draining bag covered to promote privacy. It continues, (R41) is at risk for skin complications r/t being admitted with multiple open areas to the skin. He is to see our (wound company) wound specialist and has DX of Type 2 DM, morbid obesity, Fracture of 5th cervical vertebrae and thoracic vertebrae. He requires assistance with the transfers. Interventions: Low air loss mattress in place, assist and encourage resident to turn and reposition every one to two hours and PRN, ensure proper body alignment, resident education on risk of not turning and repositioning approximately every two hours. It continues, (R41) risk for skin complications r/t dx of type 2 DM, morbid obesity, fracture of 5th cervical vertebra and thoracic vertebra, requires assists with transfers and is non-compliant. Interventions: Assess and document of progress of areas weekly, Observe and assess regularly, protect elbows and heels if being exposed to friction, protect heels, skin assessment weekly. R41's MDS, dated [DATE], documents R41 is cognitively intact, with a BIMS of 14. R41 requires extensive assistance from one staff member for all ADLs. R41 has a urinary catheter in place, and is always incontinent of bowel. R41's Skin Monitoring: Comprehensive CNA Shower Review only documents one shower being done on 7/12/23. The Facility's Shower Schedule, undated, documents R41 is scheduled for a shower/skin checks on Wednesday and Saturday Evenings. On 7/17/23 at 9:26 AM, R41 was lying in bed, appeared unshaven, unkempt, with his hair messy. R41 stated he broke his neck and was basically paralyzed, but he can now use his arms, but his legs aren't working yet. R41 stated he gets maybe one shower a week, and gets incontinent care while in bed. On 7/18/23 at 9:16 AM, R41 was seen lying in his bed, and stated he has not been bathed or showered this week yet. On 7/19/23 at 8:25 AM, R41 was seen lying in his bed. R41 stated he gets a shower on Wednesdays, and should be getting one today. 5. R45's Admission Record, undated, documents, R45 was admitted to the facility on [DATE]. R45's Care Plan, dated 6/5/23, documents, (R45) requires assist with daily care needs r/t weakness from lung cancer, sacral cancer, lumbago and emphysema. Interventions: Assist resident with ADLs, encourage/Assist with turning and repositioning every two hours and as needed, keep clean and dry after each incontinent episode, monitor skin integrity during routine care and report abnormal findings, one person assist for transfers. It continues, (R45) has a self-care deficit in dressing and grooming r/t weakness/pain. R45's MDS, dated [DATE], documents R45 is cognitively intact with a BIMS of 14. R45 requires extensive assistance from one to two staff members for all ADLs. R45 is always incontinent of bladder and frequently incontinent of bowel. There was no Shower Sheet completed for R45, indicating that a shower or bath was given. The Facility's Shower Schedule, undated, documents R45 is scheduled for a shower/skin checks on Monday and Thursday Days. On 7/17/23 at 9:06 AM, R45 was lying in bed and appeared to have greasy, messy hair, with his mouth extremely dry, with dry flakes on his tongue and lips. R45's teeth appeared very brown and decaying. R45 stated he's been here around 20 days or so, and he does not get any showers. On 7/18/23 at 9:07 AM, R45 stated he was already cleaned up (incontinent care) this morning; still appeared unshaven, hospital gown on. R45's mouth appears to be very dry, with his lips dry and flaky, his tongue is still very dry. R45's teeth are dry with particles visible. R45 stated they do not do any oral care on him. On 7/18/23 at 11:35 AM, V14, LPN (Licensed Practical Nurse), was administering medications to R45 via g-tube, and when finished, V14 did not provide any oral care to R45 when his mouth was visibly dry and flaky. On 7/19/23 at 8:21 AM, R45 was lying in bed and appeared unkempt with messy hair, unshaven, and his mouth extremely dry with flakes on tongue, and particles on teeth. R45 stated it has been about two weeks since his last shower/bed bath. On 7/19/23 at 4:18 PM, V30, Regional Director of Operations, was advised of R45's dry and flaky mouth and tongue. V30 checked for herself and stated, He does have a very dry mouth. I will have someone do some oral care right away. V30 sent a staff member to swab R45's mouth and provide some gel for his lips. The Facility's Activities of Daily Living Policy, dated 9/2022, documents, A program of activities of daily living is provided to prevent disability and return or maintain residents at their maximal level of functioning based on their diagnosis. Procedure: A. Resident self-image is maintained, Resident is positioned at sink or bedside with all necessary equipment within reach, Privacy is provided for resident, Equipment and instruction for oral care are provided, showers or baths are scheduled, and assistance is provided when required.

Based on interview and record review, the facility failed to monitor and implement nutritional interventions to prevent weight loss for 1 of 3 residents (R2) reviewed for nutrition in the sample of 8. This failure resulted in R2 sustaining a 51-pound (lbs.) weight loss (24.51%) from 2/10/23 through 3/24/23. Findings include: R2's Face Sheet documents she was admitted to the facility on [DATE]. R2's Progress Note, dated 1/16/2023 at 4:35 PM, documents R2 was on contact isolation for being COVID positive. R2's Care Plan dated, 1/20/2023, Focus Area: (R2) is on a regular diet and is consuming 75-100% of all meals. She feeds herself with no difficulties. She is alert and verbal and is able to make her needs known. Current weight is 194 pounds. She has a diagnosis of SIADA, Hypertension, Diabetes type II, hyperlipidemia, constipation and carcinoma. R2's Care Plan Intervention addressing weight, dated 7/8/2022, documents, Monitor weight and report significate gain/loss to Medical Doctor and family. R2's Care Plan Intervention for Dietary, dated 7/8/2022, documents, Monitor labs as ordered and report results to the Physician. R2's Weight and Vitals Summary Report documented on 2/10/22, R2 weighed 208 pounds (lbs.). R2's Dietary Nutrition at Risk Form Initial visit, dated 2/10/2023 at 12:56 PM, documented Resident is triggering for weight gain. Recently COVID positive, 8/4/2022 203.5 pounds. 9/7/2022 196 pounds. Had a period of weight loss, now with gain. R2's Dietary Nutrition at Risk Form Initial visit, dated 2/24/2023 at 1:00 PM, documented Resident is triggering for weight gain, Recently COVID positive. 2/10/2023 208 had period of weight loss, now with gain. Continue Regular diet and weekly weight monitoring. Will follow. R2's Weight and Vitals Summary Report documented R2's weight on 3/2/2023 at 11:34 AM, was 169 pounds. This was 39 lbs. weight loss in one month or 18.75%. R2's Dietary Nutrition at Risk Form Initial visit, dated 3/3/2023 at 12:12 PM, Resident is triggering for weight gain, Recently COVID positive and started eating all meals in her room. Had period of weight loss, now with gain. Drinks up to 7 regular (soda)/day and doesn't want to get up. Plan to start encouraged to dining room with meals. Continue regular diet and weekly weight monitoring. Will follow. This form did not address R2's weight loss noted in the Weight and Vital Summary Report. R2's Dietary Nutrition at Risk Form Initial visit, dated 3/10/2023 at 11:48 AM, 169 pounds (will request re-weigh). Recently COVID positive and started eating all meals in her room. Drinks up to 7 regular (soda)/day and doesn't want to get up. Plan to start encouraged to dining room with meals. Continue regular diet and weekly weight monitoring. R2's Weight and Vitals Summary Report documented R2 continued to lose weight and on 3/14/2023 at 1:57 PM, R2's weight was documented as 168.2 pounds. R2's Dietary Nutrition at Risk Form Initial visit, dated 3/17/2023, 169 pounds. Recently COVID positive and started eating all meals in her room. Drinks up to 7 regular (soda)/day and doesn't want to get up. Plan to start encouraged to dining room with meals. History of diabetes. Did not find any recent blood glucose levels or A1C, Rec to obtain. Weight loss may be due to uncontrolled blood sugars. Will follow. R2's Weight and Vitals Summary Report dated 3/24/2023 at 2:30 PM, documented R2 weighed 157 pounds. This was 51 lbs., or 24.51% weight loss from 2/10/23 to 3/24/23. R2's Dietary Nutrition at Risk Form Initial visit, dated 3/24/2023, 157 pounds. Recently COVID positive and started eating all meals in her room. Drinks up to 7 regular (soda)/day and doesn't want to get up. Plan to start encouraged to dining room with meals. History of diabetes. Did not find any recent blood glucose levels or A1C, Record to obtain. Weight loss may be due to uncontrolled blood sugars. Will follow. R2's Progress Notes, dated 3/24/2023 at 11:23 AM, Late Entry: Note Text: Psychosocial Note SSD, (Social Service Director), Met with (R2) to discuss her decline in weight and overall health. She stated that she was not depressed however she missed her family and husband. She stated that her daughter comes to visit her all the time. SSD asked (R2) if she would like to get up, get dressed and come to activities, she stated no. (R2) is experiencing major isolation and depression symptoms. She has been refusing meals and activities. However, when trying to address her isolation and depression she denies both. SSD told her that we would follow up Monday to see if she is doing better. R2's Nurse's Notes, dated 3/24/2023 at 1:14 PM, documents, Resident has refused meals throughout shift today. Resident refused breakfast and lunch. DON and SS, (Director of Nursing and Social Service Director), aware. Resident continues to feel nauseated. Informed resident she should try to eat, education provided when refusing meals. R2's Note does not document the Dietician or family member was contacted regarding R2 refusing meals. R2's Nurse's Notes, dated 3/24/2023 at 2:13 PM, Late Entry: Note Text NP aware of refusal of meals and medication. New Order for CBC (Complete Blood Count), UA (urinalysis) C/S (culture and sensitivity) and Psych referral. R2's Nurse's Notes, dated 3/27/2023 at 11:54 AM, documented Weight Warning, Value 157.0 pounds. -5% change over 30 days; -10.0% change over 180 days, RD, MD, resident/family aware. R2's Nurse's Notes, dated 3/27/2023 at 2:11 PM, documents, (R2) refused all meals and most medications throughout shift. (R2) was educated on the importance of eating and taking her medication. Resident continues to refuse. R2's Nurse's Notes does not document the Doctor of the family was contacted regarding R2 refusing to eat or take her medication. R2's Comprehensive Metabolic Panel Lab Report Collection Date of 3/27/2023 at 9:45 AM documented that R2's albumin level was 3.2 (normal 3.5-5.5 g/dl). R2's Nurse's Notes, dated 3/28/2023 at 6:28 AM, Resident went to (hospital) about 11:30 AM. Resident was admitted to hospital for UTI, (urinary tract infection), and N/V, (Nausea and vomiting). R2's Nurse's Note, dated 3/30/23, documented R2 was readmitted to the facility with diagnoses of Pyelonephritis. R2's Dietary Nutrition at Risk Form Initial visit, dated 3/31/2023 at 1:35 PM, Recently COVID positive and started eating all meals in her room. hospitalized last week 2/2 (secondary to) UTI, (urinary tract infection), N/V (nausea/vomiting). PICC (peripherally inserted central catheter) and antibiotics, refusing meals and medication. NP, (Nurse Practitioner), aware, will add sugar free health shakes with meals. Continue to encourage by mouth intake. R2's Care Plan was not updated after January 2023 and does not reflect her refusing meals, or weight loss. R2's April 2023 Physician Order Sheet (POS) documents diagnoses of dementia, type 2 diabetes mellitus without complications, hypertension and schizophrenia, psychotic disturbance, mood disturbance and anxiety, and acute kidney failure. R2's POS documents she is on a regular texture diet, thin liquids consistency, and sugar free health shakes three times day; Blood glucose per finger stick as needed for signs/symptoms if hyperglycemia/hypoglycemia. The POS also documents R2 has an order for Glucophage tablet 1000 milligrams (MG), give 1 tablet by mouth two times a day related to type 2 diabetes mellitus without complications; Sitagliptin phosphate tablet 100 mg, give 1 tablet one a day for diabetes; and Trulicity Solution Pen Injector .75 MG/0.5 ML (dulaglutide) inject 1 applicatorful subcutaneously one time a day every Monday related to type 2 diabetes mellitus without complications. No other Dietary Nutrition at Risk Form was provided by the facility after 3/31/2023. R2 left the faciity on [DATE]. No Dietary Forms were found. On 7/6/2023 at 2:34 PM, V17, Corporate Traveling Nurse stated, These are all of the Dietary Notes we have on (R2). I know we were in the middle of replacing our former Dietician (V17), but I will have to get back to you. R2's Nurse's Note dated 4/16/23 documented R2 was sent to hopsital for change of condition. On 6/30/2023 at 3:35 PM, V2, Director of Nursing, (DON), stated, I have only been the DON here since February. (R2) was independent and was able to transfer herself without staff assistance from her wheelchair to the bathroom. I know she was confused at times. We would tell her to call for assistance, but she did not always do that, and she wanted to be independent, but she got so sick back in April. She was going in out of the hospitals, and she was declining in her health, and losing weight. (R2) was not eating, and not wanting to come out of her room before she went out to the hospital. On 7/11/2023 at 9:43 PM, V22, Licensed Practical Nurse, (LPN), stated, I remember (R2). She was a patient here for a long time. She stopped eating and refusing her medication. Back in April, she was in out of the hospital. I remember sending her out at least three times. On 7/8/2023 at 12:00 PM, V20, Dietician, stated, I was going into the facility every Friday once a week. The facility would provide me a list of residents with their weights. I would review resident's weights and make recommendations. I would look at what they provided and make my recommendations. If the residents' weight was not on the sheet, then I was not aware of any weight loss. I did not become aware of (R2's) weight loss until 3/10/2023. At that time, I went from four buildings to eight buildings, and that facility we were having issues with the scale. We had discussed this at a meeting, and the facility had then made a charge nurse responsible for the weights and they were going to have one person in charge of getting the weights. As far as I know, they were fixing the scale as well. When I saw (R2's) weight loss, I asked for the facility to reweigh her, which I was not provided until the following week. I saw that (R2) had a diagnosis of diabetes and they told me she was drinking 7 (soda brand) a day, and I was concerned about her sugar levels, but there were no labs for me to review and I was concerned, and I was pushing for her labs to get try to get a better understanding of what was going on. I did not see any labs before 3/27/2023. Normally, when a resident is taking oral diabetic medication, our labs are drawn every 3 months. Then at that time, (R2) was sent out to the hospital and I know her labs were off. The Weight Change Policy, with a review date of 9/2022, documents, It is the policy of this facility to monitor the nutritional status of all residents, including all significant or trending patterns of weight change.

