Every finding on record at Carlinville Rehab & HCC

Based on interview and record review, the facility failed to prevent resident to resident abuse in 2 of 4 residents (R5, R6) reviewed for abuse in the sample of 17. Findings Include:1.On 4/15/26 at 1:50 PM, R5 was unable to recall any details of the alleged incident with R16. R5's Face Sheet, undated, documents R5 has the following diagnoses: Hemiplegia/Hemiparesis following CVA (Cerebral Vascular Accident), Bipolar Disorder, Weakness, and Cognitive Communication Deficit.R5's MDS (Minimum Data Set), dated 3/23/26, documents R5 has a BIMS (Brief Interview of Mental Status) score of 15, indicating R5 is cognitively intact.R5's Progress Note, dated 1/19/26 at 4:51 PM, documents the following: SSD (Social Service Director) visited resident today. Resident stated that she has no trauma from the resident to resident. Resident stated that she just ignores the other resident now.On 4/15/26 at 2:35 PM, R16 stated she did hit and pull R5's hair, she shouldn't have done it, and she is sorry. R16 stated her and R5 get along and she hasn't had any further incidents with R5 or any of the other residents. R16's Face Sheet, undated, documents R16 has the following diagnoses: Cerebral Infarction, PTSD (Post Traumatic Stress Disorder), Depression, and Bipolar Disorder.R16's MDS, dated [DATE], documents R16 has a BIMS score of 15 and is cognitively intact.R16's Progress Note, dated 1/19/26 at 4:49 PM, documents the following: SSD visited resident today. Resident stated she has no trauma from the resident to resident. Resident stated that she knows she should not have touched the other resident.The Facility Abuse Investigation Final Report, dated 1/23/26, documents the following: Resident to Resident altercation on 1/16/26 involving R5 and R16. R5 reported to Administrator when she was coming into the building from smoking, R16 pulled her hair and hit her in the back of the head for moving too slowly. R16 reported she was attempting to get to her table and asked R5 to move. According to R16, R5 then called her a fat cow. R16 explained she asked R5 to move and again, she refused at which time she said she barely hit her on the head and pulled her hair. R16 felt that she did not harm R5, although admitting she should not have done what she did. R5 stated she told R16 she was going as fast as she could when R16 told her to get out of her way. R5 stated she was then told to move now and then R16 called her names regarding her weight. R5 explained she did retaliate by calling R16 names as well. R5 stated they bantered back and forth, with R16 eventually hitting the back of her head and pulling her hair twice. R5 explained she had not been injured but felt R16 should not have done this. After the completion of a thorough investigation, we did find evidence to substantiate R16 pulled R5's hair and hit her lightly on the head as R5 was not moving fast enough. Although this incident did occur, both residents stated they were not harmed and had a disagreement. The residents haven't had any further occurrences since the initial incident. Residents have had a discussion, resolving their issues. Care plans have been updated to include both residents' meeting with social services to discuss any further frustrations and effective communication with other residents. Both residents have also been educated to request staff assistance when attempting to navigate challenging interpersonal situations.2. On 4/16/26 at 10:10 AM, R6 stated there was an incident with her former roommate R17, when she (R6) was in bed and R17, who is confused was telling her she shouldn't be in that room, it was hers and she (R17) was going to take care of her. R6 started R17 then grabbed her TV (Television) remote, began swinging it around and hit R6 on the right hand and head, causing bruising and pain to her hand. R6 stated the facility wanted to get her hand x-rayed but she knew it wasn't broken so she decided not to have it done. R6 stated she hasn't had anything like that happen since. R6 stated she feels safe in the facility. R6's Face Sheet, undated, documents she has an admitting diagnosis of Acute Respiratory Failure with Hypoxia.R6's MDS, dated [DATE], documents R6 has a BIMS score of 15, indicating she is cognitively intact.R6's Progress Note, dated 2/13/26 at 5:05 PM, documents the following: Around 5:05 PM, this nurse heard yelling coming from resident's room. Resident roommate observed to be swinging bedside remote at resident. Resident states that she got hit 3 times on the hand, forearm, and head. Roommate taken out of resident's room immediately. Some redness noted to resident's left forearm no other new skin issues noted. Administrator in the facility made aware of resident-to-resident event. Around 5:10 PM the NP (Nurse Practitioner) called made aware of the resident-to-resident event. Around 5:20 PM, resident's son called and was made aware of the situation and spoke with resident herself. Resident states she is okay now that the other resident is out of her room.R17's Face Sheet, undated, documents R17 had an admitting diagnosis of Malignant Neoplasm.R17's MDS, dated [DATE], documents R17 had a BIMS score of 15, indicating she was cognitively intact.R17's Care Plan, dated 2/20/26, documents R17 can get physically aggressive towards other residents.R17's Progress Note, dated 2/13/26 at 5:08 PM, documents the following: Around 5:05 PM, heard yelling coming from resident's room. When walking into the room resident was observed to be sitting on the side of the bed holding her TV remote. Resident noted to be swinging her bed remote at roommate. When this nurse tried to approach resident to grab the bedside remote, resident then began to swing remote at writer. Resident's roommate states that the resident swung and hit her with the bedside roommate 3 times. This nurse called for help. Resident was assisted to reclining wheelchair and removed from the room immediately. Administrator here in the building and reported resident to resident event. Resident moved to room B-05B. At 5:10 PM. NP called and updated about resident-to-resident event. At 5:17 PM, resident's sister, was called. Voicemail left to call the facility back. Around 6:00 PM, resident's sister called back and was updated about resident observed behaviors. Per resident's sister this is totally abnormal behavior for resident. Resident has never been aggressive in the past nor tried to harm someone. Sister also informed of resident moving to another room. This nurse informed sister that I will inform hospice and will call her with an update/new orders. Around 6:15 PM, new orders received for urinalysis with culture & sensitivity and to start Sertraline 50mg (milligrams) daily. Around 7:00 PM, resident's sister updated about new orders.The Facility's Abuse Investigation Final Report, dated 2/13/26, documents the following: On 2/13/26 it was reported by V15, RN, that it was reported to him by R6 that R17 hit her with the TV remote. V15 separated the two residents immediately. R6 had a head-to-toe assessment and no concerns were identified. V17 was moved to a different room. R6 was unable to be interviewed further as she had been out of the facility since 2/15/26 for medical issues, unrelated to current incident. R17 did not remember the incident and only knows of it due to interview/report. V17 explained she is not typically aggressive, and she found out she also had a UTI (Urinary Tract Infection) and believed this to be the cause of her behavior. V15 stated that R6 reported to him that R17 hit her three times with the TV remote on her hand. V15 reported hearing R6 yell and when he entered the room, he found R17 waving the remote in the air. The IDT (Interdisciplinary Team) reviewed the investigation and based on statements, the facility determined R17 most likely hit R6 with the TV remote due to an altered state caused by a UTI.On 4/16/26 at 2:30 PM, V1, Administrator, stated she would expect the residents to be free from abuse.The Abuse, Prevention, and Prohibition Policy, dated 11/2025, documents the following: Each resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone.

Based on observation, interview, and record review the facility failed to administer an ordered intravenous, IV, antibiotic, timely transport, and contact prescribing Physician for 1(R2) of 3 residents in the sample of 23. This failure resulted in R2's course of treatment being interrupted, R2 needing to have six additional days of IV antibiotics, and the potential of septic infection. Findings include:R2's undated face sheet documents an admission date of 11/28/2025 and a discharge date of 12/4/2025. Diagnosis include Fournier Gangrene, Chronic Kidney Disease, Bacteriuria, Urinary Tract Infection, Acute Kidney Failure, Malignant Neoplasm of Rectum, Colostomy Status.R2's Minimum Data Set, MDS dated R2's MDS dated [DATE] documents R2 has no cognitive deficits. R2 is dependent for rolling, sitting and transfers. R2's baseline care plan dated 12/4/2025 documents The resident has Catheter: Neurogenic Bladder. Interventions include Catheter Care, Position catheter bag and tubing below the level of the bladder and away from entrance room door. R2's order sheet dated 11/28/2025 Ceftazidime-Avibactam Intravenous Solution Reconstituted 2.5 (2-0.5) GM (Ceftazidime-Avibactam Sodium) Use 0.94 gram intravenously two times a day for antibiotic until 12/08/2025 11:59PM.R2's November medication administration sheets, MARS, dated 11/1/2025-11/30/2025 documents Ceftazidime-Avibactam Intravenous Solution Reconstituted 2.5 (2-0.5) GM (Ceftazidime-Avibactam Sodium)Use 0.94 gram intravenously two times a day for ABT until 12/08/2025 11:59PM. R2's 11/28/2025 PM, 11/29/2025 AM and PM dose, 11/30/2025 AM and PM doses all marked as Hold.R2's December medication administration sheets, MARS, dated 12/1/2025-12/31/2025 documents Ceftazidime-Avibactam Intravenous Solution Reconstituted 2.5 (2-0.5) GM (Ceftazidime-Avibactam Sodium) Use 0.94 gram intravenously two times a day for ABT until 12/08/2025 11:59PM. R2's 12/1/2025 AM and PM doses and 12/1/2025 AM and PM doses marked as Hold. R2's progress notes dated 11/28/2025 at 7:00AM document The nurse reported that R2 was newly admitted to the facility with intravenous, IV, antibiotics for Clostridioides difficile, C diff, and Extended Spectrum Beta-Lactamase, ESBL, in the urine. The pharmacy informed that the ordered antibiotic is not available and cannot be supported. The nurse was advised to contact the hospital or prescribing provider to request an alternative medication. The patient remains stable per the nurse. Rounding provider to follow up. R2's progress notes dated 11/28/2025 at 5:15PM documents Call received from pharmacist at to notify that he cannot supply IV antibiotic until Monday 12/1/2025 due to having to order from a different pharmacy.R2's progress notes dated 11/28/2025 at 5:32PM documents Received call from pharmacist. Pharmacist states that he is unable to obtain IV antibiotic for supply, he is also unable to suggest appropriate interchange due to not having culture and sensitivity for reference. V23, Facility Nurse Practitioner, NP, notified of above, with suggestion to attempt to contact ordering hospitalist for new antibiotic. current order antibiotic to be placed on hold pending new orderR2's progress notes dated 11/29/2025 at 11:32PM document Antibiotic/ESBL urine/CDIFF (Vancomycin) IV antibiotic remains on Hold until Monday. No adverse side effects, ASE, noted from medication, Afebrile. R2 voicing no concerns/complaint/discomforts. Able to make needs and or wants known. IV site free of signs of infection with dressing clean, dry, intact, CDI. R2's progress notes dated 12/1/2025 at 11:57AM document Health Status Note Note Text: call placed to V20, Infectious Disease Physician, at this time to notify of unavailable antibiotic order, message provided to nurse in with patient. awaiting response. R2's progress notes dated 12/3/2025 at 5:04PM documents Received call from nurse V20's office with orders to send R2 back to hospital for continuing treatment of IV antibiotics if unable to obtain from any pharmacy for treatment outside of hospital. Per V20 statement is he will not change the IV medication as it is the only medication that can be used. R2's progress notes dated 12/3/2025 at 6:26PM documents Emergency Medical Services, EMS, in facility, refusing to take resident to Emergency Department, ED.R2's progress notes dated 12/3/2025 at 7:38PM out of town EMS refused at 6:23PM. Out of town EMS refused at 6:25PM. Out of town EMS at 6:36PM refused. Out of town EMS at 7:01PM refused. Out of town EMS at 7:37PM refused. Out of town EMS at 7:42PM refused. Out of town EMS at 7:45PM refused. Out of town EMS at 8:08PM refused. Out of town EMS at 8:18PM refused. On 12/9/2025 at 12:46PM V4, Minimum Data Set, MDS Coordinator, stated R2 was discharged on an IV that is usually only given in hospitals. We got a hold of the Infectious Disease Doctor, IDD, and the IDD wanted R2 to go back to the hospital for the IV med to be given there. Then we had an issue with getting him back to the hospital. We could not get an ambulance to come get him. He was almost 500# and was too big for us to take him in our van. We have our own transportation but R2 was too wide to fit. On 12/11/2025 at 11;30AM V4 stated I did not realize the order to hold the IV antibiotic did not come from V20. The order came from V23. On 12/9/2025 at 12:49PM V2, Director of Nursing, DON, stated R2 came to the facility on [DATE]. The pharmacy could not get the IV antibiotic until 12/1/2025. He was still on his oral antibiotics. We called and got a hold of V20 he said to hold the IV antibiotic until 12/1/2025. The pharmacy then said they could not get the IV antibiotic at all. We tried several times to get a hold of V20. V20's office finally called on 12/3/2025 and said R2 could only get that IV antibiotic in the hospital. I was here until 10:00PM on 12/3/2025 trying to get different ambulance companies to agree to transport R2. We called bariatric companies and could not get anyone to come. Finally, a company agreed to come get him on the morning of 12/4/2025. On 12/11/2025 at 11;30AM V2 stated I was under the impression the order to hold the antibiotic was from V20. The order came from V23.On 12/11/2025 at 12:45PM V3, Assistant Director of Nursing, ADON, stated R2 got here on 11/28/2025. Pharmacy called and said they could not get the IV antibiotic that was ordered. We tried to call V20, and they were unavailable, and it was the weekend. We called V23 that is over us and V23 is who gave us the order to Hold the IV antibiotic until Monday 12/1/2025 when we could get in touch with V20. On 12/11/2025 at 2:00PM V20 stated The facility should not have accepted (R2). By the facility accepting (R2) and then not being able to provide prescribed antibiotic caused an interruption in treatment. This was a near miss for (R2) and it is unacceptable. There was a miscommunication between the hospital and the facility. The antibiotic prescribed is very expensive and no facility can afford it. (R2) was readmitted with an abscess of the pelvis and needed another 6 days of antibiotic therapy due to the interruption of therapy. (R2) needed assessment and to resume antibiotic therapy. Our office was not notified that (R2) was not getting the antibiotic until 12/2/2025. On 12/12/2025 at 11:00AM V20, ID, stated When I say (R2) was a near miss I mean (R2) had the potential for septic infection and recurrence of infection. (R2) was readmitted with an abscess of the pelvis and needed another 6 days of antibiotic therapy due to the interruption of therapy. On 12/12/2025 at 11:15AM V22, Pharmacist, stated I dealt with this situation involving (R2). The reason the antibiotic was unavailable was due to the logistics of the antibiotic. It was unavailable from our primary and secondary supplies. The reason is the dose of the drug. It is a mandatory compound drug. It is a very new drug. It is very unstable. It is for immediate use only. There is no extended stability. The drug is so new and so unstable it would have to be sent out every 12 hours. (R2) should've never left the hospital. Had we been contacted prior to (R2) being discharged I would've been able to tell them that this antibiotic was unavailable. We don't typically get advanced notice. We don't typically get forms prior to admission. On 12/16/2025 at 11:15AM V1, Administrator, and V5, Social Services Director, SSD, stated All our referrals go through our corporate office. A clinical liaison through our corporate office is who does the screening and they let us know who and when they will be coming. We may get 2-day notice or we may get 1 hour. V5, SSD, stated I give V2, DON, the packet when I get it for her to look at the orders. On 12/16/2025 at 12:35PM V2, DON, stated On 11/26/2025 in the afternoon was my first day as DON. On 11/26/2025 I received the discharge packet for (R2). In the packet were his preliminary orders. I am not sure if those orders were sent to pharmacy or not. Then the next day was Thanksgiving. The orders could've gone to Pharmacy on 11/28/2025. Facility Medication Administration policy dated 11/2025 states Medications shall be administered according to established schedules. Administration times can be changed to meet each facility's unique resident population and to maintain compliance with state and federal laws. A physician's order for specific times supersedes any routine schedule. Residents may request alternate medication schedules. Such times must be documented on the resident's medication administration record and care plan.