Based on interview and record review, the facility failed to provide supervision to prevent elopement for 1 of 9 residents (R3) reviewed for supervision to prevent accidents in the sample of 15. This failure resulted in an Immediate Jeopardy when R3 exited the facility twice, once found standing next to a busy roadway in the rain, and once found ambulating around a nearby neighborhood. This failure has the potential to not only affect R3, but R2, R4, R7, R8, R9, R10, R11, and R12, who have been identified as a high risk for elopement by the facility. The Immediate Jeopardy began on 3/24/23 at 6:50 PM, when R3 eloped from the facility, and was found out in the rain by a busy street. The staff was unaware of R3's had exited the facility, and failed to check on the door alarm. Again on 4/18/23 between 7:00 PM and 7:15 PM, R3 eloped from the facility and was found in a nearby neighborhood, with the staff unaware of R3's exit. The staff reset the door alarm without investigating the outside perimeter. R3 was brought back to the facility by persons who lived in the nearby neighborhood around 7:45 PM. V1, Administrator, V2, Director of Nursing, and V3, Regional Clinical Nurse ,were notified of Immediate Jeopardy on 5/3/23 at 4:04 PM. The surveyor confirmed by record review and interview the Immediate Jeopardy was removed on 5/4/23 but noncompliance remains at Level Two because additional time is needed to evaluate the implement and effectiveness of the in-service training. Findings include: 1. R3's Admission Record, undated, documents R3 was admitted to the facility on [DATE]. R3's Electronic Medical Record, documents R3's diagnoses include Alzheimer's Disease, Dementia, Anxiety Disorder, Major Depressive Disorder, Multiple Sclerosis, and Asthma. R3's Minimum Data Set (MDS), dated [DATE], documents R3 has a severe cognitive impairment and requires Supervision to Limited Assistance from one staff member for all her Activities of Daily Living (ADLs) including ambulation. R3's Care Plan Focus, dated 2/24/23, documented R3 is at risk for falls due to her cognitive deficit, history of falls, and poor balance. R3's Care Plan, updated 3/17/23, documents, (R3) is at high risk for elopement r/t (related to) exit seeking behavior. The Care Plan Interventions to address this focused problems documented with the initiation dates are as follows: 3/17/23 Allow concerns to be expressed, monitor whereabouts as needed or PRN (as needed) when she is compliant; 3/17/23 Praise resident when cooperative; 3/24/23 When wandering increases, redirect into common areas, encourage reminiscing with resident; 4/18/23 MD (Medical Doctor) notification PRN; 4/18/2023 enhanced supervision; and 4/19/23 Enhanced Supervision with 1:1. R3's Care Plan focused area, dated 3/17/23, documents, (R3) Demonstrates significant mood distress/depression related to wanting to leave facility. The Interventions to address this focus problem were as follows with the following initiation dates: 3/17/23, Communicate care, empathy, sensitivity, and compassion for the resident and what he/she is going through while educating the person on the stages of grief and loss, discuss factors that interfere with the above in counseling. It continues, (R3) is under the services of (Local Hospice) care due to a terminal diagnosis. It continues, (R3) is at high risk for falls r/t dx (diagnosis) of Alzheimer's, being unsteady on feet and forgetting to use wheelchair at times. Interventions: Monitor for changes in gait or ability to ambulate, keep bed in lowest position, floor mats while in bed, fall risk assessment quarterly and as needed, encourage resident to keep room free of obstacles/ clutter; 4/11/23: Attempt to redirect resident when near inaccessible areas. It continues, (R3) has a self-care deficit in ambulation r/t weakness. Interventions: 1. Explain procedure to (R3). 2. Apply gait belt. 3. Lock wheelchair brakes. 4. Assist to standing position. 5. Supervise (R3) to ambulate from room to dining room to meals three times a day. 6. Encourage to ambulate full distance. 7. Allow for periods of rest if needed or appears tired. 8. May pull w/c (wheelchair) behind for safety. 8. Praise all efforts. R3's Elopement Evaluation, dated 2/22/23, documents R3 has a No Risk for Elopement. R3's Nurse's Note, dated 3/13/23 at 1:45 PM, documents Administrator: Resident very confused. Making multiple attempts to exit building. Staff are remaining 1:1 with resident. Calls made to family to update them about resident exit seeking and becoming angry and aggressive. Daughter states that she is notable to return until Wednesday and she does not think that it is a good idea for her mom to call and talk to her husband. Resident attempted to pull the fire box off the wall. she pinched Admin hand. Unable to redirect resident. Resident safety is priority. R3's Nurse's Note, dated 3/13/23 at 2:48 PM, documents, Resident had increased behaviors this shift, resident was trying to escape building, pull fire alarm, and was sticking her nails into staff skin, hospice, notified with N.O. (new order) for Zyprexa 5 MG (milligram) BID (twice a day) and 5 MG daily PRN mid-day. R3's Nurse's Note, dated 3/16/23 at 9:08 PM, documents, Resident has been up all shift, not easily to redirect. She is currently in bed, resting, call light in reach. R3's Nurse's Note, dated 3/18/23 at 9:26 PM, documents, Resident continues with (Local Hospice), alert with confusion. Resident requiring redirection and 1 to 1 care most of evening. Medication compliant with no other issues, resting in bed with call light in reach. R3's Nurse's Note, dated 3/24/23 at 9:58 PM, documents, Around 6:50 PM resident escaped out back door on 200-hall with her wheelchair and a diaper on her head in the rain. Retrieved resident and brought her back in facility. No injuries noted. Notified administrator. On 5/2/23 at 7:45 PM, V7, Certified Nurse's Aide (CNA), stated, I was here when (R3) eloped on 3/24/23 around 6:40 PM. I was at the front door because my fiance brought me a delivery, it was raining so we were standing at the front door waiting for it to lighten up, when I happened to look outside and saw (R3) standing at the street corner holding her wheelchair and a clean (incontinence brief) on top of her head to keep the rain off her. I grabbed the Nurse that night and we ran out and got her back in. When I got back inside, I was hearing the door alarm still going off, and no one had checked it. I think we were short staffed that night. The next morning, I told the DON who said she knew nothing about it. Nobody even asked me anything else about it. I know everyone knew about it because people were laughing at the fact that she had a (incontinence brief) on her head. R3's Nurse's Note, dated 3/24/23 at 9:59 PM, documents, Resident remains on (Local Hospice). She went to bed before 8:00 PM and did not take her evening medicine. Will give if she wakes up. She is exit seeking and needs constant observation. There were no documented changes to R3's Care Plan until 3/17/23, with R3 having exit seeking behaviors documented on 3/13/23 and 3/16/23. There was no elopement risk assessment completed after R3's multiple attempts to exit, until R3 eloped from the facility on 3/24/23. R3's Elopement Evaluation, dated 3/24/23, documents R3 as a High Risk for elopement, although there is documentation in R3's Nurse's Notes, dated 3/13/23, that she was exit seeking. R3's Nurse's Note, dated 4/11/23 at 6:16 PM, documents, At around 5:35 PM, resident was pushing her wheelchair into the kitchen and fell just inside the door. ROM (Range of Motion) X four WNL (within normal limit), eyes PERRLA (Pupils Equal Round Reactive Light and Accommodation). She states her right hand and fingers hurt, but she has arthritis also. She is confused and wanders constantly. Notified NP (Nurse Practitioner), who ordered X-ray of right hand and fingers. X-ray order put in. Notified her family member. R3's Nurse's Note, dated 4/15/23 at 2:01 AM, documents, Resident remains on (Local Hospice). Resident was up walking earlier in shift going in and out of other rooms and trying to take their stuff and trying to exit out the front door. Finally settled down and went to bed. Call light within reach. R3's Nurse's Note, dated 4/16/23 at 10:03 PM, documents, Resident remains on (Local Hospice). She is up and down all shift, wandering about the facility. She is exit seeking and needs to be watched. R3's Nurse's Note, dated 4/17/23 at 00:16 AM, documents, Resident continues on (Local Hospice). Up walking the halls. No complaints or concerns at this time. R3's Nurse's Note, dated 4/17/23 at 11:46 AM, documents, Resident continues hospice care. Hospice nurses in facility today to see resident. No new orders received at this time. Resident continues to be non-compliant with ambulation status and is encouraged to ambulate with assistance. Resident denies pain or discomfort at this time. pleasant and cooperative with staff and care. Will continue to monitor. R3's Nurse's Note, dated 4/18/23 at 6:58 PM, documents, Resident wanders around facility. Redirection and reassurance is given. Hospice care continues. Frequent contact for ensured patient safety. There is no further documentation in R3's Nurse's Notes that identified R3 eloped from the facility on 4/18/23. The Facility's Incident Report, dated 4/18/23, documents, Nursing Description: Resident exiting facility unauthorized. Resident wearing long sleeve sweater, blue jeans, and pink slippers. Outside temperature was approximately 63 degrees and dry. Resident Description: I went for a walk, no I didn't, I was with the people that help me. Immediate Action Taken: Resident assessment: skin, pain, and psychosocial completed. MD and family notified. Initiating enhanced supervision. This Incident Report did not document where R3 was found, who found R3, and at what time she was found. V6's, Registered Nurse/RN, written statement, dated 4/18/23, documented, I heard an alarm go off. I stood up from my seat to further hear where the sound was coming. I noticed 2 CNAs on 200 side of the building and asked them to check the door and reset the alarm. This was around 19:15. I heard the alarm shortly after, and again request the CNAs on my hall to check and reset the alarm. I also requested them to make sure the door wasn't ajar. Around 19:45 PM, a couple arrived @ (at the front door. They were escorting (R3). The couple stated 'We found her sitting in our car. She was talking to our friend in front of our mom's condo.' On 5/2/23 at 7:10 PM, V6 stated, I was here when (R3) eloped. I had two CNAs working on that hall that night. One CNA was sitting in a chair in the hall and the other was with a resident at that time. (R3) wandered around a lot so we made her a one-on-one. The staff were all aware to keep an eye on her. At around 7:15 PM on 4/18/23, I heard a door alarm going off, both CNAs were on the hall, so I figured they had it under control. I had to yell down the hall for them to check the door. One CNA reset the code. Then the door alarm went off again and I asked them if they pulled the door shut, so they did and reset the alarm again. I don't know how they didn't see (R3), or hear the alarm if they were down the hall. I was relying on the CNAs to keep an eye on her. Nobody knew that (R3) was gone until around 7:45 PM, when a couple showed up at the front door with (R3) and stated that (R3) was at their condo. (R3) had on jeans, a long sleeve sweater, and pink slippers. (R3) had the remote to her television in one hand and her roommates lunch slip in the other hand. I think that is how the couple knew she came from here. No one, including myself, went outside to do a perimeter check to look for a resident until the managers showed up. Then we all did a resident check. The CNAs are always on their phone with earbuds in, so that may be the reason they didn't hear the alarm. I feel like we had enough staff that night, however, the staff that were here were not doing their jobs, and no one is holding them responsible. I do know that the one-on-one for (R3) is happening 24 hours a day now, including nights. (R3) always walks around the facility, and I know that she got out about two to three weeks ago (3/24/23) while it was raining, and staff went out and brought her back in. V23's, CNA, written statement, undated, documented, I was working 2:30-10 PM shift, where resident, (R3) got out the building. She was not assigned to my group, but eyes were kept on her until around 7p. During that time, I was assisting my residents to bathroom and to bed when this incident occurred. V25's, CNA, written statement, dated 4/18/23, documents, I (V25) was on 100 hall putting resident to bed. So, I was in their rooms when the alarm was going off. I couldn't hear because their TV is always on, and you cannot hear the alarm. So I was doing my job. (R3) is a fast lady she gets around she is to [sic] much to handle when you have a group to do she need to be a 1 on 1, but I am sorry for what happened but I am glad she is ok and made if back safe. V24's, CNA, written statement, dated 4/18/23, documents, I was helping another CNA put a resident to bed. I heard the alarm go off constantly so after I was done helping I went to put the code in and turned it off. As I was into another resident's room, the alarm went off again, I did the same think and turned it off but this time, I pulled the door all the way up. I also went out the same door going for my break but I never seen a resident outside. V26's, RN, written stated, dated 4/18/23, documents I (V26), was working on April 18, 2023 when resident (R3) eloped. I took my break after I finished my first med pass and documentation at approximately 1900. I finished my break and came back inside approximately 1915 through the front door. As I walked in, I got to the nurses' station and a CNA asked 'Where's the alarm coming from?' It sounded like two alarms were going off. I checked the front door and found I had not latched the door all the way so I looked outside for anyone, didn't see anyone outside and closed the door fully and reset the alarm. I walked back to my assigned hall (100) after hearing the staff members on 200 were addressing a door alarm at the end of that hallway. I began my med pass, checking that all my resident were present and accounted for they were. I continued with my med pass. At approximately 1945, I was notified that there was an elopement on the 200 hall. Resident, (R3) was brought to the nurses' station to being enhanced monitoring. On 5/2/23, V4, Neighbor, at 11:02 AM, stated, I live in the subdivision next to the nursing home, and I have a Ring camera that points toward the nursing home. V4 stated, When I looked at it, I saw a little old lady walking around by herself. Then approximately thirty minutes later, I saw some residents from the subdivision walking her back to the nursing home. I couldn't see where exactly she went or how far she got, but I did see them walking her back. I called the nursing home after I saw the video, and no one answered the phone. I called the nursing home hotline, which is what the answering machine said to do. V4 stated she was concerned as this is a busy road if she would have gotten out on the main road, she could have been killed. On 5/2/23 at 1:30 PM, V5, Certified Nursing Assistant (CNA), stated, I was here when (R3) got out. We all heard alarms going off, but couldn't figure out where they were coming from. I first went to the 300-hall, but that wasn't it, so by time I got to the 200-hall, the CNA who was working that hall shut off the alarm, but then it came back on. I think the door was not closed all the way. I used the restroom, and when I got out, they told me that (R3) got out and then some people brought her back. The Maintenance man is the one who told me that he watched the facility's video from the camera in the hall, and it looked like (R3) had punched in some numbers on the keypad and pushed the door open. She may have thought she was putting in the correct code and went on out. There was not a room to room search for residents until the management team arrived. I was told that (R3) had on her slippers but not sure about a coat or anything else. On 5/2/23 at 3:32 PM, V2, Director of Nursing (DON), stated, I was called in that night, and I know when I got here, we did a room-to-room search of all residents. I cannot say if it was done prior to my arrival. On 5/2/23 at 3:50 PM, V5, CNA, stated, (R3) went out the door at the end of her hall. The managers watched it on the camera and saw her enter a code and exited the door. They said (R3) must have watched a staff member enter the codes and either memorized it, or knew that the code would open the door, and when no one was around, she attempted to put the code in and then exited. All the big shots came in and investigated it. We all got in-serviced on elopements, and they changed all the combinations on every door. Now (R3) is a one-on-one for elopement risk. On 5/4/23 at 2:35 PM, V14, Maintenance Director, stated, I was called in on 4/18/23 after that lady (R3) got out. I checked all the doors, and that door (R3) went out seemed to be faulty. That door alarm worked when opened, but I believe the magnetic lock was faulty, and once the door closed, it would quit chirping. If the door didn't close all the way, the alarm would still sound. I have since fixed this issue. I check all the doors in the facility every day. I have nothing documented that I checked the doors prior to 4/18/23, but now I have a form to complete every day to document things like that. I started in April 2023 so cannot speak if drills were done prior to 4/18/23. I have been doing elopement drills just about every day. I did one on the evening (4/18/23) that lady got out and we have been doing them since. I can tell you that there is still a lot of work to be done yet. On 5/4/23 at 12:25 PM, V2 stated, I would expect all staff to respond to any door alarm and to follow the facility's policy on elopement. I would expect all staff to check the perimeter of the building, inside and out, if a door alarm goes off without visibly seeing a resident exit the building. On 5/3/23, the facility provided the following information which identified the residents who were at risk for elopement: -R2's Elopement Evaluation, dated 4/18/23, documented R2 was at high risk for elopement. -R4's Elopement Evaluations, dated 11/23/22 and 4/18/23, documented R4 was at high risk for elopement. -R7's Elopement Evaluation, dated 2/24 and 4/18/23, documented R7 was at high risk for elopement. -R8's Elopement Evaluation, dated 4/18 and 5/2/23, documented R8 was at high risk for elopement. -R9's Elopement Evaluation, dated 3/22 and 4/18/23, documented R9 was at high risk for elopement. -R10's elopement Evaluation, dated 3/1/23, documented R10 was at high risk for elopement. -R11's Elopement Evaluations, dated 4/18 and 5/2/23, documented R11 was at high risk for elopement. -R12's Elopement Evaluation, dated 12/19/22, documented R12 was at high risk for elopement. The Facility's Elopement Policy, dated 4/2023, documents Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. This does not include alert and oriented residents who handle themselves outside the facility and choose to leave the facility, even if against medical advice and sometimes, common on sense. While presenting different care challenges, these alert residents are not in the same category of potential danger as the residents with impaired cognition trying to leave the facility, and their absences from the facility are not considered to be an elopement. Residents who are at risk to elope are closely supervised to keep them safe in their environment, while allowing them to move freely about the safe environment. 1. Any resident identified as an elopement risk will have pictures available, one kept at the reception desk and the others in a facility-designated area. 4. Residents at risk to elope will be closely monitored. 6. Access doors on some units are alarmed so that staff can secure the environment rather than the resident and can intercede when a resident wants to leave the unit or safe area. When possible, staff is advised to walk with the resident off the unit or area, rather than restrict him from leaving. 7. All staff are responsible for responding to a door/elevator alarm immediately. This response will include visual check on the immediate vicinity surrounding the door/elevator that tripped the alarm, including the stairwells and outside area. 11. If someone identified at risk to elope is discovered missing from the unit, the Resident Elopement Plan is followed. The Facility's Elopement Policy, updated 5/2023, documents Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. This does not include alert and oriented residents who handle themselves outside the facility and choose to leave the facility, even if against medical advice and sometimes, common sense. While presenting different care challenges, these alert residents are not in the same category of potential danger as the residents with impaired cognition trying to leave the facility, and their absences from the facility are not considered to be an elopement. Procedure: 1. Upon admission, designated facility staff will complete the elopement observation. 2. Any resident identified at risk to elope will be reviewed every 90 days or with significant change in condition. 3. If a resident not determined to be a risk for elopement, and at a later date develops elopement behaviors, then the resident will be reviewed at the time and then quarterly until they are no longer an elopement risk. General: Residents who are at high risk to elope are placed on enhanced supervision to keep them safe in their environment, while allowing them to move freely about the safe environment. Guideline: 1. Any resident identified as an elopement risk will have pictures available, one kept at the Reception Desk and the others in a facility-designated area. 2. Any resident identified at risk to elope upon admission will have the Elopement Risk identified and included in the Interim Plan of Care. A comprehensive elopement prevention plan of care will be developed at the first care plan meeting. The plan will be reviewed at least every 90 days or more often if necessary. 3. There will be a Master List of all residents at risk to elope. The Social Service Department or designated staff will update the list as additional residents are determined to be at risk to elope and it will be reviewed weekly. The list will be available at the nurses' stations and reception area. 4. Residents at risk to elope will be closely monitored. 5. The Activity and Nursing staff together provide a variety of programs and items designed to help redirect residents into safe areas. 6. Access doors on some units are alarmed so that staff can secure the environment rather than the resident and can intercede when a resident wants to leave the unit or safe area. When possible, staff is advised to walk with the resident off the unit or area, rather than restrict him from leaving. 7. All facility staff are responsible for responding to a door alarm immediately. This response will include visual check of the immediate vicinity surrounding the door that tripped the alarm, including the stairwells and outside area. 8. If a cause for the alarm sounding cannot be immediately determined, a head count on all residents is completed utilizing a resident roster. 9. If the cause of the alarm is the resident attempting to leave the unit, the following measures will be taken: a. Resident will be redirected to the unit b. Additional monitoring of the resident as determined by the IDT. c. Update care plan as appropriate. The facility took the following actions to remove the Immediacy: A. Identification of Residents Affected or Likely to be Affected: 1. R3 was assessed on 3/24/2023 and on 4/18/2023 by V3, RN, Regional Nurse Consultant, and on 5/3/2023 by V2, RN, DON. Resident remains in facility with implementation of enhanced supervision on 4/18/2023. 2. All residents were assessed for elopement risk by V27, LPN (Licensed Practical Nurse), Wound/IP Nurse ,and reassessed by V19, SSD (Social Service Director), V37, RN/MDS (Minimum Data Set) coordinator, and V27 on 5/3/2023, to be ongoing for new residents will be assessed for elopement risk and residents with newly identified exit seeking behaviors will be reassessed for elopement risk. 3. Enhanced monitoring orders which include monitoring residents 1:1, every 15 minutes, every 30 minutes, every hour, or as otherwise determined by the IDT (Interdisciplinary Team)/physician were obtained by V3 for any residents identified to be at moderate or high risk for elopement on 4/18/2023, and to be ongoing for any newly identified exit seeking behavior and new admissions with identified exit seeking behavior. 4. Care plans were updated with interventions to address identified risks by V3 on 4/18/2023, and to be ongoing to include all new residents and as needed for newly identified exit seeking behaviors. B. Actions to Prevent Occurrence/Recurrence: 1. The corporate and leadership team V3, V28, Corporate, V29, Corporate, V30, Corporate, and V2 reviewed elopement policy and procedures on 4/18/2023, and revised elopement policy on 5/3/2023. Revisions made to tailor building specific needs such code color updated to yellow, removal of electronic monitoring devices, and response required when cause of alarm is not immediately identified including an immediate whole house head count. 2. The interdisciplinary team including V1/Administrator, V2, V19, V17 (Office Manager), V31, V27, V32, V33, V14, V34, V21 (medical records), V35, Admission Coordinator, and V12(CNA/Staffing Director) will provide training to all staff related to the above-mentioned policy to be completed on 4/18/2023 and 5/3/2023, to be ongoing for new hires and agency staff. 3. The training will also include providing supervision/monitoring to prevent elopements and recognizing when a resident exits the facility or has newly identified exit seeking behaviors to be ongoing to include new hires and agency staff. 4. All agency staff and new hires will be educated on the above policies prior to beginning their shift by V1, V2, and V12, to be ongoing. 5. Safety checks of all potential exits daily to ensure they are secure. This will be done by the maintenance supervisor, V14, to be ongoing. 6. V14 will conduct elopement drills at least three (3) times a month, at different shifts to ensure compliance to be ongoing. 7. The elopement drill will be evaluated by the Administrator, V1, and any identified concern will be addressed. Additional staff training will be completed on an ongoing basis. 8. An Ad-Hoc QAPI meeting will be held weekly for four (4) weeks by the QAPI team to discuss this removal plan and identify if additional interventions are necessary to be ongoing. 9. Monitoring/auditing of ongoing education of staff for elopement policy and procedures, daily safety checks of all potential exits, and elopement drills and ongoing assessments of new residents and residents with newly identified issues regarding elopement by V36, Sister facility's Administrator/Corporate, will continue for a minimum of three months to be ongoing and will part of the QAPI process. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 5/4/2023 On 5/4 and 5/8/23, the surveyors validated the removal of the abatement by observations of all exit doors to ensure they were in operating order and alarmed. The surveyors reviewed all in-services. The last day in-services were provided to staff were on 5/4/23, and were completed by V1. The surveyors reviewed the facility's policies and Code Yellow response list. Surveyors observed V22 doing walking rounds to ensure whereabouts of residents at risk for elopement and documenting these observations. The Enhanced Supervision Form monitoring tool was reviewed for all residents at risk for elopement and included times of observations. Surveyors reviewed care plans of those residents who have been identified at risk for elopement and verified they had been updated. Employees were interviewed to ensure that they were aware of current policies and procedures and had been in-serviced.

Based on interview and record review, the facility failed to assess and manage pain by ensuring pain medication was administered as prescribed for 1 of 3 residents (R3) reviewed for pain management in a sample of 9. This failure resulted in R3 experiencing uncontrolled pain that resulted in hospital visit, increased anxiety, increased behaviors, and feelings of helplessness. Findings include: R3's Care Plan, dated 1/17/2023, documents PAIN: (R3) has an alteration in comfort due to recent C6 (cervical spine) fracture due to trauma from an assault prior to coming to the facility. He receives pain medication as ordered. It continues Interventions: Administer pain meds (medication) and treatments as ordered. It also documents (R3) displays difficult behaviors when dealing with staff concerning med pass and housekeeping. It continues Intervention: Give medication as ordered. R3's Minimum Data Set, dated dated [DATE], documents R3 is cognitively intact. R3's Discharge Instructions from a (metropolitan) area hospital, dated 1/16/2023, documents R3 was in the hospital because: C6 Fracture, Trauma. Prescriptions/Home Medications: Medications to Continue with No Changes, Printed Prescriptions Tramadol (Tramadol 50 mg oral tablet) 1 tab(s) Oral Every six (6) hours as needed Pain - Moderate. Refills: 0. Patient instructions: Next dose due at 3 PM if needed. R3's Admission Assessment, dated 1/16/2023 at 3:45 PM, documents R3 was experiencing pain at time of assessment. R3's Physician Order Sheet, Active Orders as of : 2/9/2023, documents 1/16/2023 Tramadol HCl Tablet 50 MG *Controlled Drug Give 50 mg by mouth every 6 hours as needed (PRN) for pain take by mouth 50mg every 6 hours PRN. The facility Manifest, dated 1/17/2023, documents R3's Tramadol was delivered on 1/17/2023 at 5:44 PM. R3's Medication Administration Record, dated 1/1/2023-1/31/2023, documents 1/16/2023 3:23 PM, Tramadol HCl Tablet 50 MG by mouth every 6 hours as needed for pain take by mouth 50mg every 6 hours PRN. It continues R3 received the first dose of Tramadol on 1/18/2023 at 7:00 PM. It also documents, 1/16/2023 Monitor and document pain level every shift. It continues with 1/25/2023 at 10 PM, first documentation of a pain assessment. R3's Nurses Notes, dated 1/16/2023 at 3:50 PM, documents. Note Text: Resident is a [AGE] year old white male admitted to room (number) from (Regional Medical Center). Alert and oriented x 4. Vision and hearing is WNL (within normal limits). Does not wear glasses or hearing aide. Owns all teeth. Heart sounds regular and loud. Lung sounds clear bilaterally. No cough noted. Respiratory even and non labored. Bowel sounds positive in all four quadrants. Able to ambulate independently. Refused to let this nurse perform a skin assessment since resident is tired from transferring. States he would like to be left alone for a while so that he can be settled in. Has a service dog. Denies being in any pain other than his 'typical' spinal pain. admitted to SNF (skilled nursing facility) with a diagnosis of C6 fracture. Orders noted to wear his Miami J Collar at all times. Regular diet for food and drinks. VS (vital signs) WNl. Medication list only has order for Tramadol. This nurse called and spoke with (V11, Nurse Practitioner/NP). This nurse faxed pharmacy Tramadol script. Awaiting medication. Resident is in his room at this time. Oriented to call light. R3's Nurses Notes, dated 1/17/2023 at 12:51 PM, documents, Note Text: The resident asked the CNA (Certified Nursing Assistant) to inform the nurse that he wanted pain meds at 10 am. this nurse got in report he was given pain meds at 6 am this morning. the nurse called the pharmacy and verified his order for Tramadol 50 mg, we was informed that it was out for delivery and should arrive sometime today. The resident did not have any other (order) for pain meds. this nurse called the doctor and got an order for Tylenol. (V12, Physician) okay the order for every 6 hour prn. resident was not happy with this nurse. this nurse tried to explain to him what was going on he told me he did not want to hear what I had to say because he got what he wanted all day yesterday and I was holding his meds. this nurse went to get another staff member so he could talk to them about his issue. social service and (V13, Previous Director of Nursing/DON) notified. Resident also stated he will walk to the store to get meds if he has to. R3's Nurses Notes, dated 1/18/2023 at 9:53 AM, documents, Note Text: Resident c/o tingling down left arm, nausea, was sitting up on side of bed. Laid back down by self and called nurse, who checked V/S stable, requesting to go to hospital. R3's Local emergency room Record, dated 1/18/2023, documents [AGE] year old with C-6 fracture who presents with pain in left shoulder after not receiving consistent pain medicine the last several days. Differential includes exacerbation of pain secondary to healing fracture and to Aspen collar. It also documents R3 presented to the hospital due to left shoulder/arm pain. R3 states since arriving at the (Nursing Facility), he has been asking for meds, but have not received, and has had a flare and pain. He is wearing an Aspen Collar and states they do not seem to care. He is upset and can't stand the pain. He does not have any weakness. No symptoms of illness. It also documents, Pain Assessment: 0-10 Pain Score: 9 Pain Type: Acute pain. It continues to document that R3 received Medication Hydromorphone (DILAUDID) injection 1 mg, lidocaine (LIDODERM) 5 % patch 1 patch transdermal, and tramadoL tablet 100 mg oral. The After Visit Summary Visit report from (Local Hospital), dated 1/18/2023, documents Instructions: Continue to wear Aspen Collar, When patient request his p.r.n. meds please give them to him. Medications as prescribed. R3's Nurses Note, created date 1/19/2023 at 7:25 PM, documents Late Entry: 1/18/2023 at 2:45 PM Note Text: returned from (Local) ER (emergency room ) visit. no new orders noted. resident requesting Acet (Acetaminophen/ Tylenol) and Ibuprofen to be given in alternating doses every 3 hours. (V11) notified per Celo (secure messaging system for healthcare) of request. On 2/8/2023 at 10:15 AM, R3 stated he is having problems with his pain being under control, and that this has been going on since his admission to the facility. R3 stated when he was in the hospital, he was receiving Tylenol, ibuprofen, and Tramadol given at staggered times to help control his pain. R3 stated he would still have some pain, but it would be manageable. R3 stated he came to the facility with a prescription for Tramadol, gave it to the nurse, and told her his medication was given a certain way at the hospital, and he would like to continue it that way at the facility. R3 stated he spoke with the admitting nurse, and she told him his medication would be in that night. R3 stated he knew that it would take some time for him to be processed, and accepted the nurse's answer. R3 stated as long as he knew it would be there that night. R3 stated he went back later that night and asked for his pain medication because he was starting to feel more pain. R3 stated he was told again that his pain medication was not there, and they were waiting on his medication. R3 stated he asked multiple times during the night, and the medication was not there, and he did not receive anything for pain. R3 stated this continued the next day as well. R3 stated his pain was getting worse and worse. R3 stated he was told he did not have any pain medication ordered other than the Tramadol that was not there. R3 stated the nurse did get him some Tylenol, but by then the pain was horrible, and the Tylenol didn't touch the pain. R3 stated that he was in so much pain that his arms were getting numb and he felt tingling in his fingers. R3 stated he had asked and asked and asked for his medication and had not received it. R3 stated he has a broken neck and the pain was horrible. R3 stated he requested to go to the hospital to get some pain relief. R3 stated he can't get his pain medication properly to help manage his pain. R3 stated, It's horrible. R3 stated he was homeless prior to his injury, and doesn't know if that plays a part in this. R3 stated, It's not like it's medication that you can get high off. I just want my pain medication and not to be in pain. R3 stated his anxiety is through the roof because this is a daily battle, and he knows every day he will be in pain and have to fight to get his pain medication. R3 stated when you don't get the medication, then the pain is more and by the time they give it to you it doesn't do s***. R3 stated, I have to fight for myself. Because no one else will. I get angry and yell and curse the staff. It's the only way they will do something. It's Horrible. What do I have to do to get help? I went to the nurse, admission lady, head of the facility and nothing. I feel helpless. On 2/9/2022 at 2:10 PM, V17, Pharmacist, stated R3's script for Tramadol was received at the facility on 1/17/2023. R3 stated the medication was delivered to the facility on [DATE] at 5:44 PM. V17 stated the Cubex was accessed for him on 1/17/2023. V17 stated the (medication dispensing system) is a system in the facility that houses multiple medications that can be accessed by the facility if needed. V17 stated if the medication is in the (medication dispensing system), the nursing staff can use it. V17 stated with Tramadol, a prescription is required. V17 stated if the script is sent in to the pharmacy, then the pharmacy sends a code to the facility, and the medication can be accessed. On 2/9/2023 at 2:30 PM, V14, Licensed Practical Nurse (LPN), stated she admitted R3 to the facility. V14 stated she remembers him because he was young. V14 stated she was an agency employee, and this was her first time doing an admission at this facility. V14 stated R3 arrived at the facility later than she was originally told he would get there. V14 stated when R3 came in, he asked for time to allow him to get settled. V14 stated she was ok with that. V14 stated she worked a double that night, and is not sure when she got done with his orders, but that she did verify them and sent them to pharmacy. V14 stated later in the day, R3 did ask about his medication and if they were available for him. V14 stated she told him she had sent the script over to the pharmacy, and they should be in that night. V14 stated R3 seemed to be ok with that answer. V14 stated R3 did request his medication before she left the shift, and she was not able to give him any because it was not here. V14 stated they checked the emergency medication box, and there was not any Tramadol in there. V14 stated they had pulled the last one. V14 stated she has worked at the facility since, but has not been his nurse. On 2/9/2023 at 3:50 PM, V15, Registered Nurse (RN), stated depending what time the admission comes in, depends on how she does her admission process. V15 stated if the resident comes before the medication pass, then she has time put everything in and send to pharmacy. V15 stated you want to get it in as soon as you can so that the medication comes in that night. V15 stated the pharmacy is in Chicago, and if you get it in late, then the medication doesn't come in until the next day. V15 stated sometimes they get admissions that come in during the medication pass, and the medication pass has to be continued. V15 stated upon completion of the medication pass, then the medication is put in and sent to the pharmacy. V15 stated this causes the medication to come out the next day. V15 stated they use the (medication dispensing system) and if the medication is in there, they use it. V15 stated sometimes the dose ordered is different than what's available, or it may not be any there. On 2/14/2023 at 3:10 PM, V16, RN, stated there was a problem with R3's medication. V16 stated she was not sure of the exact reason, but that it did take some time for the medication to come in. V16 stated R3 is alert, able to voice his needs, and can walk independently. V16 stated R3 usually comes to the nurses station and ask for his medications. V16 stated she attempted to get R3 a Tramadol from the (medication dispensing system) on 1/17/203, because the medication was not here and was not able to. V16 stated the Tramadol was empty. V16 stated recently she came in, and was notified of R3 having a behavior and yelling and screaming at the staff. V16 stated she spoke with R3 about it, and was told he had been asking for his medication for 2 hours, and the nurse would not give it to him. V16 stated she checked, and R3 had not received the requested pain medication, and gave it to him. V16 stated R3 is alert, knows what's going on, and she has not experienced R3 to lie. On 2/15/2023 2:40 PM, V2, Director of Nursing, stated if a resident has an order for medication, she would expect the staff to give the medication. On 2/15/2023 at 2:40 PM, V10, Nurse Practitioner, stated R3 not receiving his pain medication caused him to experience an increase in pain. V10 stated this is significant because who wants to be in pain and wait until their pain is at certain level and ask for it and then wait to receive it? V10 stated she has seen R3 today and made some changes to his medication regimen to better manage his pain. V10 stated R3 is demanding and needs attention. V10 stated she has instructed the staff at the facility to give R3 his medication. V10 stated R3 was not under her care upon his admission to the facility. R3 stated R3 is under her care now, and she will be managing his pain from now on. V10 stated if R3 had an order for medication, she would expect that medication to be given. The Facility's Pain Manage Policy documents General: To facilitate and provide guidance on pain observations and management. To facilitate resident independence, promote resident comfort and preserve resident dignity. This will be accomplished through effective pain management program, independence, and enhance dignity and life involvement. Guideline: The pain management program is based on a facility-wide commitment to resident comfort. Pain is defined as whatever the experiencing person says it is and exists whenever he or she says it does. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Policy: 2. Pain will be assessed at least once every shift and documented in the EMAR (Electronic Medication Administration Record) using the pain scale appropriate for the patient.