Based on observation, interview and record review the facility failed to provide a palatable meal to residents at the facility. This failure has the potential to affect all 79 residents residing at the facility. Findings include: 1. During resident council meeting on 6/24/2025 at 10:30 AM R26, R29 and R49 all stated their food is cold when served. R26's Minimum data set (MDS), dated [DATE], documents R26 is cognitively intact. R29's MDS, dated [DATE] documents R29 is cognitively intact. R49's MDS, dated [DATE], documents R49 is cognitively intact. The facility Resident Council Minutes, dated May 8, 2025, documents issues/concerns; food cold. The facility Resident Council Minutes dated June 3, 2025 documents issues/concerns: cold dinner and breakfast. On 6/24/2025 at 11:41 AM food temperatures obtained from steam table prior to first tray; rice 206 degrees, corn 188 degrees, mashed potatoes 152 degrees, gravy 140 degrees, corned beef 162 degrees. On 6/24/2025 12:52 PM during noon meal a test tray was obtained and removed from cart when the last meal tray was served to residents. The test tray consisted of mashed potatoes with gravy, corn, corned beef, and rice. The corned beef was cold, tough and hard to chew, the mashed potatoes with gravy was warm, the rice was cold, gummy and had no taste. The food temperatures obtained per surveyor were corn 140 degrees, mashed potatoes and gravy 131 degrees, rice 119 degrees and corned beef 117.8 degrees. On 6/25/2025 at 12:20 PM V4, Dietary Manager stated she would expect food to be served at the correct temperature and to be palatable. The facility policy general Dining experience, undated, documents residents will have an exceptional dining experience that enhances their quality of life and provides attention to the individual resident's plan of care and dining wishes. The policy documents meal will be nourishing attractive and palatable. The policy documents meals will be served at the appropriate texture and consistency to meet the individuals plan of care, but not limiting the right to make personal choices. The facility policy Monitoring Food Temperature for Meal Service, undated documents food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures. The policy documents roast pork 145 degrees Fahrenheit (F) for 4 minutes , stuffed foods or casseroles 165 degrees F 15 seconds. 2. On 6/23/25 at 11:02 AM, R3 stated, The food is bad. It is either burnt or just plain bad. The chicken patty is hard as a brick. I order out a lot because of how bad the food is. R3's admission Record, print date of 6/24/25, documents R3 was admitted on [DATE]. R3's MDS, dated [DATE], documents R3 is cognitively intact. 3. On 06/23/25 at 11:05 AM, R10 stated, The food is awful. It is cold. I always eat in my room. R10's admission Record, print date of 6/25/25, documents R10 was admitted on [DATE]. R10's MDS, dated [DATE], documents R10 is cognitively intact. 4. On 06/23/25 at 11:00 AM, R60 stated, The food portions are small. It isn't hot but lukewarm. R60's admission Record, print date of 6/24/25, documents R60 was admitted on [DATE]. R60's MDS, dated [DATE], documents R60 is cognitively intact. The CMS 671 Long Term Care Facility Application for Medicare and Medicaid dated 6/23/2025 documents a facility census of 79 residents.

Based on observation, record review and interview the facility failed to store food in a manner to prevent food borne illness. This has the potential to affect all 79 residents at the facility. Findings include: 1. On 6/23/2025 at 8:40 AM there was bowl of ice cream on the floor of walk in freezer. In the dry storage room, 2 boxes of apple juice unopened and 10 large cans of chicken noodle soup in the case were sitting on the floor. The white upright freezer in the dry storage room contained a open, unlabeled, and undated package of 8 turkey patties. A bag of chicken patties in the box that were opened and undated. The 3 compartment refrigerator in kitchen contained 2 single serving bowls of cottage cheese that were uncovered and undated. 3 lettuce salads with cheese covered with clear wrap that were undated. Next to salads on a plastic tray plastic was an individual container of salad dressing and a white condiment container of mayonnaise both were uncovered and not labeled. On 6/25/2025 at 12:20 PM V4, Dietary Manager stated can goods should not be stored on the floor an opened food should be covered, labeled and dated. The facility policy Food Storage (Dry, Refrigerated, and Frozen), undated, documents food shall be stored on shelves in a clean, dry area, free from contaminants. The policy documents leftover contents of cans and prepare food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. The policy documents to store dry food on shelves six inches off the floor to allow for proper sanitation. The CMS 671 Long Term Care Facility Application for Medicare and Medicaid dated 6/23/2025 documents a facility census of 79 residents.

6. During resident council meeting on 6/24/2025 at 10:30 AM R26, R29 and R49 all stated call lights are not answered timely. R26, R29 and R49 all stated it is worse on the night shift due to agency staff, and they are always on their phones. R26's MDS, dated [DATE], documents R26 is cognitively intact. R29's MDS, dated [DATE], documents R29 is cognitively intact. R49's MDS, dated [DATE], documents R49 is cognitively intact. The Facility Resident Council Minutes, dated April 1, 2025, documents issues/concerns: hall daily, lights. The Facility Resident Council Minutes, dated May 8, 2025, documents follow-up concern from last meeting; call light times. Based on interview and record review, the facility failed to answer call lights in a timely manner for 8 of 18 residents (R3, R26, R29, R48, R49, R53, R60, R174) reviewed for dignity in the sample of 43. Findings include: 1. On 06/23/25 at 10:30 AM, R48 stated, At night it can take up to an hour and a half for them to come in and answer the light. R48's Face Sheet, print date of 6/24/25, documents R48 was admitted on [DATE]. R48's Minimum Data Set, (MDS), dated [DATE], documents R48 is moderately cognitively impaired and requires partial to moderate assistance with Activities of Daily Living (ADL's) and mobility. 2. On 06/23/25 at 10:43 AM, R53 stated at night it takes a long time for them to come in because they are talking on their phones. R53's admission Record, print date of 6/24/25, documents R53 was admitted on [DATE]. R53's MDS, dated [DATE], documents R53 is cognitively intact, requires assistance from staff for ADL's, and is dependent on staff for mobility. 3. On 6/23/25 at 11:02 AM, R3 stated, At night, I have waited 2 hours for them to answer my call light. R3's admission Record, print date of 6/24/25, documents R3 was admitted on [DATE]. R3's MDS, dated [DATE], documents R3 is cognitively intact and requires assistance from staff for ADL's and mobility. 4. On 6/23/25 at 11:00 AM, R60 stated, It can take over a half an hour for them to come if someone is on break. R60's admission Record, print date of 6/24/25, documents R60 was admitted on [DATE]. R60's MDS, dated [DATE], documents R60 is cognitively intact and requires assistance with ADL's and mobility. 5. On 06/23/25 at 10:55 AM, R174 stated, Sometimes it takes over an hour for someone to come in. This morning I had to walk up to the nurses station to get help. R174's admission Record, print date of 6/24/25, documents R174 was admitted on [DATE]. R174's MDS, dated [DATE], documents R174 is cognitively intact and requires assistance with ADL's and mobility. On 6/25/25 at 11:40 AM, V30, Regional Director of Operations, stated, We do not have a call light policy. I expect the call light to be answered in 5 minutes or less.