Based on observation, interview, and record review, the facility failed to assist with feeding, monitor weights, and implement progressive interventions to prevent weight loss for 1 of 3 residents (R40) reviewed for weight loss in a sample of 26. This failure resulted in R40 having a significant weight loss of 10% in 1 month and 17 % in 3 months. Findings include: R40's Admission record, dated 09/29/2022, documented an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R40's Care plan, dated 06/23/2022, documented, Provide one-to-one staff intervention to promote proper nutritional intake. It continues, Offer between meal snacks & meal substitutions, as appropriate. Offer the resident a bedtime snack. R40's Minimum Data Set (MDS), dated [DATE], documented her cognition was moderately impaired, and she required limited assistance of 1 staff member for eating. R40's Dietary Evaluation, dated 08/30/2022, V18, Dietician, documented, 85 (year old) resident with significant weight loss June-August. The facility was unable to provide any further Dietary Evaluations prior to 08/30/2022. R40's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Diet (Mechanical)/SOFT texture, THIN LIQUIDS consistency, Health shake with all meals; May take meds whole one at a time in applesauce. It continued to document, , [MEDICATION(S)] Tablet 7.5 MG Give 1 tablet by mouth at bedtime for (weight) loss. On 9/27/2022 at 12:30 PM, R40 was served her lunch tray. A Certified Nursing Assistant (CNA) prepared it by opening containers and then walked away. R40 had a partitioned plate containing cooked cabbage, beef, bread and butter, and a health shake. On 9/27/22 at 12:45 PM, R40 fed herself approximately 2 bites of a sweet potato, and drank some of her health shake. V6, CNA, was sitting at the table, but was assisting 2 other residents. V8, Licensed Practical Nurse, (LPN) walked up, spoke to R40, but didn't provide and verbal cues or assistance. V8 then walked away and returned at 12:50 PM. At that time, V8 was standing up as she assisted R40 with a few bites and drinks, and then she walked away and assisted another resident. At 1:00 PM, R40 stated the sweet potato was really good. R40 consumed approximately 40% of it. Her bread was covering her cabbage, and no beef was consumed. R40's Weights and Vitals summary, dated 09/29/2022, documented on 6/10/2022, her weight was 140.0 pounds (LB) and on 07/01/2022, R40's weight was 125.7 LB. This was a 14.3 lb. weight loss, or a 10.1% weight loss. The summary documents on 8/11/2022, R40's weight was 117.5 LB. , a 17% weight loss in 3 months. R40's Care Plan was not revised with progressive interventions after her August 2022 weight loss. R40's Physicians Order Sheet, dated 9/27/2022, documented an order dated 9/26/2022, Admit to (local) Hospice. On 9/28/2022 at 12:15 PM, V2, Director of Nurses (DON) stated weekly weights should have been done starting on admission, and they should have weighed her (R40) on admission instead of 3 weeks later. V2 continued to state they used R40's hospitals discharge weight. On 9/28/2022 at 12:25 PM, V18, Dietician, stated R40 has had a significant weight loss, and she required assistance from staff to eat. On 9/28/2022 at 2:49 PM, V19, Registered Nurse, stated R40 requires staff to hand her food and encourage her to eat. The facility's policy, Activities of Daily Living, dated 01/2021, documented, C. Adaptive equipment, assistance and instruction are given as required. The facility's policy, Weight Change Policy, dated 09/2022, documented, 2. Upon identification of a newly significant weight change, complete NAR's weekly review tool. 3. Notify Dietician, physician and resident representative. 4. Dietician will review and provide recommendations.

Based on interview, observation, and record review, the facility failed to provide assistance, supervision, and implement progressive interventions to prevent falls for 2 of 6 residents (R38, R196) reviewed for falls in the sample of 26. This failure resulted in R38 falling and sustaining a laceration to the back of the head, requiring 5 staples. Findings include: 1. R38's Admission Profile, print date of 9/28/22, documents R38 was admitted on [DATE], and has diagnoses of: difficulty walking, unsteadiness on feet, repeated falls, Dementia, and [CONDITION(S)]. R38's Fall Risk Evaluations, dated 8/24/22, 8/27/22, 8/31/22 and 9/5/22, all document R38 is a high fall risk. R38's Minimum Data Set (MDS), dated [DATE], documents R38 is severely cognitively impaired and requires limited assistance of 2 staff members for bed mobility, extensive assistance of 2 staff members for transfer and toilet use, limited assistance of 1 staff member for walking in room and on the unit and extensive assistance of 1 staff member for locomotion in a wheelchair. This MDS also documents R38 is not steady and only able to stabilize with staff assistance. R38's MDS, dated [DATE], documents R38 is severely cognitively impaired, requires supervision and set up for bed mobility, limited assistance of one staff member for transfer, walking in room and on the unit, is totally dependent on one staff member for locomotion in a wheelchair. R38's Care Plan, revision date 9/26/22, documents, FALL: (R38) is at high risk for falls as evidenced by Cognitive deficits, Functional Deficits, History of Falls and [CONDITION(S)]. She takes [CONDITION(S)] medication which cause potential for adverse reactions. She also isn't able to communicate her basic needs at times. R38 had the following undated care plan interventions: Assess pattern for sleeping and encourage resident per patter/preference; Document s/sx (signs/symptoms) of adverse effects of medication on resident; Encourage appropriate use of Assistive Device; Encourage resident to keep room free of obstacles/clutter; Fall risk assessment quarterly and as needed; Keep frequently used items within reach; Monitor for any changes in condition; Orient resident to surrounding frequently, including location of bathroom, dining room, bedroom and activity locations; Promote placement of call light within reach and assess residents ability to use; Rounding at a minimum of q (every) 2 hours and prompt or assist for changing in position, toilet, offer fluids, and ensure resident is warm and dry. R38's Nurse's Note, dated 8/26/22 at 2:04 PM, documents, Resident several times today has attempted to stand up and walk- Sat down on floor next to nurses' station today- Stated, 'I wanted to sit down.' Then several moments later, resident was crawling out of bed while it was in lowest position. Mat/mattress to be placed for safety measures. Appetite was fair today. Requires assist with all ADLs (activities of daily living)- Incont (incontinent) of bowel and bladder. R38's Care Plan Intervention, dated 8/26/22, documents 8/26/22 Keep bed in lowest position. R38's Nurse's Note, dated 8/27/22 at 1:59 PM, documents, Called to dining room per family member- Resident had stood up out of wheelchair that was at table for resident lunch. She stood up, climbed over w/c (wheelchair), started ambulating towards kitchen. Resident then tried to sit on floor, bumping her head on a chair. Small knot felt with no injury. R38's Fall Investigation, dated 8/27/22, documents, Upon investigation, resident was witness by visitor, to stand from w/c in dining room, take a few steps away from table and fell to knees. RCA (Root Cause Analysis) - attempting to leave dining room. Staff to assist resident to dining room when meal service has begun and remove promptly to high traffic area at completion of resident meal. R38's Care Plan Intervention, dated 8/27/22, documents 1:30pm Take to Main dining room when meal service has begun and remove from dining room and place in a visible/high traffic area when meal is finished. R38's Fall Investigation, dated 8/27/22, documents, Investigation revealed resident attempted to get up from bed unassisted, resulting in fall. RCA- resident attempted to ambulate from bed. Was not responding to a toileting need. resident with advanced dementia, delusions and hallucinations. Staff to place pillow for support/ positioning on open side of bed to serve as boundary. R38's Care Plan Intervention, dated 8/27/22 documents 10:30PM - use pillows to help for support/positioning on the open side of bed when in bed. R38's Nurse's Note, dated 8/28/22 at 2:03 AM, documents, Resident found on floor by CNA (Certified Nurse Assistant) with resident self reporting she fell . VS (vital signs)- 97.0 (temperature)-60 (pulse)-18 (respirations)-135/68 (blood pressure) sats (oxygen saturation)- 97% on RA. 2 dime sized skin tears/abrasions sl (slight) bleeding noted to LFA (Left forearm) with a re-opened skin tear to L (left) elbow. Areas cleansed with wound cleaner and bandages applied. No complaints of pain. Neuro (neurological) check completed. Called son for resident and informed him of the incident and resident spoke to him for a while. Resident was assisted to bed. Call light in reach. R38's Social Service Note, dated 8/31/22 at 3:44 PM, documents, (R38) and I were playing BINGO and she stated that she needed to use the restroom, another CNA (Certified Nursing Assistant) took her to her room, she then refused to be toileted, and they brought her back to the nurse's station at that she was agitated and got up from her chair several times and refused redirection. I offered for her to come with me as a means to calm her down she agreed but then she became physically and verbally aggressive to the point I had to call her son. (V23, R38's son) came to the facility, she was still worked up but eventually calmed down. Myself and the (V2, Director of Nurses) explained to (V23) that since being admitted (R38) has been needing 1:1 supervision to keep her safe and that a locked dementia unit would be better suitable for her. He agreed and said that he was going to look into other facilities and let me know where to send a referral once a decision was made. R38's Nurse's Note, dated 8/31/22 at 9:32 PM, documents, CNA in room next to this resident. heard a loud 'thud'. noted that resident had fallen in bathroom. She immediately notified this nurse. This nurse went to resident's bathroom and noted that she was laying flat on her back with plate size diameter thick dk (dark) red clotty blood. resident alert and oriented to self. Resident stated 'I got dizzy and fell backward.' Placed towel under her head, then placed thick stack of 4X4s (with wound cleanser on them), to backside of head, then wrapped with kling. Careful to not move her head/neck, was log rolled slightly onto her right side. Other nurse called 911. Fire dept (department) arrived within a few minutes, sat resident up in sitting position, then resident immediately had yellow liquid emesis. Within a few more minutes the ambulance staff arrived and stood resident up, to ambulate her, to sit on stretcher. at 7:55 PM resident left per ambulance to go to (local) ER (emergency room ). R38's Fall Investigation, dated 8/31/22, documents, Upon investigation, resident attempted independent ambulation to bathroom. Staff to assist to bathroom before and after meals and at bedtime as resident will allow. therapy screen, restorative program for toileting, falling star program, mattress lowered to the floor with mat next to the open side of the bed. (R38) has a preference to be on the floor. R38's Nurse's Note, dated 8/31/22 at 10:35 PM, documents, Report received from (local) ER nurse; resident to return to facility, received 5 staples to back of head (left open to air), to monitor concussion. R38's Care Plan Interventions, dated 8/31/22 document Assist to toilet before and after meals and at bedtime as resident will allow. Therapy screen, restorative program for toileting, falling star program, mattress lowered to the floor with mat next to the open side of the bed. (R38) has a preference to be on the floor. R38's Nurse's Note, dated 9/3/22 at 1:37 PM, documents, Resident is up per wheelchair- Staples are intact to back of head. She is alert to herself only- No impulse control- High fall risk- She is with staff most of day for safety. Mattress on floor, mat near by also for safety. Neuro check was wnl (within normal limits). She requires hands on assist with all ADLs (activities of daily living). In high traffic areas. R38's Nurse's Note, dated 9/5/22 at 3:55 PM, documents, Resident sitting in w/c (wheel chair) near nurse desk. This nurse at nurse desk. Seen resident scoot to end of w/c seat and onto floor. No injury noted. Placed resident in a tilt back w/c. R38's Fall Investigation, dated 9/5/22, documents, Upon investigation, resident attempting independent ambulation, impulsive, lack of safety awareness. Resident positioned in reclining high back w/c for comfort. R38's Care Plan Intervention, dated 9/5/22, documents 3:30PM Placed resident in a wheelchair with a reclining back for comfort and positioning. R38's Nurse's Note, dated 9/5/22 at 4:45 PM, documents, Resident sitting in w/c (wheelchair) across from nurse desk. CNA sitting to the left of her in regular chair. Resident got up out of w/c and walked a few steps to the right, then fell on to the w/c scale. This nurse jumped up from the nurse desk when CNA said she was getting up; I did not get to her quick enough to stop the fall. assisted back into w/c. not injury noted at this time. spoke with D.O.N. (Director of Nurses) about assigning a sitter for the evening, she approved. R38's Fall Investigation, dated 9/5/22, documents, Upon investigation, resident with increased anxiety/ agitation. Repeated attempts to stand/ ambulate unassisted. Staff member placed 1:1 with resident until sx (symptoms) subsided. R38's Care Plan Intervention, dated 9/5/22, documents 4:30 PM charge nurse assigned a sitter to be with resident through this evening shift. R38's Nurse's Note, dated 9/5/22 at 7:25 PM, documents, Now has two small light purple areas to left mid rib cage area that is 4cm (centimeters) X 2cm and to left lower shoulder blade area that is 10cm X 3cm. denies pain at this time. no swelling or redness noted. On 9/26/22 at 10:35 AM, R38 was laying on a mattress on the floor next to the bed. On 9/26/22 at 12:30 AM, R38 is laying with her head on mattress on the floor and her legs are on the bed. R38's Care Plan Intervention, dated 09/26/2022, documents scoop mattress to minimize injury relating to resident rolling off the bed. On 9/27/2022 at 3:50 PM, R38 was sitting in her wheelchair at the nurse's station, unattended. R38 then stood up and with a wobbly gait, walked over to a resident, who was in a reclining geriatric chair, and grabbed onto his chair. She then turned and stumbled pass her empty wheelchair and tripping over the front wheels causing a wavering gait towards the nurse's station. She then grabbed onto the nurses' stations counter. R38 let go of the nurses' stations counter and walked towards the surveyor, with a very unsteady, wobbly gait. R38 then grabbed the surveyor's hands tightly and held on to the surveyor until staff came to assist her. There were no staff at the nurse's station or in the high traffic area. On 9/26/22 at 11:20 AM, V23 stated, She falls, and I guess this extra mat on the floor is so she doesn't get hurt. She crawls out of bed. I don't like the fact that she is on the floor. My dog sleeps on the floor. I don't want to see my mom on the floor, but she crawls out of bed, I guess. She fell in the bathroom not too long ago and split her head open she needed staples. I think they keep her at the nurse's station often. On 9/26/22 at 12:18 PM, V26, Registered Nurse (RN), stated, She wanders, and she falls. The mattress on the floor is in her care plan because she falls and crawls out of bed. On 9/28/22 at 2:48 PM, V19, RN, stated, (R38) is very impulsive and quick. She gets agitated and gets very combative. She will fall asleep in her wheelchair and then wake up after a few minutes and try to get up. You can put her to bed, and she will be asleep and the next thing you know she is in the hall walking using the handrails. She is very wobbly. You will see her, and you try to get to her quickly, but you can't run to her because you're afraid you will startle her. When she fell into the wheelchair scale the CNA was sitting right next to her. (R38) just got up that fast. The CNA tried to grab her, but she wasn't fast enough. The night that she fell in the bathroom, I am not sure what she was doing in there and I can't tell you when she was seen last, but she is so fast. She will be asleep and then she is awake trying to walk. We take turns looking after her. She doesn't have an assigned sitter most of the time. A CNA will watch her and then a nurse so we do the best we can but we have other things we need to do. I think the only thing that will keep her from falling is to have an assigned sitter just for her. On 9/28/22 at 9:45 AM, V2, Director of Nurses (DON), stated, We have been trying our best to keep her safe. The aides and the nurses will take turns watching her. We have tried to get family involvement so our staff can get a break. She really needs to be in a dementia unit, but the son was not real receptive to that. Realistically with the staffing crisis that we have today, I just don't have staff to dedicate just to her. V2 agrees R38 needs a 1 to 1 sitter to remain safe. The policy Fall Prevention and Management, dated 7/22, documents, General: This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. 2. R196's Care Plan, dated 9/27/2022, documents FALL: (R196) is at risk for falls related to cognitive deficits, Poor Balance and Visual Impairment. It also documents ADL: (R196) has ADL functional deficits due to corneal ulcer affecting her visual status, weakness from CHF and she requires extensive assistance with bed mobility, transfers, locomotion, toileting, personal hygiene and supervision with eating and limited assistance with the dressing ADL. She is currently on AROM (active range of motion), Bed mobility, dressing and grooming programs. She is currently receiving PT, OT (occupational therapy) and ST therapy services. She will improve bed mobility status by the next review date. It continues Monitor for changes with daily care abilities and provide more or less assist if needed. R196's Event Report, dated 9/26/2022 at 12:45 PM, documents R196 was found on the floor on her left side. C/o (complaining of) right side of cheek and right arm pain. R196's Nurse's Note, dated 9/26/2022 at 1:05 PM, documents Resident found lying on the right side of her body, along the side of the bed. Stated 'Yes' to hitting head, C/O right side of her cheek. C/O right arm hurting from fall but denies feeling like it is broken. ROM WNL (within normal limits) for resident's baseline. C/O left arm with ROM but states It's been that way, nothing new. Stated I fell out of bed, I was yelling for help, nobody came. Staff assisted her into sitting position, put gait belt on and 2 assisted her into wheelchair. Partial body assessment completed, more to be assessed after into bed. Will follow up with a note later. Only a couple of slightly red areas to right arm noted at this time. No noted call light on outside of resident's room. Vital signs being taken for follow up [NAME] checks. Socks on feet, no shoes, staff applied shoes before transfer. Bed in normal position. On 9/27/2022 from 11:30AM to 11:55 AM R196 was yelling out for help. R196's door to room was closed. No staff responded to R39 yelling. On 9/27/2022 from 12:00 PM to 12:20 PM R196 was yelling out for help. R196's door to room closed. No staff responded to R196 yelling. On 9/27/2022 from 12:30 PM to 12:40 PM R196 was yelling out for help. R196's door to room closed. No staff response. On 9/27/2022 at 12:50 PM, R196 observed on the floor. On 9/27/2022 at 12:55 PM R196 stated she tried to get up out of the bed. R196 stated she called for help, and no one came. On 9/28/2022 at 12:00 PM V2, DON, stated she would expect the staff to respond as soon as possible to a resident's yell for help.