Based on observation, interview and record review, the facility failed to provide bathing, personal hygiene and documentation for 5 of 7 (R4, R8, R21, R36 and R224) residents, reviewed for activities of daily living, in a sample of 43. Findings include: 1.On 06/23/2025 at 02:47 PM R8's hair was greasy. On 06/24/2025 at 12:33 PM R8's hair was greasy. R8's Physicians order sheet, dated 6/25/2025, documented diagnoses of Alzheimer's Disease, and Type 2 diabetes mellitus. R8's Minimum data set (MDS) dated [DATE] documented that her cognition was severely impaired and was dependent upon staff for bathing and hygiene. R8's Care Plan dated, 3/11/2025, documented an intervention of BATHING: (R8) requires the assistance from one staff member to assist with bathing. R8's Local hospice documentation, dated for 4/2025 and 5/2025 did not document that received a shower or a bath from 4/7/2025 to 5/12/2025 per hospice documentation. There was no documentation of R8 receiving a shower or bed bath from the staff at the facility. On 06/25/25 at 11:46 AM, No further documentation was presented for R8 showers after several request given to V2, Director of Nurses. The facility's Shower schedule, undated, documented that R8's shower days were Monday and Thursday in the AM On 06/25/2025 at 10:43 AM, V27, Certified Nurse Assistant, (CNA) stated that if hospice does not give a resident a shower that week, then they will give a shower. On 06/25/2025 at 10:44 AM, V26, CNA, stated that if hospice does not give a resident a shower that week, then they will give a shower. On 06/25/2025 at 10:45 AM, V21, Restorative CNA, stated that if hospice does not give a resident a shower that week, then they will give her a shower. 2. On 06/23/2025 at 11:26 AM, R21 was lying in bed asleep. Hair was greasy. On 06/23/2025 at 12:53 PM, R21 was sitting up in her wheelchair at the dining table, hair was greasy and stringy. On 06/24/2025 at 11:46 AM, R21 was sitting up in her wheelchair, at the dining room table, hair remained greasy. Physicians order sheet, dated 6/25/2025, documented diagnoses of Parkinson's Disease without dyskinesia, and need for assistance with personal care. R21's MDS, dated [DATE], documented that her cognition was severely impaired and that she was dependent upon staff for bathing. R21's Care plan, dated 4/28/2024. documented, BATHING: (R21) requires 1 staff participation with bathing. The facility's Shower schedule, undated, documented that R21's shower days were on Monday and Thursday evenings R21's shower documentation, for March 2025, documented that showers were given on 3/17/2025, 3/20/25, and 3/31/25. R21's Shower documentation for April 2025, documented that showers were given on 4/3/25, 4/10/25, 4/14/25, and 4/17/25. R21's shower documentation for May 2025, documented that showers were given on 5/8/25, 5/11/25, and 5/22/25. R21's Shower documentation for June 2025, documented that showers were given on 6/5/25, 6/9/25, 6/16/25, 6/19/25 and 6/23/25. 3. On 06/23/2025 at 830 AM, R224 stated that he hasn't had a shower in 3 weeks. Hair was messy and greasy in appearance. R224's Shower documentation, dated June 2025, documented that no showers have been given. The facility's shower schedule, undated, documented that R224's shower days were Tuesday and Friday Am. R224's Face sheet, dated 6/25/2025, documented an admission date of 6/3/2025 and diagnoses of Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery and R224's Discharge summary from a regional hospital, dated 5/28/2025 a diagnosis of blindness secondary to CMV retinitis. R224's MDS, dated [DATE], documented that his cognition was moderately impaired and that he required partial to moderate assist with bathing. R224's Care plan, dated 6/4/2025, documented that he required assistance from one staff member for bathing. 4. On 06/24/2025 at 11:07 AM, R36 stated that she writes down the dates of when she gets a shower. R36's piece of paper documented that she received a shower on 5/13/25, 5/27/25, 6/3/25, and 6/10/25. R36 stated that last week they came through and said they were going to give her a bed bath after lunch and then they never came back. R36 was lying in bed, 2nd and 3rd fingers on right hand were dirty and her hair was matted and greasy looking. R36's shower documentation for the month of March 2025, documented that showers were given on 3/18/2025 and 3/30/25. R36's April 2025 shower documentation, documented that a shower was given on 4/8/25. R36's May 2025 shower documentation, documented that showers were given on 5/13/25 and 5/27/25 and her June 2025 shower documentation, documented that showers were given on 6/10/25, 6/13/25, 6/17/25 and 6/22/25. The facility's Shower Schedule, undated, documented that R36 shower days were Sunday and Thursday evenings. R36's MDS, dated [DATE], documented that her cognition was intact and that she was dependent upon staff for bathing. R36's Care plan, dated 9/4/24, documented, (R36) requires 2 staff participation with bathing. R36's Physicians order sheet, dated 6/25/2025, documented diagnoses of Morbid (severe) obesity due to excess calories, End stage renal disease and need for assistance with personal care. 5. On 06/23/2025 at 09:34 AM R4 was asleep in bed. She had a mustache and a thick amount of hair on her chin. R4's hair was greasy. On 06/23/25 at 10:49 AM, R4 stated that someone named (redacted) shaves her, but she hasn't seen her in 2 days. R4's shower documentation for March 2025, documented that no showers were given in the month of March. R4's April 2025 shower documentation, documented that showers were given on 4/2/25, 4/8/25, and 4/16/25. May 2025 Shower documentation documented that showers were given on 5/2/25 and 5/24/25 and her June 2025 shower sheet documented showers were given on 6/2/25, 6/7/25, 6/10/25, and 6/22/25. The facility's shower schedule, undated, documented that R4's shower days were Monday and Thursday evenings. R4's Physicians order sheet, dated 6/25/2025, documented diagnoses of Chronic obstructive pulmonary disease and Legal blindness. R4's MDS, dated [DATE], documented that her cognition was intact and that she was dependent upon staff for bathing. R4 Care plan, dated 11/13/2024, documented required 1 staff participation with bathing. Her care plan also dated 6/23/2025 documented, I DO NOT LIKE TO BE SHAVED AND WILL REFUSE. On 06/25/2025 at 08:37 AM, V2, Director of Nurses was asked if there was any refusal documentation for bathing for R4, R8, R21, R36, R224 and she was unable to provide information during this investigation. On 06/25/2025 at 10:45 AM, V28, LPN, stated that the CNA's let them know if a resident refuses a shower and that the shower book has the schedule. On 06/25/2025 at 10:50 AM, V27, CNA, stated that the shower schedule is in the book and the chart in (electronic medical record) when the resident refuses. V27 stated that the resident is approached several times if they refuse. On 06/25/2025 at 10:54 AM, V26, CNA, stated that the shower schedule is in the book and the chart in (electronic medical record) when the resident refuses and that the resident is re-approached 3 times about their bath. On 06/25/2025 at 10:55 AM, V25, CNA, stated that the shower schedule is in the book and the chart in (electronic medical record) when the resident refuses and that the resident is re-approached 3 times about their bath. On 06/25/2025 at 10:56 AM, V21, Restorative CNA, stated that the shower schedule is in the book and the chart in (electronic medical record) when the resident refuses and that the resident is re-approached 3 times about their bath. The facility's policy, Activities of Daily Living, undated, documented, This facility provides each resident with care, treatment and services according to the resident's individualized care plan.

3. On 06/23/2025 at 09:30 AM, R4 was lying in bed, asleep, and her oxygen was on per nasal cannula. R4's oxygen tubing was not dated and there was not humidity bottle. R4's Physicians order sheet, dated 6/25/2025, documented diagnoses of Chronic obstructive pulmonary disease and Legal blindness. It also documented, Oxygen Tubing - Change Weekly every night shift, every Sun for maintenance. Oxygen - clean O2 concentrator filter with water and allow to air dry weekly. Every night shifts every Sun for maintenance. It also documented an order, 2L o2 via Nasal Cannula continuously R4's MDS, dated [DATE], documented that her cognition was intact. R4's Care Plan, undated, documented, (R4) has Oxygen Therapy r/t COPD 4. On 06/23/2025 at 08:36 AM, R22 was asleep in bed, and her oxygen was running, and the tubing was coiled up on the end of her bed, but it was not on her. R22's oxygen tubing was not labeled nor dated. On 06/23/2025 at 11:06 AM, R22 was lying in bed, awake, stated that she does not wear her oxygen all the time and that she gets her nebulizer treatment every 6 hours. R22's nebulizer mask was hanging from the over bed table and the storage bag was sitting on the overbed table. R22's nebulizer tubing was not dated. R22's Physicians order sheet, dated 2/24/25, documented an order for Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083%, 3 ml inhale orally via nebulizer every 6 hours as needed but did not document an order for oxygen. R22's Physicians order sheet, dated 6/2025, documented diagnoses of Chronic obstructive pulmonary disease and influenza due to identified novel influenza A virus with other respiratory manifestations. R22's MDS, dated [DATE], documented that her cognition was intact. R22's care plan did not document interventions for oxygen nor interventions for her nebulizer. On 06/25/2025 at 11:00 AM, V28, LPN, stated that when oxygen and nebulizer tubing is changed weekly, it should be labeled and dated. V28 also stated that the nebulizer mask should be in a bag when not in use. On 06/25/2025 at 11:15 AM, V22, RN, stated that when oxygen and nebulizer tubing is changed weekly, it should be labeled and dated. V28 also stated that the nebulizer mask should be in a bag when not in use. Based on Interview, Observation, and Record Review, the facility failed to label and date Oxygen (O2) and nebulizer tubing, O2 mask, and humidified bottle, failed to provide a humidified water bottle for O2 administration, and failed to change the O2 tubing as ordered for 4 of 5 residents (R1, R4, R22, R31) reviewed for O2 therapy in the sample of 43. The Findings Include: 1. R1's admission Record, dated 6/25/25, documents R1 was originally admitted to the facility on [DATE] with diagnosis of Chronic Respiratory Failure with Hypoxia, Chronic Pulmonary Edema, Morbid Obesity, Type 2 Diabetes Mellitus (DM), Major Depressive Disorder, Dysphagia, and Hypertension (HTN). R1's Care Plan, dated 5/8/25, documents R1 has O2 Therapy related to Respiratory illness. Interventions: O2 settings per MD (medical doctor) order, monitor for signs/symptoms (s/sx) of respiratory distress and report to MD PRN (as needed), give medications as ordered by physician, monitor/document side effects and effectiveness. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and is dependent on staff for all Activities of Daily Living (ADLs). R1's Physician Order (PO), dated 2/26/25, documents Oxygen Tubing - Change Weekly, every night shift every Sun (Sunday). R1's PO, dated 2/26/25, documents Oxygen - clean O2 concentrator filter weekly, every night shift every Sun. R1's PO, dated 2/26/25, documents Oxygen 2L (liters)/min (minute) via nasal cannula (NC), continuously. On 6/23/25 at 10:30 AM, R1 was seen lying in bed on O2 at 3 L/NC via oxygen concentrator with no humidified water bottle attached, and no date on the NC tubing. On 6/24/25 at 8:28 AM, R1 has O2 on 3 L/NC without a water bottle and the NC tubing not dated. On 6/25/25 at 8:40 AM, R1 seen lying in bed with O2 on at 3L/NC via oxygen concentrator with no humidified water bottle attached to concentrator, the NC tubing is not dated. R1 stated she does not remember when her NC was last changed, stated they usually write a date on the tubing, but she does not see a date on this one. 2. R31's admission Record, dated 6/25/25, documents R31 was originally admitted to the facility on [DATE] with diagnosis of Chronic Respiratory Failure with Hypoxia, Morbid Obesity, Aortic Valve Stenosis, Myocardial Infarction, Dysphagia, Spinal Stenosis, Polyneuropathy, Lymphedema, Type 2 DM, Anxiety Disorder, Depression, and Osteoarthritis. R31's Care Plan, dated 4/16/25, documents R31 has O2 Therapy related to respiratory failure. Interventions: O2 settings per MD order, position resident to facilitate ventilation/perfusion matching: Use upright, high Fowler's position whenever possible to allow for optimal diaphragm, monitor for s/sx of respiratory distress and report to MD PRN. R31's MDS, dated [DATE], documents R31 is cognitively intact and is dependent on staff for ADLs. R31's PO, dated 2/27/25, documents O2 at 2L/min via nasal cannula PRN. R31's PO, dated 2/27/25, documents Oxygen - clean O2 concentrator filter weekly, every night shift every Sun. R31's PO, dated 2/27/25, documents Oxygen - Change nebulizer and nebulizer tubing weekly, every night shift every Sun. R31's PO, dated 7/25/24, documents 2-L per NC cont. every shift. On 6/23/25 at 10:40 AM, R31 was seen lying in bed with O2 on at 2 L/NC via oxygen concentrator with the humidified bottle of water almost completely empty and dated 6/16/25. R31 stated it usually runs dry and she must remind them that she needs a new bottle. R31's NC is dated 6/16/25. On 6/24/25 at 8:30 AM, R31 was seen lying in bed with O2 on at 2 L/NC via oxygen concentrator with the humidified water bottle now empty and both the bottle and NC are still dated 6/16/25. On 6/25/25 at 8:38 AM, R31 was seen lying in bed with O2 on at 2L/NC, via oxygen concentrator with the humidified water bottle still empty and both the water bottle and NC still dated 6/16/25. On 6/25/25 at 1:15 PM, V1, Administrator, stated I would expect the nurses to provide a humidified water bottle for residents on oxygen, label the water bottle and the oxygen tubing when applying a new one, and changing them weekly as ordered. The Facility's Oxygen Administration Policy, dated 3/2025, documents in part General Guidelines: 1. Oxygen therapy is administered by way of an oxygen mask or nasal cannula. Equipment and Supplies: 2. Nasal cannula, nasal catheter, mask (as ordered). 3. Humidifier bottle. 10. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. 11. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated. 12. Replenish water in humidifying jar as needed.