Based on interview, observation, and record review, the facility failed to prevent the formation of pressure ulcers, failed to treat pressure ulcers as ordered by the physician and failed to provide pressure relief for residents with pressure ulcers for 2 of 2 residents (R39, R33) reviewed for pressure ulcers in the sample of 26. This failure has resulted in R39 developing an unstageable, pressure ulcer to the right knee. Findings include: 1. R39's Admission Record, documents R39 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R39's Care Plan, dated 6/28/22, documents (R39) has both potential for and actual impairment to skin integrity r/t (related to) fragile skin, combative behaviors and was admitted with a non-blanchable discoloration to the right hip area which was noted to be a Stage one pressure injury. He was seen by the wound specialist and he noted it was an unstageable pressure injury on 7/5/22. He requires extensive assistance with bed mobility and is always incontinent of his bowels and has an indwelling urethral catheter. Returned from the hospital on 8/25/22 with new left lateral ankle Unstageable DTI (deep tissue injury). It continues 9/27/2022 DTI to right inner knee. 9/27/2022 MASD (moisture associated [CONDITION(S)]) to coccyx. R39's Care Plan Interventions document 6/21/22- Treat right hip wound as per POS/TAR (physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R39's undated Care Plan Intervention documents (R39) needs staff to apply protective incontinent briefs and he wears (Pressure relieving) boots bilaterally to lower extremities when in bed. R39's September 2022 POS, documents 9/2022 Left lateral ankle: Apply [MEDICATION(S)] and calcium alginate. Cover with bordered dressing. every day shift for To Promote Wound Healing. It also documents 9/20/2022 Right hip: Apply [MEDICATION(S)] and leave OTA (open to air) every day and evening shift To Promote Wound Healing. It continues: Right inner knee: Apply [MEDICATION(S)] and leave OTA every day and evening shift for To Promote Wound Healing. R39's Skin and Wound Evaluation, dated 9/27/2022, documents New Facility Acquired Pressure Ulcer. Deep Tissue Injury: Persistent non-blanchable deep red, maroon or purple discoloration to right knee. On 9/26/22 at 7:40 AM, R39 was lying in bed on his left side in fetal position with his knees pressed together, no pressure relieving between his legs or knees. On 9/26/22 at 10:20 AM, V15, Registered Nurse (RN)/Wound Nurse, performed treatment to R39's pressure ulcers. R39 was lying in bed with pressure relieving boot on left foot and wedge between the outside of R39's left knee and the mattress. R39 had nothing between his legs and/or knees. R39's knees were pressing together, skin on skin. V15 removed the old dressing, dated 9/25/2022, from R39's right hip. The dressing contained a border dressing and calcium alginate. The dressing had a dark brown drainage to the dressing with a foul odor present. V15 then performed the treatment to the wound, leaving the wound open to air. V15 did not clean the wound bed prior to performing treatment. V15 then removed the old dressing to R39's left ankle, dated 9/24/2022. V15 then applied performed treatment and applied [MEDICATION(S)], calcium alginate and border dressing. V15 did not clean the wound. On 9/27/2022 at 1:50 PM, when asked what is the plan for R39's wounds, V22, Wound Doctor, stated, The facility needs to stop using the wrong treatment. V22 stated he has put new orders in place today. V22 stated he would expect the nurses to follow the orders written, and would expect the nurses to clean the wound when performing the treatment. On 9/28/2022 at 10:50 AM V24, Certified Nursing Assistant (CNA), and V25, CNA, assisted R39 into the bed. V24 and V25 assisted R39 onto his back. There was no pressure relieving device between R39's knees. R39 had a 2 centimeter (cm) by (x) 2 cm purple and black discolored circular unstageable pressure ulcer to R39's right inner knee. The pressure ulcer was intact with black wound edges and approximately 1cm of dark purple, and black discoloration to the top and left side of the wound bed. V24 stated the pressure ulcer to R39's inner leg was new. V24 stated R39 obtained the wound due to his legs being pressed together. On 9/28/2022 at 12:00 PM V2, Director of Nursing (DON), stated she expects the staff to follow the physician orders. V2 stated she would expect the nurse to perform the correct treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/28/2022 at 1:30 PM, V2 stated the facility had no other pressure ulcer/wounds and/treatment policy other than what was previously given. On 9/29/2022 at 10:10 AM, V15 stated R39 does not move around in the bed. V15 stated the only movement she is aware of is when he is not on his left side, he will flip over to that side. V15 stated R39 has fragile skin and will get wounds and pressure ulcers quickly. V15 stated R39 is dependent on staff for care. V15 stated the pressure ulcer to R39's knee is new. V15 stated R39 is supposed to always have something in between his knees. V15 stated this has always been the case. V15 stated the pressure ulcer to R39's knee is because of his knees being pressed together. The Facility's Skin Management: Monitoring of wounds and documentation, dated 1/2022, documents, It is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility. 2. R33's Care Plan, dated 8/18/2022, documented, Treat the Left buttock wound as per (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] R33's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Left buttock: Apply Santyl, [MEDICATION(S)] oint (ointment), crushed [MEDICATION(S)], and calcium alginate. Cover with dry dressing, everyday shift for To Promote Wound Healing related to PRESSURE ULCER OF LEFT BUTTOCK, STAGE 4 (L89.324) AND as needed. On 9/28/2022 at 8:25 AM, V15, removed R33's old dressing. After she took a picture of the open pressure sore, V15 then applied the medication, calcium alginate and the bordered gauze dressing, without cleansing the wound. On 9/28/2022 at 10:19 AM, V2 stated R33's pressure ulcers should have been cleansed before applying R33's treatment.

Based on interview and record review, the Facility failed to ensure staff implemented appropriate interventions for combative residents to prevent injury during care for 1 of 3 residents (R2) reviewed for accidents in the sample of 8. This failure resulted in R2 sustaining a large 10 centimeter (cm) by 7 cm by 0.1 cm skin tear to her right forearm during care. Finding includes: R2's Wound Evaluation and Management Summary, dated 3/8/2022, documents R2 has diagnoses of [CONDITION(S)] disease, congestive heart failure, depression, diabetes mellitus, [CONDITION(S)], and hypertension. R2's Physician Order Sheet for 3/2022 documents a diagnosis of cognitive communication deficit. R2's Minimum Data Set (MDS), dated [DATE], documents R2 is an extensive assist of two plus staff (3/3) for bed mobility, transfers, toilet, and personal hygiene. R2's Care Plan, undated, documents R2 is at risk for falls related to impaired cognition and weakness. The Care Plan documents R2 is on anticoagulant therapy ([MEDICATION(S)] and aspirin) related to history of transient ischemic accident, purpura to bilateral upper extremity, right shin. (R2) has potential/actual impairment to skin integrity related to fragile skin, medication use ([MEDICATION(S)]) and was noted to have senile purpura to bilateral upper extremity and right knee area. The Care Plan documents R2 is not always able to express the need for assistance when she is incontinent of bowel and bladder. The Care Plan documents R2 displays behavioral symptoms related to becoming combative with staff and are manifested during care. The Care Plan did not document specific interventions staff should implement when R2 becomes combative. R2's Skin Tear Report filed by Facility on 3/7/2022 at 8:05 AM, documents, skin tear noted to lower right forearm upon entering room to do a glucose finger stick, CNA (Certified Nurse's Aide) exiting room as nurse entered stated resident combative with care, pulling CNA's hair, striking out at staff, etc. Noted smear of blood on grab bar of bed from resident striking arm when swinging at staff. Resident unable to give description. Skin tear right hand. Combative with care, upon investigation, reported that resident was combative during an incontinence care, pulling CNA's hair, striking out. Struck arm on grab bar of bed causing discoloration with skin tear. Area cleansed with dressing applied. Staff to leave in safe manner and re-approach when calmed if combative during care. The Report documented only one CNA was providing care, although R2's MDS documents two CNAs should provide care to R2. R2's Hospital Records, dated 3/7/2022 at 9:29 PM, Daughter wants patient evaluated for bruises and skin tear right forearm stating it was enlarged. Patient is from (Facility). Large skin tear on right forearm. There were steri strips that were minimally adhesive. Skin care cleaned with wound cleanser. R2's Wound Evaluation and Management Summary, dated 3/8/2022, documents, This patient has multiple wounds. She has a shear wound on the right forearm for at least 3 days duration. There is moderate serous exudate. Shear wound of the right forearm full thickness, Wound size 10 centimeters (cm) length x 7 cm in width x 0.1 cm in depth. On 3/9/2022 at 10:18 AM, V2, Director of Nursing, stated, (R2) became combative with care with staff and grabbed the Certified Nursing Assistants (CNA) hair and hit the grab bar with her arm and obtained a large discoloration to the area along with a large skin tear. This incident was witnessed by the CNA when she was trying to get away. The nurse was entering the room as the CNA was leaving because she was trying to get away. (R2) has very fragile skin and has been diagnosed with senile purpura, which makes the skin very delicate. On 3/9/2022 at 1:45 PM, V7, CNA, stated, I always do care on (R2) at the end because she is at the end of my hall. I was doing incontinent care on (R2) and rolled her towards me, and she was on her right side, and she started getting in a mood and I was wearing hair that day and (R2) grabbed it and I yelled for help and tried to get the hair off so I could escape. I was able to get it off and I was gently telling (R2) to calm down as I was trying to finish, and I do not think she understood me because she was grunting and thrashing, and I never touched her arm or hand. I just finished the care and as I was leaving the nurse was coming in (V8, Registered Nurse /RN) to check her blood sugar levels. I did not see anything on her arm or hand, but I was just trying to get my hair and get out of there. I did not see any blood. On 3/9/2022 at 10:44 AM, V6, Registered Nurse (RN) stated, If a resident becomes combative during care, I expect staff to stop, make sure the resident is safe and then try again later and or ask for help. On 3/10/2022 at 9:25 AM, V9, CNA, stated, If a resident would be combative during care, I would make sure they were safe, the call light was within reach and walk away until the resident had calmed down. Then I would go back and check on them. (R2) when she gets frustrated, she pushes at me, I see that she is getting worked up, so I just leave her, wait and come back. (R2) is an extensive assist of one staff. On 3/10/2022 at 9:28 AM, V10, RN/MDS Coordinator, stated, If a resident became combative during care, I would redirect them and make sure they were safe, walk away and then re-approach or have someone else try. I was not working that night but had heard that (R2) was combative during care and had a skin tear to her arm. I was not working though when this happened. On 3/10/2022 at 9:30 AM, V11, CNA, stated, If a resident would become combative, I would stop was I doing, trying to redirect them and leave them alone and then re-approach them later on. (R2) can be combative at times. She will swing her arms when she gets upset. I will just leave her and try again later. She is an extensive assist of one staff for care. I usually do not have any issues as I just leave her alone and then come back. On 3/10/2022 at 11:22 AM, V8, RN, stated, I went into (R2's) room as I was going in, I was going to do a finger check as I was entering the room (V7) was leaving the room. It was around 6:15 AM when I went into the room, and (V7) told me as she was leaving that (R2) was pulling her hair and fighting with her. When I entered the room her gown and blankets had blood on them, and I was not sure what had happened, and I was assessing her and saw she had a large area to her right arm that had been bleeding. There was blood on her blankets and her gown. I do not know how it occurred, but I do I know when a resident becomes resistant to care we are to leave them alone, make sure they are safe and come back later. I cannot say what happened with (V7). I do not remember her being wet I think she was dry as I remember checking her and changing her gown, but I did not have to change her diaper. I cannot say if there was any blood on the grab bar that was not my focus. I just wanted to clean (R2) and treat her wound. I cleansed her wound, put triple antibiotics ointment on it and wrapped it in gauze. It was a very large skin tear and some of skin was missing. On 3/10/2022 at 3:21 PM, V2 stated, I expect staff to leave the resident in a safe manner and re-approach when calm. On 3/10/2022 at 4:20 PM, V2 stated there was no policy on combative residents and how to approach them.

Based on interview and record review, the facility failed to provide pain management for 1 of 4 residents (R4) reviewed for pain management in the sample of five. This failure resulted in R4 experiencing severe pain exhibited by him crying and having an increased level of anxiety following admission to the facility from the hospital. Findings include: 1. The Admission Record documented R4 as a [AGE] year old male admitted to the facility on [DATE] following hospitalization and surgery for [REDACTED]. R4's Minimum Data Sheet ((MDS) dated [DATE] documented R4 to be cognitively intact. Hospital Discharge Orders, dated 4/26/17, include pain medication as follows: [MEDICATION NAME] 2 milligrams (mg), 1-2 tabs by mouth every 4 hours as needed (PRN), [MEDICATION NAME] 30 mg, 1 tab by mouth every 12 hours for 30 days, [MEDICATION NAME] 325 mg, 1 tab by mouth every 6 hours as needed for pain or fever, [MEDICATION NAME]-[MEDICATION NAME] 10-325, 1 tab by mouth every 6 hours as needed for pain and [MEDICATION NAME] 50 mg ,1 tablet by mouth every 8 hours as needed for pain. Hospital Discharge records, dated 4/26/17, documented the last dose of pain medication R4 received prior to his transfer to the facility was [MEDICATION NAME] 30 mg at 9:02AM and [MEDICATION NAME] given at 11:17 AM. The Resident Data Collection sheet documented R4 arrived at the facility on 4/26/17 at 6:00 PM. The sheet documented yes with reference to pain on admission with description written as pain to coccyx. Documentation under comments is written Surgical wound to coccyx. The form was not signed by staff. On 6/20/17 at 2:13 PM, R4 stated he did not get any pain medication after being admitted to the facility until the next day. When R4 was asked to score his pain, R4 described it as horrible and added that he was crying he was in so much pain. R4 stated he was told by the admitting nurse that none of his medication, including his pain medication, would be in until the next day as it came from a pharmacy in (Southern Illinois City). R4 stated he lay in pain all night. When asked to score his pain the night of his admission, R4 stated it would have been a 10 all night. The first Progress Note written following admission was dated 4/27/17 at 2:17 AM by E8, Registered Nurse (RN), and documented, resident arrived by ambulance in stable condition. DX (diagnoses)[MEDICAL CONDITION], r/t (related to) gangrene surgical opening of the coccyx for debridement. Open area 35 cm (centimeter) in length, 9.5 cm in width and 4.5 cm deep, wound vac (vacuum) placed. There was no assessment of pain documented on the day R4 was admitted from the day shift through to 6:00 AM on 4/27/17. The next Progress Note, dated 4/27/17 at 16:01 (4:01 PM), written by E9, License Practical Nurse (LPN), documented Resident is alert and oriented x 3, he is able to make his needs known and He c/o (complaints of) pain even after the dose of [MEDICATION NAME]. On 6/21/17 at 12:25 pm, E9 stated she gave R4 his 9:00 AM dose of [MEDICATION NAME] 30 mg around 8:00 AM on 4/27/17 stating she had pulled it from the emergency box (E-box). E9 stated R4 scored his level of pain at that time as a 10. E9 stated she recalled R4 to have a horrible wound that went from the top of his coccyx down through his buttocks into his scrotum and that he had to have a [MEDICAL CONDITION] due to the gangrene. On 6/21/17 at 2:00 PM, E2, Corporate Registered Nurse stated E8, Registered Nurse (RN) was the admitted nurse and worked second shift 4/26/17 until 6am on 4/27/17. E2 stated E8 is no longer employed by the facility. The April 2017 Medication Administration Records (MAR) confirm R4 received no pain medication from 6:00 PM 4/26/17 when he was admitted until 9:00 AM on 4/27/17 when E9 pulled [MEDICATION NAME] from the E-box. R4's MAR indicated [REDACTED]. There is no documentation of the effectiveness of the [MEDICATION NAME] given R4 at 8am on 4/27/17 or any follow-up recorded in the progress notes on the status of R4's pain throughout the day on 4/27/17 while he waited on his medication to arrive. On 6/20/17 at 2:32pm, Z1, Pharmacy Manager, stated that the facility has an emergency box with controlled substance in it that is accessible for the nurses to use when the pain medication has not been delivered yet. Z1 confirmed that E9 took [MEDICATION NAME] 30mg from the emergency box at 8am on 4/27/17 but stated no other pain medication was used from the box before that time even though the [MEDICATION NAME] and [MEDICATION NAME] would have also been available. Z1 also stated the box contained oral [MEDICATION NAME] that could have been substituted with a call to the physician until R4's medications arrived from the pharmacy. On 6/21/17 at 2:25pm, Z2, R4's Primary Physician, stated R4 would have had severe pain due to the extent and size of the wound describing it as massive. Z2 stated R4 had the [MEDICAL CONDITION] done when they debrided the gangrene due to it extending from just below his coccyx, down including his rectum and into the scrotum. Z2 stated the nurse should have pulled from the E-box (emergency box) and/or called him as this resident would have needed his pain medication. Z2 stated it would have been appropriate for them to get it from a local pharmacy as a STAT order which they can do through their pharmacy services. The Emergency Box contents list was reviewed and noted to contain [MEDICATION NAME] 50 mg, [MEDICATION NAME] 5/325 and [MEDICATION NAME] in oral and liquid form. The facility's policy/procedure entitled Pain Management dated 2015 documents its purpose as To facilitate resident independence, promote resident comfort and preserve resident dignity by provide an effective pain management program. Under general guidelines, the facility documents it will: promptly and accurately assessing and managing pain to the greatest extent possible, encouraging residents to self report pain, aggressively assessing pain in non-verbal and cognitively impaired residents, increasing comfort and reducing depression and anxiety in residents, optimizing the residents ability to perform activities of daily living and monitoring treatment and efficacy and side effects. The policy continues to document that pain will be assessed and managed in a timely manner, especially if it is of recent onset. The policy entitled Pharmacy Hours and Delivery Schedule dated 1/27/14 documents New orders communicated to the (Pharmacy) after the fax cut-off time will automatically go into the next regular delivery for the facility and The medication therapy should be initiated promptly if the new order is a medication contained in the convenience box or emergency box supply. The policy also documents An emergency delivery can be requested by faxing the pharmacy, writing the word STAT in large bold lettering in the upper right-hand corner of the order sheet. After faxing the order, please contact the pharmacy by phone to alert them that you faxed a STAT order. 2. The Admission Record identifies R3 as an [AGE] year old female admitted to the facility on [DATE] from the hospital following a surgical repair of a fracture left hip. The MDS dated [DATE] documents R3 to have no cognitive impairment. The Hospital Discharge Records dated 5/16/17 document orders for [MEDICATION NAME] 50 mg, 1 tab every 6 hours PRN and Tylenol 325 mg tabs 2 every 4 hours PRN for mild pain. Comprehensive Pain Assessment (undated) identifies R3's pain at the left [MEDICAL CONDITION], describes it as aching and throbbing and requires pain management intervention. On 6/21/17 at 11:55 AM, R3 was sitting quietly in a chair beside her bed. R3 recalled the night she arrived at the facility stating it was terrible that night as they did not have her pain medication available until the next day. R3 stated she has moderate pain in her left thigh area and rubbed it as she spoke. R3 stated she did get Tylenol the next day but had to wait for the [MEDICATION NAME]. R3 stated she usually takes a [MEDICATION NAME] around 5:00 AM to get her through the day and again around 9:00 PM to help her sleep since she sustained a [MEDICAL CONDITION]. R3's Progress notes dated 5/17/17 show R3 received a dose of Tylenol at 5:47 AM although the May 2017 MAR indicated [REDACTED]. The next pain medication R3 was documented as receiving was documented in the Progress note to be given at 19:47 (6:47pm.) The MAR indicated [REDACTED]. On 6/21/17 at 2:25pm, Z2, R4's Primary Physician stated the nurses should have utilized the E-Box for R3's pain medication.

Based on interview, observation and record review, the facility failed to ensure treatments are done according to physician's orders, failed to coordinate pressure ulcer care with wound clinic and failed to follow prevention plans including timeliness in turning and repositioning for 2 of 4 residents (R3 and R4) in a sample of 11. This failure resulted in a decline in wound status for R3 on 12/17/15 which the facility was unaware of. Findings include: 1. R3's Minimum Data Set ((MDS) dated [DATE] documents R3 has no cognitive impairment and requires extensive assist of two staff for bed mobility and transfers. The MDS documents R3 to have a [MEDICAL CONDITION] and urinary catheter along with having 1 stage III pressure ulcer and 2 stage IV pressure ulcers she was admitted to the facility with. The December 2015 Physician's Order Sheet (POS) documents R3 goes to the Wound Clinic Weekly for management and includes orders for a pressure relieving cushion in wheelchair, up in W/C (wheelchair) 2 hour intervals, one hour intervals before and after meals and from 7pm to 9pm along with orders for Prostat 30cc BID (two times daily), Vitamin C 500mg bid, and [MEDICATION NAME] 1 packet BID. Labs dated 12/22/15 document R3's Pre-[MEDICATION NAME] as low at 15 (Normal 20-40.) R3's Braden score dated 8/24/15 score her at moderate risk of 14 with 12 or below considered high risk. The care plan dated 10/18/15 identifies R3's risk adding prefers to sit up in chair at bedside all day and is uncooperative with laying down. Interventions include: may be up for meals and therapy only, assist with repositioning and pressure relief at least every one to two hours, provide diet and nutritional supplements as ordered, and treatments as ordered to left and right buttocks. The care plan failed to address R3's refusals of timely repositioning with alternate interventions to ensure R3 stays off her coccyx area as ordered by the physician. On 12/22/15 at 10:35am, R3 was sitting in her wheelchair at bedside. R3 stated she has been in her wheelchair without repositioning since before breakfast about 8:30am. R3 stated she had a dressing on her bottom and that it had not been changed since yesterday afternoon. R3 stated the dressing orders were changed and it was now suppose to be done twice daily. R3 stated the facility nurses do not always follow the wound clinics orders. On 12/22/15, R3 remained in her wheelchair from 10:35am through lunch until 2:55PM. At 2:55pm, R3 was transferred to bed by E7 and E8, Certified Nurses AIdes (CNA's.) E6 Licensed Practical Nurse (LPN) entered the room to do the treatment change. Both CNA's confirmed that R3 had been in her wheelchair since early in the morning. When R3 was rolled to her right side, her coccyx dressing had drainage visible across the entire dressing and the entire lower edge of the dressing was loose with the wound bed gaping and visible. The packing was balled up saturated with gray drainage. The wound bed had large patches of grayish yellow material present. The left buttock dressing was intact but also had drainage visible throughout the dressing. When E6 removed the left buttock dressing, the wound bed also had some gray matter over the base of the wound. No odor was noted. Z1, R3's daughter in law was present during the dressing change and stated compared to the last time I saw it, it looks worse. R1 replied Yes, that's what the wound clinic says. R1 stated the wound clinic has complained that the facility does not follow physician's orders or always use the appropriate supplies. Wound Care documentation dated 12/3/15 documents orders for 2 larger pressure ulcers. Wound #3 is identified as the Midline Sacrum which measured 10.5 centimeters (CM) long x 11.5 cm wide x 3.2 cm deep, undermining at 1 o'clock to 3 0' clock with a maximum distance of 2.8cm. The note identifies a large amount of purulent drainage noted with a large amount of necrotic tissue within the wound bed including adherent slough. Wound #4 location is noted on the left ischium measuring 4.8cm x 2.7cm x 0.8cm with bone exposed, large amount of purulent drainage and medium amount (34-66%) of necrotic tissue within the wound bed including adherent slough. Orders given the facility for the Sacrum ulcer were santyl - nickel thick to the wound bed (the wound vac (vacuum) is on hold for the sacral wound - do not apply the vac to the sacral wound this week, The orders for the left ischium were Wound Vac to wound continuously at 125mm/hg pressure, black foam - purocol AG (may use plain purocol), then [MEDICATION NAME] (sent with patient), then green foam to wound bed, frame the wound with wound vac drape, track the suction pad out and away from wound and bony prominence, do not place suction directly over the wound. December 2015 Treatment Administration Records (TAR) reflects the orders correctly for the Ischium but there is no initials or documentation on the TAR that shows the treatments were actually done except on 12/6/15 with HOLD written in on 12/10. Wound Clinic notes dated 12/10/15 identify decline documenting Sacral wound appears larger, several areas of edges and base are necrotic - blue, purple, burgundy, not bleeding when cut, other areas are sloughy, entire area debrided today. Treatment order changes were made for the left ischium - change dressing every other date - Wound Vac change on Monday, Wednesday, and Friday. Hold Vac today and tomorrow, place Saturday 12/12/15, until Saturday, follow same orders as sacrum. Orders for the Sacrum - Change outer dressing twice daily (Leave [MEDICATION NAME] in place until Saturday,then change whole dressing) DO NOT USE [MEDICATION NAME] ON ANY WOUNDS. December TARs for treatment changes dated 12/10/15 shows the dressings were not changed according to orders dated 12/10/15 with the [MEDICATION NAME] boxed off for 12/13-12/14 and 12/16-12/17/15 with no initials present. The TAR shows no initials on 12/12/15 for the Wound Vac being placed with the order on the TAR documenting wound vac on hold til Sat (no date). This order had HOLD written in for 12/10/15 and 12/11/15. There are no initials for treatments being done to the Sacrum or ischium even though an arrow is drawn to 12/10/15 for the start of the treatment. Wound Care Progress notes dated 12/17/15 document My orders were not transcribed correctly last week. The wound Vac was not stopped on the ischium, nor was it started on the sacrum. All of the ulcers are worse today. The sacral wound is as necrotic as it was last week. The note also documents R3 telling the wound clinic that she did not have dressing changes for 2 days. The POS 12/17/15 reflects orders from a Wound Clinic dated 12/17/15 to hold the wound vac treatment and start treatments of cleansing the wounds with Normal Saline (NS), cut [MEDICATION NAME] AG to size, cut [MEDICATION NAME] transfer dressing to fit over wound wedge, fill wound with gauze, cover with 4 x 4 ABD BID (Twice daily.) December TAR documents these treatments were done on the 3-11 shift on 12/17/15 and on 7-3 shift daily from 12/18/15 thru 12/22/15 but no other times. Nurse Progress notes document treatments done 12/19, 12/20, and 12/22/15 on 3-11 shift that are not initialed off on the TAR. No treatments are documented as being done on the 3-11 shift 12/21/15 On 12/23/15 at 1pm, Z2 Wound Clinic Manager stated they see R3 on a weekly basis and have had problems with communications with the facility. Z2 stated following orders for dressing changes are a problem adding there have been times when R3 has come into the clinic with the wrong treatment on or they've used dressings they specifically are not to use. E2 stated the clinic will send new orders for supplies the facility does not have and then they'll change it without contacting them in a timely manner without notification to the clinic. Z2 stated the Wound Physician, Z3, would say the facility was not following physician's orders for wound treatment has contributed to the decline or lack of improvement in R3's wound. Z2 stated the facility has never contacted them in regards to obtaining wound status documentation and have never contacted them in regards to not following physician's orders when supplies are not available. On 12/23/15 at 2pm, E1 Administrator and E2, Director of Nursing confirmed they have no documentation from the wound clinic except orders and have requested them numerous times. E2 stated R3 will return from the clinic with new orders but have no other information such as wound status /measurements etc with it. E2 stated the Facility has it's own wound nurse (E5 Registered Nurse RN) who does measurements on a weekly basis. E2 stated the facility nurses have called the wound clinic numerous times to clarify orders and agrees that documentation on the TARs could be better stating that some nurses may document treatments in the progress notes. Both E1 and E2 state R3 is resistant to timely repositioning and refuses often to go to bed for dressing changes. On 12/29/15 at 10:53am, E2 stated Z3, Primary Physician made arrangements for R3 to go to the Wound clinic and that there are times when the facility does not have the clinic's supplies as ordered and they will use comparable supplies they have. There is no coordination of care between the wound care clinic and the facility according to E5 Registered Nurse/Wound Nurse who agreed on 12/22/15 that she does not get any information from the wound care clinic in regards to the status of the wounds ie improvement, decline. E5 stated she does her own weekly measurements but follows the wound clinics orders. E5 stated she felt R3's wounds are looking better and often after [MEDICATION NAME], they will get larger. E5 stated she doesn't really want to compare her wound assessments with the clinic due to them [MEDICATION NAME] them and added it depends on how someone measures as to whether the measurement findings would be the same. Weekly Skin alteration records completed by E5 dated 12/11/15 for the sacrum pressure ulcer fails to identify the area as being larger with necrotic tissue recorded by the wound clinic on 12/11/15 but documents the wound base being yellow with 25-50% beefy red. E5 documented no change for the healing process even though the wound physician documented a decline in the wound which required debridement. On 12/17/15, E5 again document no change for wound healing with no necrotic tissue identified or declined as documented by the wound care physician. The weekly Skin alteration records for the left ischium also shows conflict between the two evaluations. E5's report dated 12/11/15 fails to reflect the area as being larger as documented by the wound clinic yet identifies an improvement in the wound status. E5 failed to document any necrotic tissue prior to R3 going to the wound clinic. There is no evidence the facility identifies the necrotic tissue and adherent slough the wound clinic documents even though they see R3's wounds more frequently. On the 12/17/15 report, R5's wound report documents 100% beefy red wound bed with no change to the wound status although the wound clinic documents all ulcers are worse today on 12/17/15. The facility policy dated 1/2014 entitled Decubitus Care/Pressure Areas documents it is the policy of the facility to ensure a proper treatment program has been instituted and is being closely monitored to promote healing of any pressure ulcer, once identified. 2. On 12/22/15 from 10:45 AM-1:00 PM, R4 sat in the wheelchair in R4's room without the benefit of repositioning based on 15 minute or less observation intervals. Nurse/Physician Communication Record, dated 12/7/15 documents that R4 had a newly discovered right ear decubitis measuring 1.0 centimeters (cm) by 0.5 cm, by 0.2 cm. The record documents that orders were received to clean area on right ear with wound cleanser, apply medi-honey, cover with purauol and a 2 inch by 2 inch dressing daily and as needed. Wound Treatment Evaluation Record dated 12/21/15 documents that the right ear pressure ulcer, measured, 0.7 cm by 0.3 cm by 0.1 cm. laboratory results dated [DATE] documents R4's serum [MEDICATION NAME] was 2.9 (normal range 3.2-4.8). laboratory results dated [DATE] documents that R4's Total Protein was 5.3 (normal range 5.7-8.2) On 12/22/15 at 1:00 PM R4 stated I have been in this chair since I got out of bed this morning. No one has stood me up or changed my position . I didn't want the lunch today. No one offered me anything different to eat On 12/23/15 at 8:50 AM, E5, Wound Nurse/MDS Coordinator stated (R4) is at risk for pressure ulcers and is dependant on staff for mobility, turning and repositioning. We reposition (R4) every 2 hours when (R4) is in the chair and bed. (R4) current right ear area because (R4) likes to sleep on the right side. (R4) refuses the nutritional supplements and we have notified the (E10), Wound Nurse Practitioner

Based on observation, interview, and record review, the facility failed to follow standard and contact isolation precautions/ protocols when caring for residents with infections, failed to clean and disinfect medical equipment, failed to implement ongoing surveillance of employee isolation practices for residents with Clostridium difficile (C-diff) and failed to track and trend an outbreak of upper respiratory infections (URI). This has the potential to affect all of the 56 residents living in the facility. This failure resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 11/01/13, the facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the Infection Control policies and procedures. Findings include: 1. The facility's policy and procedure entitled, Gastrointestinal Tract Infections, dated 4/01/07, documents, in part, "The facility is committed to providing a safe and healthy environment for residents and to minimize or prevent the spread if infections. PURPOSE To minimize the risk of gastrointestinal tract infections to residents by: Surveillance for signs and symptoms; diagnosis; hygiene and precautions. PREVENTION Stress hand washing (even if gloves are worn) for employees and residents after touching feces or items soiled with feces, or after providing personal care for the infected resident." 2. The facility's policy and procedure dated 4/01/07 and entitled, 'Initiating Isolation' documents, in part, "Isolation precautions are required for certain infected residents to prevent the spread of disease to other residents, employees and visitors. PROCEDURE Place necessary equipment and supplies in the room that will be needed during isolation. Maintain isolation precautions until no longer indicated." 3. The Center for Disease Control, CDC, guidelines documents under 11.1 Environmental Measures "Certain pathogens (e.g.......C. difficile) may be resistant to some routinely used hospital disinfectants. Also, since [DIAGNOSES REDACTED]icile may display increased levels of spore production when exposed to non-chlorine based cleaning agents, and the spores are more resistant than vegetative cells to commonly used surface disinfectants, some investigators have recommended the use of 1:10 dilution of 5/25%...hypochlorite (household bleach) and water for routine environmental disinfection of rooms and with patients with [DIAGNOSES REDACTED]icile when there is continued transmission." 4. The facility policy entitled, 'Hand washing' documents, in part, "PURPOSE-Medical asepsis to control infection. To reduce transmission of organisms from resident to resident. To reduce transmission from nursing staff to resident. To reduce transmission of organisms from resident to nursing staff. Wash hands before and after resident contact. Wash hands when soiled." 5. The facility policy and procedure dated 4/01/07 and entitled, 'Standard Precautions' documents, in part, "All employees are expected to practice standard precautions. Purpose-To reduce both the risk of transmitting infections and the likelihood of exposure to blood-borne pathogens. Wash hands after touching or coming in contact with blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed, before and after resident contacts, and when otherwise indicated to avoid transfer of microorganisms to other residents or environments. Gloves: Change gloves between tasks and procedures on the same resident and after contact with material that may contain a high concentration of microorganisms. Remove gloves and discard properly after use, and wash hands immediately before touching non-contaminated items and environmental surfaces, and before going to another resident." 6. In an interview on 10/29/13 at 8:50 AM, during the initial tour of the facility, E17, Minimum Data Set (MDS)/ Care Plan Coordinator, stated R6 and R7 are a married couple rooming together. R6 is on isolation for[DIAGNOSES REDACTED]. R7's Physician's Progress Note, dated 10/16/13 documents, in part, the [DIAGNOSES REDACTED]. An interview was conducted on 10/30/13 at 1:05 PM with R6, R7, and Z5 (R6's grandson). R6 and R7 both agreed they did not want to be separated, and they wanted to stay in the same room together. R6 said the nurses have talked to them about[DIAGNOSES REDACTED]. Z5 said he took his grandparents to the doctor yesterday. Z5 stated, "No one has given me any education about[DIAGNOSES REDACTED] except for my grandma." 7. On 10/29/13 at 1:32 PM, E11, Certified Nurses Aide (CNA) had on gloves and was assisting R6 while toileting. E11 was not wearing an isolation gown. R6 had a loose bowel movement (BM) on the toilet. At that time, R6 stated she (R6) is incontinent of bowel at times since having[DIAGNOSES REDACTED]. R6 stood up from the toilet while E11 used disposable wipes to clean R6's rectal area. E11 had on the same soiled gloves as she touched the tube of barrier cream and applied the cream to R6's buttocks. In an interview on 10/29/13 at 1:32 PM, E2, Director of Nursing (DON) stated, "I expect them to use gown and gloves if they are doing anything to do with BM for (R6)." 