3. On 06/23/2025 at 01:17 PM, V8, Activity Director, without benefit of hand hygiene, passed a lunch tray to R226. V8 set up R226's meal tray. She then exited R226's room into the hallway to the meal cart. 4. On 06/23/2025 at 01:19 PM, V8, Activity Director, without benefit of hand hygiene, then retrieved the meal tray for R224 and took it to his room. She set up his tray and explained what was on his tray. On 06/25/2025 at 10:50 AM, V28, LPN, stated that hand sanitizer should be used in between residents when passing meal trays. On 06/25/2025 at 10:52AM, V27, CNA, stated that hand sanitizer should be used in between residents when passing meal trays. On 06/25/2025 at 10:53 AM, V26, CNA, stated that hand sanitizer should be used in between residents when passing meal trays. On 06/25/2025 at 10:55 AM, V25, CNA, stated that hand sanitizer should be used in between residents when passing meal trays. On 06/25/2025 at 10:56 AM, V22, RN, stated that hand sanitizer should be used in between residents when passing meal trays. On 06/25/2025 at 10:58 AM, V12, Restorative CNA, stated that hand sanitizer should be used in between residents when passing meal trays. On 06/25/2025 at 11:05 AM, V8, Activity Director, stated that hand sanitizer should be used in between residents when passing meal trays. On 06/25/2025 at 11:31 AM, V2, Director of Nurses, stated that they have a Skills Checklist for Handwashing but not an actual policy. Based on Interview, Observation, and Record Review, the facility failed to provide proper hand hygiene while assisting residents during meals for 4 of 24 residents (R6, R224, R226, R277) reviewed for hand hygiene in the sample of 43. The Findings Include: R6's admission Record, dated 6/25/25, documents R6 was originally admitted to the facility on [DATE]. R277's admission Record, dated 6/25/25, documents R277 was originally admitted to the facility on [DATE]. On 6/23/25 at 1:00 PM, V7, Certified Nursing Assistant (CNA), was seen sitting in a chair between R6 and R277. V7 was assisting R6 with her food, then would turn and assist R277 with her food. V7 failed to do hand hygiene between residents. V7 was seen grabbing the arms of her chair, grabbing R6's wheelchair to move her closer to the table, yawning while covering her mouth with her hand, rubbing her face, and then grabbing a dinner roll by her bare hands and asking R277 if she wanted it, all while assisting both residents with their meals and failing to provide any hand hygiene. On 6/25/25 at 1:15 PM, V1, Administrator, stated I would expect the staff to do hand hygiene while assisting residents with feeding in the dining room. On 6/25/25 at 11:10 AM, V2, Director of Nursing (DON) stated We don't have a hand hygiene policy. We only use the Handwashing Skills Checklist. The Facility's Handwashing Skills Checklist, undated, only documents the process of how to wash your hands and does not include when staff should be washing their hands.

Based on interview and record review, the facility failed to offer pneumonia vaccines for 5 of 5 residents (R3, R7, R10, R53, R62) reviewed for vaccines in the sample of 43. Findings include: 1. R53's admission Record, print date of 6/24/25, documents R53 was admitted on [DATE] with diagnoses of Type 2 diabetes and Sleep Apnea. R53's Immunization Record fails to document R53 has had the pneumonia vaccine or declined the vaccine. 2. R10's admission Record, print date of 6/25/25, documents R10 was admitted on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease. R10's Immunization Record fails to document R10 has had the pneumonia vaccine or declined the vaccine. 3. R3's admission Record, print date of 6/24/25, documents R3 was admitted on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease. R3's Immunization Record fails to document R3 has had the pneumonia vaccine or declined the vaccine. 4. R62's admission Record, print date of 6/24/25, documents R62 was admitted on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease. R62's Immunization Record fails to document R62 has had the pneumonia vaccine or declined the vaccine. 5. R7's admission Record, print date of 6/24/25, documents R7 was admitted on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease. R7's Immunization Record fails to document R7 has had the pneumonia vaccine or declined the vaccine. On 6/24/25 at 3:30 PM, V2, Director of Nurses, stated the pneumonia vaccine was not offered this past year. V2 stated she did not know why but they are working on fixing that. The facility has not had an outbreak of pneumonia over the winter or recently. On 06/25/25 at 11:17 AM V29, Travel Nurse Manger, stated We offer the pneumonia vaccination upon admission and yearly. For the policy on who receives the vaccine we follow the CDC (Center for Disease Control) guidelines.

Based on interview and record review, the facility failed to prevent physical abuse for 1 of 1 resident (R67). This failure affects two residents (R43 and R67) reviewed for abuse in the sample of 43. Findings include: R43's Health Status Note, dated 4/25/2025 at 5:33 PM, documents, Note Text: Resident in dining area got up from sitting went to kitchen window picked up cup of thickened cold liquid. while walking back to her seat she threw out cup of liquids onto another resident (R67). (R67) was tended to and incident was witnessed by 2 kitchen helpers (V4) and (V23). R43 denies doing this upon questioning. (R67) received head to toe assessment without injury. Administrator was informed. R43's Abuse Final Report, dated 5/2/25, documents, On 4/25/25, (R43) was walking to the dish window in the dining room and poured her drink on (R67). Staff intervened and (R43) promptly returned to her seat. It continues, At conclusion of the investigation, based on staff statements, the incident did occur. On 6/25/25 at 9:20 AM, V1, Administrator, stated residents can not throw water on other residents that is abuse. R67's admission Record, print date of 6/24/25, documents R67 was admitted on [DATE]. R67's Minimum Data Set (MDS), dated [DATE] documents R67 is severely cognitively impaired. R43's admission Record, print date of 6/24/25, documents R43 was admitted on [DATE]. R43's MDS, dated [DATE], documents R43 is moderately cognitively impaired. The Abuse, Prevention and Prohibition Policy, dated 3/2025, documents, The facility prohibits mistreatment, neglect, or abuse of residents.