8. On 10/30/13 at 8:16 AM, E15, Licensed Practical Nurse (LPN), used a glucometer from his medication cart to check R6's blood sugar. E15 placed the glucometer directly on R6's over bed table, picked up the tissue he had used as a barrier on the table, removed his gloves, took the glucometer and his trash out of the isolation room, placed the glucometer directly on top of the medication cart and placed the trash into the trash can on the medication cart. E15 reentered R6's room and washed his hands with soap and water. E15 did not clean the glucometer or the top of the medication cart. E15's medication cart was continuously observed as E15 passed his medications until 9:25 AM. E15 did not clean the glucometer during this time. 9. On 10/30/13 at 7:35 AM, E8 and E32, CNA's were getting R7 ready for the day. E32 brought the mechanical lift into the isolation room. E32 and E8 used the lift to transfer R7 into his wheel chair. E8 moved the mechanical lift back into the hallway. The mechanical lift was not cleaned after being used in the isolation room. 10. In an interview on 10/30/13 at 9:58 AM, E32 was unsure of the type of infection that R6 currently has. E32 said R6 had "staph (Staphylococcus aureus), no MRSA (Methicillin Resistant Staphylococcus aureus), no it is[DIAGNOSES REDACTED]." When E32 was asked what type of PPE should be used for R6, E32 stated, "Nothing else besides gloves at all times. (R6) would have her own gait belt and stuff for vital signs." During the interview, E32 entered R6's isolation room without wearing gloves, checked the drawers for R6's dedicated equipment, but did not find any. E32 stated, "I don't see it. They should have their own." E32 used hand sanitizer on her hands as she left R6's room. E32 also said the mechanical lift is used for R7, but there was nothing special to be done with it after use in the isolation room. 11. During observation of medication administration on 10/30/13, at 3:40 PM, E13, LPN removed a glucometer from the top drawer of her medication cart and set it on top of the cart. E13 applied gloves, picked up the glucometer and entered R15's room to obtain a blood sample. After obtaining the blood sample and the results, E13 left R15's room and used the same gloves to unlock the medication cart. E13 used a wet bleach wipe to cleanse the glucometer for less than 15 seconds, then placed it directly on the top of the medication cart to dry. The glucometer remained wet for less than 15 seconds. After E13 drew up insulin into a syringe, she applied gloves and administered it to R15 at 3:15 PM. E13 removed her gloves and then touched R33's (R15's roommate) wheelchair to pull her backward without cleansing or washing her hands. At 3:50 PM, E13 cleansed her hands with sanitizer, took the same glucometer, used previously on R15 from the top of the cart and placed a testing strip into the glucometer. E13 applied gloves and re-entered the room to obtain a blood sample from R33 at 3:53 PM. E13 placed the glucometer on the top of the cart, removed her gloves and cleansed her hands. After administering insulin by injection to R33 at 3:55 PM, E13 removed her gloves, unlocked the medication cart, then cleansed her hands. E13 failed to cleanse or disinfect the glucometer after use on R33. At 4:00 PM, E13 prepared a medicated inhalation solution for R16 and used a stethoscope to check R16's pulse, then placed the stethoscope on her neck. E13 attached the face mask and receptacle containing the medication on R16's face and turned on the nebulizer machine without wearing gloves. E13 then left R16's room. E13 did not cleanse her hands. At 4:05 PM, E13 obtained a different glucometer that had been sitting on top of the medication cart, prepared the testing strip and applied gloves. E13 entered R6's room and lanced her forefinger to obtain a blood sample. E13 did not wear a protective gown. A small red sign on the outer left door frame of R6's room read, "STOP See nurse for instructions". PPE was located in a container outside R6's room. In an interview at that time, E13 reported R6 was on contact isolation for the bacteria[DIAGNOSES REDACTED] in her stool. E13 removed her gloves and brought the glucometer from R6's room and placed it directly on the medication cart without cleansing or disinfecting it. E13 failed to cleanse her hands before unlocking and opening the cart to prepare an insulin syringe for R6. E13 then briefly wiped the glucometer with a bleach wipe and placed the wet glucometer directly on the top of the cart. The glucometer remained wet for less than 15 seconds. E13 gloved, entered R6's room and administered the insulin to R6's right forearm. At 4:12 PM, E13 then removed her gloves and disposed of them in R6's room, left the room, unlocked the medication cart and cleansed her hands with sanitizer. At 4:15 PM, E13 applied gloves and picked up the glucometer and entered R6's isolation room to obtain a blood sample from R7. E13 removed her gloves and carried the contaminated glucometer out of the room, placing it directly on top of the medication cart. E13 prepared the insulin for R7 while wearing gloves, then entered R7's room to administer it at 4:18 PM. E13 then removed her gloves, left R6 and R7's room and disposed of them in the receptacle on the medication cart. E13 unlocked the medication cart then cleansed her hands with sanitizer. E13 then cleansed the glucometer with a bleach wipe for less than 10 seconds and placed it directly on the top of the cart to dry. The glucometer remained wet for less than 15 seconds. At 4:20 PM, R16 came up to E13 and reported she had completed the nebulizer inhalation therapy treatment. E13 then entered R16's room and picked up the face mask, opened the base from the mask and rinsed them with water in R16's bathroom without wearing gloves. E13 place the wet mask and base into a plastic bag before washing her hands. At 4:25 PM, E13 placed the stethoscope from around her neck and placed it onto the top of the medication cart without sanitizing the diaphragm and bell. E13 gloved and then used the second glucometer (previously used on R6) to obtain a blood sample for R35. E13 left R35's room placing the used glucometer directly on the medication cart next to the stethoscope. E13 removed her gloves and cleansed the glucometer with a bleach wipe for less than 10 seconds, then cleansed her hands with sanitizer. The glucometer remained wet for less than 15 seconds. E13 then wiped the diaphragm and bell of the stethoscope with an alcohol wipe and placed it back on the cart. At no time, from 3:40 PM to 4:25 PM did E13 appropriately sanitize this glucometer to prevent the spread of infection. 12. On 10/31/13 at 8:25 AM, E7, LPN exited R7's room (an isolation room) carrying a glucometer in her gloved hands. E7 continued to wear the soiled gloves as she touched the medication cart, opened the drawer, and placed the glucometer into the drawer. E7 did not clean the glucometer. E7 stated, "No, I hadn't cleaned the glucometer after I used it." E7 removed the glucometer from the drawer, placed the glucometer directly on top of the medication cart, and wiped the front and sides of the glucometer with a bleach wipe. The glucometer remained visibly wet for 2 minutes. 13. On 10/30/13, at 9:40 AM, E6, CNA was interviewed related to infection control policy and procedures. E6 stated she was unaware if any resident in the facility had[DIAGNOSES REDACTED]. E6 reported information about residents with infection or in isolation is provided in morning report by the nurse on that hall. 14. On 10/30/13, at 9:50 AM, E5 was interviewed related to infection control policy and procedures. E5 could not identify if anyone in the facility was on isolation. E5 reported no resident in the facility had an infection and the nurse would have informed her. 15. On 10/30/13, at 10:00 AM, E7, LPN was interviewed about infection control policies at the facility. E7 incorrectly identified R6 as having [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE) with ESBL (Extended Spectrum Beta Lactamase). E7 reported the staff are responsible for reading the 24 hour Communication Log for current information related to residents with infections and informing the CNA staff. 16. In an interview on 10/30/13 at 10:04 AM, E34, Housekeeper explained that her manager tells her when there is anyone on isolation, but she hadn't been told about anyone on isolation at this time. 17. In an interview on 10/30/13 at 10:31 AM, E8, CNA, stated, "if toileting (R6) need to wear gloves. We don't need to wear anything else. Protocol is that (R6) has her own thermometer, blood pressure cuff, and stethoscope." 18. In an interview on 10/30/13 at 10:44 AM, E20, CNA stated after using the mechanical lift in an isolation room, "We would wipe it down with alcohol pads or sanitizing wipes that are used for pericare." 19. In an interview on 10/30/13 at 11:00 AM, E15 stated, "I have never seen them (CNA's) gown going into (R6's) room. There should be gowns in (the isolation cart)." E15 looked in the isolation cart, but did not find any gowns. E15 stated, there were "none available. I would say they haven't been using them since they are not available." 20. On 11/13/13, the facility provided a list of the residents that use the mechanical lift on the 100 hall as follows: R7, R11, R40, R41. 21. On 10/30/13, at 8:50 AM, E36, Housekeeper, was cleaning R6's and R7's room. R6's was on contact isolation for[DIAGNOSES REDACTED]. After cleansing the room, E36 removed a broom from her cart which was outside the room. E36 swept the floor and placed the broom back on the cleaning cart. E36 stated she was going to mop the floor with a floor cleaner. E36 did not mop the floor with a 1:10 ratio of bleach disinfecting solution. After mopping the floor, E36 placed the mop back into the mop bucket. She pushed the cleaning cart to the other side of the facility. E36 entered into the housekeeping room, then emptied her mop bucket water into the sink. She refilled the mop bucket with water and floor cleaner. At no time, did she disinfect the bucket or remove the broom which was used to clean R6's room. At 9:20 AM, E36 pushed her cleaning cart down the hallway. E36 stated she was going to continue to clean other residents' rooms. The Material Safety Data Sheet for the above floor cleaner used on 10/30/13 was reviewed. This cleaner did not contain bleach. 22. On 10/29/13 at 11:40 AM, E15 used a glucometer to check R35's blood sugar. E15 placed the glucometer directly on the medication cart prior to cleaning the glucometer. E15 then wiped the glucometer with a (bleach wipe). The glucometer air dried remaining wet for less than 30 seconds. E15 did not clean the top of medication cart where the glucometer had been. 23. The bleach wipe's label documents, in part, "Active ingredient: Sodium hypochlorite. Directions for use: Allow treated surfaces to remain wet for 5 minutes." 24. On 11/13/13, E1, Administrator reported the following residents use the glucometers from the medication cart shared for use for the 100 hall and a portion of the 300 hall. The residents included are: R6, R7, R15, R33, and R35. 25. The Physicians Order Sheet (POS) for 10/2013 documents R8 has [DIAGNOSES REDACTED]. On 10/29/13, at 1:03 PM, E8 and E9, CNA put on gloves to transfer R8 from his wheelchair using a sit to stand mechanical lift. After positioning R8 in bed, E8 and E9 used the same gloves to use the sit to stand lift to transfer R8's roommate, R9 from his wheelchair to his bed. E8 and E9 failed to change gloves, cleanse or wash their hands after care for R8, before moving on to provide care for R9. 26. On 10/30/13, at 10:20 AM, E7, LPN prepared to do a treatment for [REDACTED]. E7 washed her hands and applied gloves. E7 removed R8's pants and the closure tabs of the incontinent brief before pulling the brief down to expose R8's buttocks. E7 pulled R8's buttocks apart with the same gloves to expose the wounds to R8's coccyx. E7 used the same soiled gloves to pick up a clean wash cloth and enter the bathroom to wet the wash cloth. E7 cleansed R8's buttocks and wounds with the cloth, removed her gloves and dried R8's buttocks and coccyx area with a clean towel. At that time, E7 stated, "I probably should have gloves on." On 10/30/13, at 10:25 AM, E7 washed her hands and applied gloves. E7 opened the tube of barrier cream, applied some onto her hands and applied the cream to both pressure areas. E7 used the same gloves to apply a protective barrier wipe around the cream before removing her gloves. E7 disposed of the gloves in a plastic bag, then pulled R8's brief and pants up without washing her hands. On 10/ at 10:27 AM, E7 washed her hands and without applying gloves, turned R8 onto his left side, removed the tabs of his incontinent brief to expose R8's right hip to check his skin condition. E7 then reapplied the tabs to the brief, pulled up his pants and repositioned R8 to his right side with a draw sheet. E7 then did the following without wearing gloves or washing her hands: placed a pillow behind R8's back, gave him the call light, placed the bed in the low position, moved the bed next to the wall, pulled back the privacy curtain, went into the hall to obtain a sheet and a blanket from the linen cart, folded the blanket and placed it between his feet while touching his legs, pulled the privacy curtain again, touched her clothing with both ungloved hands, touched a pillow and placed it under R8's feet, covered R8, raised up the bed with the remote control panel, picked up a towel, turned off the light and left R8's room without washing her hands. On 10/30/13, at 10:41 AM, after exiting R8's room, E7 opened the shower room door with her unwashed hands to dispose of the soiled linen bag. E7 then washed her hands in the shower room. 27. The POS for 10/2013 documents a [DIAGNOSES REDACTED]. On 10/29/13, at 1:05 PM, R3 stood up from her dining room chair. The chair was soaked with urine. The back of R3's pants and the inside of the right leg were soaked with urine. E14, CNA assisted R3 to sit on the toilet and removed R3's disposal incontinent brief and pants while wearing gloves. R3's pants and incontinent brief were heavily soaked with urine. E14 disposed of the wet brief. With the same soiled gloves, E14 then touched R3's soiled pants, removed R3's shoes and applied a clean brief to R3. E14 began pulling up R3's soiled and wet pants when R3 stated, "Are these the dirty ones?" E14 replied, "No", pulled up the soiled pants and put R3's shoes back on using the same soiled gloves. R3 asked E14 for wet toilet paper as she was standing holding onto a wheeled walker. E14 touched the faucet with soiled gloves to turn on and off the water, and gave R3 toilet paper that had been soaked with water. R3 wiped her front perineal area with the wet toilet paper to cleanse herself. E14 used the soiled gloves to give R3 some dry toilet paper. On 10/20/13, at 1:30 PM, E14 removed her soiled gloves and pulled up R3's clean brief and soiled pants after touching the gait belt without washing her hands. R3 propelled herself to the sink to wash her hands with E14 holding onto the gait belt. R3 then ambulated from the bathroom wearing the wet pants and sat down in her wheelchair as E14 was holding the gait belt. E14 then washed her hands and left the room. 28. On 10/29/13, at 11:50 AM, E30, CNA, used gloves as he provided perineal care to R1. R1's adult incontinent brief was soiled with both urine and stool. E30 used the same soiled gloves to apply barrier cream. E30 continued to use the same soiled gloves as he pulled up R1's clean incontinent brief and pants, and transferred R1 into the wheelchair. E30 then removed the soiled gloves and washed his hands. 29. On 10/30/13, the facility's Nosocomial Infection Log from 10/2012 through 10/30/13 was reviewed. The January 2013 Nosocomial Infection Log documents the following 18 residents had upper respiratory infections (URI's) : R1, R18, R20, R24, R38, R42, R43, R46, R47, R48, R49, R50, R51, R52, R53, R54, R55 and R56. The Log failed to document any diagnostic test were completed to determine the causative organisms of these URI's. On 10/31/13, at 8:50 AM, an interview was conducted with E35, Infection Control Nurse/Registered Nurse (RN). E35 stated she only gathers and documents information on the log for infection control purposes. E35 stated she is not responsible for tracking or trending this information. E35 stated E2, DON, is responsible for analyzing this information. When questioned why there were a large number of residents with URI's in January 2013, E35 stated at that time of year there was a lot of flu, but she was not sure what was going on during that time. On 11/6/13 at 1:05 PM, an interview was conducted with E2. E2 stated she and E35 were responsible for the infection control program. E2 stated she goes through the Infection Control Log and looks for patterns and trends to identify where the infections may have originated. E2 stated if they find the problem with infection control, they fix it, inservice staff and re-evaluate the system. E2 stated she thought there was a flu-type virus in the building in January 2013. E2 stated she was not sure if staff were educated on infection control procedures during this time. E2 stated she was not sure if the County Health Department were informed of the outbreak. On 11/7/13, at 11:00 AM, an interview was conducted with E2. E2 stated she called the County Health Department and they did not receive any notice regarding an URI outbreak in the facility in January 2013. E2 stated she could not find any documentation that inservices regarding infection control were conducted in January 2013. 30. The facility's Inservice documentation for the past year was reviewed on 11/7/13. There is no documentation of any inservices on Infection Control or[DIAGNOSES REDACTED] for direct care staff prior to the current survey. Housekeeping staff was inserviced for: Contaminated Isolation Rooms on 2/28/13,[DIAGNOSES REDACTED] on 3/18/13, Infection Control on 3/29/13, PPE (Personal Protective Equipment) on 3/29/13, Procedures for Infection Control and Introduction to Infection Control on 6/13/13. 31. The Resident Census and Conditions of Residents, CMS 672, dated 10/29/13 documents that the facility has 56 residents living in the facility. The Immediate Jeopardy situation was identified and determined to have begun on 10/30/13, at 2:00 PM, after observations and interviews failed to show the facility had an ongoing program in place for infection control. E1 and E2 were notified of the Immediate Jeopardy on 10/30/13 at 10:30 AM. Based on observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. On 11/1/13, the facility completed inservicing all staff regarding infection control procedures including handwashing, isolation protocols, need for PPE, cleaning/disinfection protocols, use of glucometer for residents with infections, need for dedicated equipment and handling of linens. 2. On 10/30/13, E4, Director of Social Service held a meeting with R6 and R7 to educate them regarding[DIAGNOSES REDACTED] and to explain the risks of sharing a room. 3. On 10/30/13, the facility placed dedicated equipment in R6's and R7's room. 4. On 10/30/13, the facility performed a review of all isolation rooms and to ensure the proper PPE and disinfection equipment was present and available for staff use. 5. On 10/30/13, R6's and R7's Care Plan were updated. 6. On 10/31/13, R6's room was cleaned and disinfected with a 1:10 ratio of bleach solution, including the floor. All equipment, including the mechanical lifts were cleansed with this solution. 7. On 11/1/13, after the facilty completed inservices, the facility conducted return demonstrations on handwashing and infection control procedures and protocols.