Based on record review and interview, the facility failed to provide the physician with the pharmacy recommendation and to provide limitations or rationale for a physician ordered as needed anti-anxiety medication, for 1 of 3 (R56) residents reviewed for psychotropic medication review, in a sample of 43. Finding includes: R56's Physicians order sheet, dated 6/2025, documented diagnoses of Alzheimer's disease with late onset, Cognitive communication deficit, Neurocognitive disorder with Lewy bodies, Major depressive disorder, Generalized anxiety disorder and panic disorder. R56's Minimum Data Set, dated [DATE], documented that his cognition was severely impaired and that he has had no behaviors exhibited. R56's Care plan, dated 9/10/2024, documented, Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. R56's Physician's order sheet, documented an order dated 3/1/2025, Lorazepam 0.5 milligrams (mg) take 1 tablet by mouth every 4 hours as needed for anxiety, (shortness of breath), restlessness or agitation. On 06/24/2025 at 4:15PM, V2, Director of Nurses (DON) stated that she was not aware that the Ativan had not been reordered every 14 days. R56's Pharmacy Medication recommendation, dated 12/18/24 and 1/21/25, both documented recommendations for Quetiapine 100mg every morning and 200mg every night to be decreased to Quetiapine 100mg every morning and 150 mg every night. Theses were not sent to R56's Physician. R56's Pharmacy Medication recommendation, dated 3/18/2025, for Quetiapine 100mg every morning and 200 mg every night to be decreased to Quetiapine 100mg every morning and 150 mg every night. This gradual dose reduction was sent to the physician on 3/19/2025 and the medication was reduced. R56's Pharmacy Medication recommendation, dated 2/12/2025, documented Buspirone 30mg twice daily to be decreased to Buspirone 30 mg in the morning and 15 mg at night. This was not sent to his Physician. R56's Physicians order sheet, dated 2/27/2025, documented an order for Buspirone 30 mg every morning and every night. On 06/24/2025 at 01:34 PM, V2, DON, stated that she did not see any notes on when R56's doctor was contacted or what had happened with his Pharmacy Medication Recommendations. On 06/24/2025 at 02:19 PM V2, DON, presented documentation that on 3/19/2024 R56's Nurse Practitioner signed off on the recommendation, but she was unable to find documentation that the Pharmacy recommendations from 12/18/24, 1/21/25 and 2/12/25 were addressed by R56's Physician. On 06/24/2025 at 4:15PM, V2, DON, stated that she does not have documentation where the doctor was notified about R56's Pharmacy recommendations nor does she have an updated physician's order for R56's Lorazepam. The facility's policy, Psychotropic Medication Use, dated 2/2025, documented, 4. Based on assessing the resident's symptoms and overall situation, the medical practitioner will determine whether to continue, adjust or stop existing psychotropic medication. It continues, 6. The timeframe for PRN (as needed) psychotropic medications, which are not antipsychotic medications, will be limited to 14 days unless a longer timeframe is deemed appropriate by the attending physician or the prescribing practitioner. The timeframe for PRN psychotropic medications which are antipsychotic medications is limited to 14 days without exception, unless the attending provider evaluates the resident and deems it necessary.

2. On 06/23/2025 at 08:28 AM R225 enteral feeding was not properly labeled and dated. An unknown enteral feeding was infusing at 45ml/hr. R225's Physicians order sheet, dated 6/18/2025, documented, an order for Every shift Nova Source Renal 45ML/Hr. continuous it also documented, NPO diet, NPO texture, NPO consistency R225's Physicians order sheet, dated 06/2025, documented diagnoses of encephalopathy and esophageal varices without bleeding. R225's MDS, dated [DATE], documented that R225 was rarely to never understood and that she required a feeding tube (e.g., nasogastric or abdominal (PEG) for nutrition. R225's Care plan, dated 5/29/2025, documented, My dietary preferences will be honored. Foods I dislike are: NPO. My favorite beverages are: NPO. My favorite foods are: NPO no documentation of tube feeding or flushing. On 06/25/2025 at 11:00 AM, V28, LPN stated that tube feeding orders are found in the physician order sheets and when a new tube feeding is hung, the bag is labeled with date, type of feeding, rate of feeding, residents name and nurses initials. V28 also stated that the new syringe and bottle should also be labeled and dated. On 06/25/2025 at 11:17 AM, V22, RN stated that tube feeding orders are found in the physician order sheets and when a new tube feeding is hung, the bag is labeled with date, type of feeding, rate of feeding, residents name and nurses initials. V28 also stated that the new syringe and bottle should also be labeled and dated. Based on Interview, Observation, and Record Review, the facility failed to follow physician orders and appropriately label resident tube feeding for 2 of 2 residents (R69 and R225), reviewed for tube feeding in the sample of 43. The Findings Include: 1. R69's admission Record, dated 6/24/25, documents R69 was admitted to the facility on [DATE] with diagnosis of Neoplasm of colon, Cerebral Palsy, Dysphagia, Epilepsy, Gastrostomy, and Anemia. R69's Care Plan, dated 5/15/25, documents R69 requires tube feeding for Swallowing problem. Interventions: Check for tube placement and gastric contents/residual volume per facility protocol and record, hold feed if greater than 15 ml (milliliter) aspirate, needs assistance/supervision/cueing with tube feeding and water flushes, needs the HOB (head of bed) elevated 45-degrees during and thirty minutes after tube feed, RD (Registered Dietitian) to evaluate quarterly and PRN (as needed), monitor caloric intake, estimate needs, make recommendations for changes to tube feeding as needed. R69's Minimum Data Set (MDS), dated [DATE], documents R69 has a moderate cognitive impairment and requires substantial/maximal assistance for Activities of Daily Living (ADLs). R69's Physician Orders (PO), dated 4/21/25, documents Enteral Feed every 4-hours Flush Peg-Tube with 150 ML (milliliter) of water. R69's PO, dated 4/21/25, documents Enteral Feed every shift for G-Tube Isosource 1.5 at 60 ML/hour 23 hours/day. May stop for therapies. R69's PO, dated 4/18/25, documents Flush Peg-Tube with 60 ML of water before & after administration of medication or Bolus, every shift for Peg-Tube management. R69's PO, dated 4/18/25, documents Enteral Feed (see order) diet, NPO (nothing by mouth) texture, NPO consistency, Peg-tube in place. R69's PO, dated 4/18/25, documents Enteral- Change feeding syringe daily, label with name and date, every night shift for G-Tube. R69's Dietary Note, dated 5/26/25 at 10:03 AM, documents RD Tube Feeding Review: HT (height): 67, WT (weight): 5/12 127.6# (pounds), BMI (body mass index): 20.0, resident remains on tube feeding and flush of: Isosource 1.5 @ (at) 60 ML/hour for 23 hours with water flush of 150 ML Q (every) 4 hours. At this time no tolerance concerns reported. Present feeding and flush is providing: 1380 ML total volume formula, 2070 calories, 94 GM (gram) protein, 1949 ML free water. Note free water calculation does not include water flushes with medications. Wts (weights) at this time are showing a loss of 17% in the last month with WT on 4/14 and 4/20 154#. No lab or skin concerns reported at this time. Note present tube feeding and flush is exceeding estimated needs for calories/protein/fluids. At this time no change in tube feeding or flush. Will request to recheck WT and to place on weekly Wts for monitoring. Refer to RD as needed. R69's Electronic Health Record, Vitals/Weights, since admission date, documents R69's Weights: 4/17/25 at 154lbs, 5/12/25 at 127.6lbs, 5/28/25 at 129.2lbs, 6/4/25 at 125.1lbs, 6/11/25 at 131.6lbs, 6/12/25 at 129lbs, and 6/18/25 at 128.7lbs. All weights are not consistent