A. Based on observation, interview and record review, the facility failed to assess, identify causative factors contributing to falls; implement, monitor and modify interventions to prevent falls; provide adequate supervision to prevent falls ; and provide safe transport and transfer procedures to prevent injury for 4 of 7 residents (R3, R8, R10 and R12) reviewed for falls and injuries in the sample of 14. This failure resulted in R3 falling and sustaining a right wrist fracture. Findings include: 1. R3's Physician's Order Sheet (POS) dated October 2013 documented she had partial [DIAGNOSES REDACTED]. R3' Minimum Data Set (MDS), dated [DATE] and 6/6/13 documents she was moderately impaired cognitively. The MDS, dated [DATE], documents she required extensive assistance of one staff person for transfers, ambulation and toileting. The MDS documents she was not steady and only able to stabilize with human assistance when moving from the seated to standing position, turning around, moving on and off toilet and surface-to-surface transfers. On 10/29/13, at 1:05 PM. E14, Certified Nurse's Aide, CNA, asked R3 to stand up from the dining room table. R3 stood, grabbed her walker and began to walk down the hallway toward her room. R3's gait was steady. At 1:20 PM, E14 assisted R3 onto the toilet. E14 exited the bathroom, closed the bathroom door and left R3 alone on the toilet unsupervised. E14 left R3 alone on the toilet for two to three minutes while gathering R3's clothes. On 10/31/13, at 3:05 PM, an interview was conducted with R3. R3 stated she was able to transfer herself to the toilet and from her wheelchair. R3 stated "They don't want me to, but I can." The facility's Occurrence Report, dated 11/8/12, documents at 11:30 AM, R3 was found sitting on the floor in Room 40. The Occurrence Report documents "Has history of transferring self and ambulating short distances without assist. Has unrealistic views of limitations. Resident said she wanted to sit in the library and read. She said she did this. When trying to sit back in her wheelchair, she got her footing wrong and landed on the floor. Noted resident ambulating in the hallway shortly after with assist of walker. " The Recommendation documents "Refer to restorative therapy." The facility's Occurrence Report, dated 1/8/13, documents at 4:20 PM, R3 was found in her room on the floor. The Occurrence Report documents "She stated that she was on the commode and slipped self to floor and scooted self to bedside to attempt to get self up off floor." The Occurrence Report documents she had been toileted at 3:45 PM. The Recommendation documents "Educate Resident regarding refusing toileting." R3's Care Plan was revised on 1/9/13 "Bruise noted on coccyx. Had been in B/R (Bathroom) on commode et (and) scooted to bed. Did not use B/R call light prior to fall on 1/8/13." The Care Plan documents "Notify SS (Social Service) if res (resident) refusing toileting schedule. One on ones as needed re: toileting." The facility's Occurrence Report, dated 5/5/13, documents at 7:35 PM, "Visitor came up to nurses station and notified me that the resident was on the floor in her bathroom. " The Report documents "When encouraged to use her call light, the resident states ' I know I should, but I don't want to bother you girls.' " The Occurrence Report documents R3 had been toileted at 7:00 PM. R3's Care Plan, revised on 5/6/13 documents "Reviewed care plan for falls (and) no recommendations noted at this time." The facility's Occurrence Report, dated 5/10/13, documents at 7:12 PM, "I was notified by CNA staff that the resident was on the floor in her room. Upon entering the room, I visually observed the resident sitting upright on the floor on her buttocks. She was close to the entry door of the room with her back facing the door." The Report documents "Had her pants and undergarment around her ankles. Noted that she was incontinent of stool. Her wheelchair was in the bathroom with wheels locked. Water was running in sink." The Report documents " Resident has history of frequent falls which often occur when she is attempting to toilet herself. Despite frequent reminders to use her call light for assistance and toileting schedule, the resident continues to transfer herself without assistance." The Occurrence Report documents she had been toileted at 6:40 PM. R3's Care Plan was not revised after this fall to implement any new interventions to prevent her from falling in the future. R3's Care Plan, dated 6/18/13, documents "Resident requires assistance with ambulation, transfers, dressing, personal hygiene. She has [DIAGNOSES REDACTED]. Currently receiving PT for strengthening following multiple falls." The facility's Occurrence Report, dated 6/30/13 documents "Resident noted on floor face down with blood noted on the floor. Resident remain alert and oriented times three." The Report documents "Resident noted w/o (without) shoes, socks only, disposable undergarment noted on floor. Believed to be on her way to bathroom. Noted resident on floor face down in Resident's own blood." The Report documents R3 was sent to the hospital. R3's X-ray report dated 6/30/13 documents R3 fractured her right wrist. R3's Fall Risk Plan of Care was revised on 6/30/13 and documents staff were to encourage R3 to wear slipper socks when up, ensure her walker was within reach when in her wheelchair or in her bed and to encourage her to call for assistance when toileting. The Physician's Order Sheet, dated 7/3/13, documents R3 should continue Physical Therapy and Occupational Therapy after she sustained her fracture. R3's Nurse's/Physician's Communication Record, dated 9/23/13, documents "Resident tried to ambulate down hall to obtain wash cloth, she stated she go woozy and fell on her right hip." R3's Narrative Nursing Notes, dated 9/23/13 at 7:30 PM, documents "Resident was ambulating down hall (without) walker and lost her balance and fell on her right hip. Another resident's family member saw her fall, denied hitting her head." The Note documents "Encouraged resident to please use her call light for assistance." R3's Progress Note, dated 9/24/13, documents R3 complained of right hip pain. The Note documents Z3, R3's Physician was notified and ordered an x-ray of her right hip. R3's Radiology Report, dated 9/24/13 documents she had no fracture. R3's Care Plan was not revised at this time with progressive interventions to prevent her from future falls. R3's Nurse/Physician's Communication dated 11/1/13 documents at 8:00 PM, R3 fell while going from her bedroom to the bathroom. R3 did not use her call light or her walker. The report documents that staff would monitor R3 and educate her to use the call light. R3's Care Plan, revision dated 11/1/13, documents "Encourage resident to use call light and to use walker when up in room with assistance or may use w/c (wheelchair)." The Care Plan was not updated with any new/progressive interventions to prevent her from future falls. On 11/5/13, at 9:55 AM, an interview was conducted with E2, Director of Nurse's (DON). E2 stated R3 was a challenge. E2 stated R3 has been in therapy since May 2013 for strengthening. E2 stated as R3 gets stronger "there we go again." E2 stated R3 has no safety awareness. E2 stated they have not implemented any new interventions but are attempting to reinforce the old interventions. 2. R12's Physician's Order Sheet, dated November 2013, documents he had a partial [DIAGNOSES REDACTED]. The facility's Occurrence Report, dated 10/26/13 at 3:15 AM documents "Noted resident lying on the floor on stomach. Had been incontinent of B & B (Bowel and Bladder)." R12's Care Plan, revision dated 10/26/13, documents "Observed on floor attempting to take himself to bathroom. No injury." The Care Plan revision dated 10/28/13 documents "Scoop mattress, hi-low bed, mat on the floor." On 11/1/3, from 1:30 PM until 3:00 PM, R12 was lying in his bed. There was no mat on his floor. 3. The Physician's Order Sheet (POS) for 10/13/2013 documents R8 has a diagnosis, in part of Cerebral Vascular Accident with Right Side Hemiparesis. The Minimum Data Set, dated dated [DATE], documents R8 requires extensive assistance for transfers and bed mobility. On 10/29/13, at 1:38 PM, R8 was seated in the dining room in his wheelchair. Multiple wound closure strips were on his right elbow covering a large skin tear with red/purple discolorations. At that time when asked, R8 stated, "The girls (Certified Nurses Aides) lost control of my wheelchair and ran me into the wall's guardrail last Friday." The Nurse/Physician Communication Record, dated 10/16/13, documents the incident with R8 sustaining two skin tears to his elbow, measuring 3.0 centimeters (cm) X 2.5 cm and 3 cm X 1.3 cm. The Nurse/Physician Communication Record, dated 10/16/13, documents, in part, "(R8) was being transported out of the cafe by staff (unidentified) in his wheelchair, resident's right arm hit a rail in the hall on side of cafe. There are 2 skin tears just below the right elbow. The area was cleansed with wound spray and (wound closure strips) are in place." The Occurrence Report, dated 10/16/13, at 12:00 PM, for R8 documents, in part, "Resident was being pushed by staff from the cafe and was bumped into the side rail in the hall. (E14, CNA) said the hall was very congested and she bumped the wall with (R8)". R8's Care Plan, dated 10/08/13, fails to document the incident including the skin tears and the treatment ordered by the physician. On 10/30/13, at 10:30 AM, E7, Licensed Practical Nurse (LPN) was interviewed about the skin tears to R8's right elbow. E7 stated, "I think he was being pushed in his chair, and they bumped him into the handrail. We did a change in condition for it." On 11/01/13, at 9:55 AM E10, Registered Nurse (RN) was interviewed about R8's skin tears to his right elbow. E10 stated, "He got it a while ago. It happened during a transfer. I heard he bumped it." The POS for 10/2013 and 11/2013 were reviewed on 11/01/13. There were no physician orders documented for treatment to R8's right elbow. On 10/29/13, at 1:03 PM, E8 and E9, CNA's transferred R8 from his wheelchair to bed with a sit to stand lift. R8's shins to both lower extremities were resting against the lift during the transfer. On 10/30/13, at 1:30 PM, after completing a treatment for [REDACTED]. A scabbed area to R8's left shin was noted with no dressing. At that time, when asked what caused the injury to the left shin, E7 stated, "He bumped it on something." POS, dated 9/9/13, documented "Cleanse left lower leg with wound cleanser, apply Optifoam, dressing every 3 days and PRN till healed." On 11/01/13, at 9:55 AM, E12, RN was interviewed about the cause of the wound to R8's left shin. E10 stated, "It's from leaning into the sit to stand lift. I remember making sure it was clean with a (foam dressing). Now we just observe for signs and symptoms of infection." The Occurrence Report for R8, dated 7/17/13, at 6:30 PM, documents, in part, "Abrasion to left lower leg. Noted area coincides with rubber area on lift. Recommendation-Inservice staff on placement of legs on lift. Noted resident kicks leg out. Also apply a barrier between his legs and the lift." The Post Incident 72 hour Follow Up form for R8, dated 7/19/13 documents a "abrasion 4 cm X 3 cm to left lower leg." The Weekly Skin Condition Evaluation, dated 9/11/13, documents, "abrasion left lower leg." The Weekly Skin Condition Evaluation form, dated 10/02/13 documents, "scabs and abrasion in left leg." The Weekly Skin Condition Evaluation form, dated, 10/09/13, documents "scabs left leg." 4. On 10/31/13 at 3:30 PM, R10 was sitting in his wheelchair during an activity in the dining room. R10's wheelchair did not have auto-lock brakes. R10's Care Plan for Fall preventions documents an intervention, dated 10/22/13, for auto-lock brakes on R10's wheelchair, In an interview on 11/1/13 at 10:25 AM with E17, Care Plan Coordinator, she observed and verified R10 did not have the auto-lock brakes his wheelchair. On 11/1/13 at 10:30 AM, E28, Maintenance Director, stated he did not remember getting a request to put the auto-lock brakes on R10's wheelchair. B. Based on observation and interview, the facility failed to maintain bathroom equipment in safe and secure condition for three of 14 residents (R8, R29 and R12) reviewed with toilet frames in the sample of 14 and (R 17, R 18, R 24, R 25, R 26 and R 27) in the supplemental sample. Findings include: From 11/1 through 11/5/13, general environmental observations were made at the facility. Some of the toilets were equipped with aluminum toilet frames. These frames had plastic arm rest attached to a metal frame which were secured to the base of toilet behind the toilet seat. The following residents had aluminum toilet frames arm rests which were loose, allowing unstable movement when weight was applied to the arms when sitting down on the toilet seat: R8, R9, R12, R17, R18, R24, R25, R26 and R27. On 11/5/13, at 9:10 AM, an interview was conducted with E28, Maintenance Director. E28 stated the legs of the toilet frames had plastic and could not be tightened. E28 stated he thought the toilet frames were older and were getting loose. E28 stated "These are too loose." E28 stated these toilet frames needed to be replaced. C ) Based on record review and interview, the facility failed to provide supervision for a safe unrestricted environment for one of 14 residents (R1) in the sample of 14 and one resident (R17) in the supplemental sample. Findings include: R1 and R17's October 2013 Physician's Order Sheet (POS) both document R1 and R17 have diagnoses, in part, of Alzheimer's Disease. The facility abuse investigations dated 2/9/13, 5/2/13, 6/4/13 and 10/1/13 document resident to resident altercations between R17 and R1. The 5/2/13 abuse investigation documents, R1 swung at R17 when their wheelchairs entangled in the hallway. The 6/4/13 abuse investigation documents, R1 swung at/hit R17 in the dining room when she bumped into R1's wheelchair. The 10/1/13 abuse investigation documents, R1 went into R17's room and hit R17. In an interview on 11/5/13 at 1:30 PM, E20, Certified Nurse Aide (CNA), explained that R1 has unpredictable behavior, but R1 did not focus on any one person. E20 said she works full-time on R1's hallway. E20 said the safety interventions for R1 are to distract her with food. On 11/6/13 at 9:55 AM, in an interview with the E2, Director of Nurses (DON), she explained R1 focuses on R17 due to R1's belief that R17 had an affair with R1's husband. E2 described preventative interventions to increase supervision and the use of aroma therapy for R1 when she gets upset. E2 explained the staff are to keep these residents separated. R1's Care Plan revised on 9/3/13 has no documentation of these interventions. R17's Care Plan revised on 8/26/13 does not document progressive interventions for R17's safety from R1 following resident to resident altercations on 2/9/13, 5/2/13, 6/4/13 and 10/1/13 .