while ranging from 125.1lbs to 154lbs but has had a weight loss compared to admission weight. On 6/23/25 at 9:30 AM, R69's G-Tube syringe is seen on a side table and is undated, a bag with feeding being infused by a pump is unlabeled, and undated, a bag of water hanging and attached to the pump is unlabeled and undated, and a syringe in a plastic container is unlabeled and undated. There are two different cartons of feeding on R69's side table next to her syringe and a gallon of distilled water. There is an 8oz carton of Ensure Original, and an 8oz carton of Jevity 1.5cal. (calories). Unsure of what is infusing into R69 due to it being unlabeled and the cartons of feedings are not what was ordered by the Physician. One carton of Ensure Original 8oz (ounce) (237 ML) = Calories 250, Total Fat 6g (grams), Sodium 210mg (milligram), Carbohydrate 41g, Protein 9g, Fiber 3g, and Sugars 23g. One carton of Jevity 1.5cal 8oz (237ml) = Calories 355, Total Fat 11.8gm Sodium 316mg, Carbohydrate 51.1g, Protein 15.1g, Fiber 5g, and Sugars 3.6g. One carton of Isosource 1.5 cal. 8.45oz (250ml) = Calories 375, Total Fat 14.8g, Sodium 330mg, Carbohydrate 44g, Protein 17g, Fiber 3.8, and Sugars 8g. On 6/24/25 at 12:20 PM, V14, Licensed Practical Nurse (LPN), stated I already checked (R69's) G-Tube, flushed it, but did not give her any feeding because she still had some in her bag. When asked what feeding R69 was getting, V14 picked up a carton of Jevity 1.5cal off the side table and stated, This is what (R69) is getting for tube feeding. On 6/24/25 at 1:43 PM, V19, Dietitian, stated I was not informed of (R69's) change in product being used. Clinically speaking, Isosource provides 1.5 cal./ml while Ensure Original only provides 1.06 cal/ml. If they are not giving the Isosource as ordered, that may be contributing to (R69's) weight loss. I would expect the facility to contact me of any product changes or if they run out of a product and need something to substitute, I can direct them with the right product. On 6/24/25 at 2:15 PM, V20, Supplies/Medical Records, stated I have plenty of the Isosource, as a matter of fact, I have a lot of cases of it on the shelf right now. On 6/24/25 at 2:32 PM, V19 stated Again, I was not notified of any changes of the Tube Feeding product for (R69). My understanding was that she was getting the Isosource as ordered. If they ran out of the Isosource, the somewhat equal product would be the Jevity 1.5 while waiting for the Isosource to come in. They both have 1.5cal./ml, however the Jevity is less in protein and other things. Any time there is a change in tube feedings, the Physician must be notified to write a substitution order until the supply comes in, because at this point, I do not have ordering privilege at that facility. I am the RD at that facility and come in monthly to review the resident's information and make notes and recommendations. On 6/25/25 at 1:15 PM, V1, Administrator, stated I would expect the nurses to administer tube feedings according to the physician's order, and to label the tube feeding bag with correct information including resident name, product name, date started, and rate of administration. On 6/25/25 at 11:05 AM, V29, LPN, Travel Nurse Manager, stated We don't have a policy on tube feeding. We use the Enteral Tube Feeding Skills Checklist. The Facility's Skills Checklist, undated, documents in part Administer only full-strength feeding tube formulas. Check the Enteral Nutrition Label against the order before administration. Add the following information: Resident name, type of formula, date and time formula was prepared, and rate of administration. Check the order to verify the type, amount, method, and rate of administration. on the formula label document initials, date and time the formula was hung.

Based on Interview, Observation, and Record Review, the facility failed to properly store medications for 1 of 1 resident's (R9) reviewed for safe medication storage in the sample of 43. The Findings Include: On 6/23/25 at 9:55 AM, R9 was seen lying in bed with a cup of medications with 12 pills/capsules in the cup. R9 stated the nurse brings them to her every morning and will leave them with her and she will take them later after she eats her breakfast. On 6/25/25 at 1:15 PM, V1, Administrator, stated I would expect the nurses, while administering medications to residents, to watch the resident take the medications and not to leave them for resident to take on their own. The Facility's Storage and Return of Drugs Policy, dated 4/2021, documents in part B. Residents' medications shall be properly labeled and stored at or near the nurse's station in a locked cabinet, a locked medication room, or in one or more locked mobile medication carts of satisfactory design for such storage. All mobile medication carts shall be under the visual control of the responsible nurse at all times when not stored either in a locked room or otherwise made immobile. I. The medication cabinet, medication room, or mobile medication cart shall be the responsibility of the person authorized to handle and administer medications.

Based on interview and record review the facility failed to administer physician ordered medication for 4 (R3, R5, R8, R10) of 4 reviewed for medication administration in the sample of 10. 1. R3's Face sheet documents an admitted [DATE]. Diagnosis include Respiratory Syncytial Virus Pneumonia, End Stage Renal Disease, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes. R3's MDS dated [DATE] documents R3 has no cognitive deficits. R3's Care Plan dated 2/9/2025 documents R3 has pain Diabetic neuropathy. Interventions include monitor/record/report to Nurse R3's complaints of pain or requests for pain treatment. Anticipate the R3's need for pain relief and respond immediately to any complaint of pain. R3's order sheets documents on 4/10/2025 Pregabalin Oral Capsule 75 MG (Pregabalin) *Controlled Drug. Give 1 capsule by mouth two times a day for pain/discomfort. R3's medication administration sheets (MARS) dated 4/1/2025-4/29-2025 documents Pregabalin Oral Capsule 75 MG (Pregabalin) *Controlled Drug. Give 1 capsule by mouth two times a day for pain/discomfort. Start 4/13/2025 at 5:00AM. Doses not documented as administered 4/18/2025 PM dose. 4/19/25- 4/22/2025 no AM or PM dose. Chart code #6 documented as reason for missed medication as to see progress notes. R3's progress notes dated 4/17/2025 at 11:00AM document Called to pharmacy for Pregabalin refill. Per pharmacy tech written script is required for further refills. New prescription form faxed to pharmacy at this time. R3's progress notes dated 4/22/2025 at 12:07AM documents Pharmacy unable to get Lyrica here until next run at this time. Pharmacist reported calling and speaking with Medical Doctor, MD. R3 reports pain in bilateral legs and hips at a 4 out of 10. R3 reports her tolerable pain level is at about a 5 or 6. R3 instructed to put on call light if pain increases past tolerable pain level. R3 repositioned by Certified Nursing Assistants, CNAs, at this time to promote comfort. R3's progress notes dated 4/22/2025 at 2:23AM documents Writer has spoken with MD three times regarding facility needing a script sent to local pharmacy. Pharmacist also spoke with MD and reported she has asked MD to send script as well and he has agreed to that but has not transmitted medication script at this time. Writer and pharmacist unable to do anything further at this time. R3 observed with eyes closed at this time with even non labored breaths. Writer and CNAs continue to round on R3. On 4/25/2025 at 1:45PM R3 sitting in bed eating her lunch. Stated I was out of Lyrica for a few days. I have neuropathy in my feet and I was in pain not having the Lyrica. I have not missed any other meds than I am aware of. 2. R5's Face sheet documents an admitted [DATE]. Diagnosis include Obesity, Type 2 Diabetes, Hypertension, Hypomagnesemia. R5's MDS dated [DATE] documents R5 has no cognitive deficits. R5 requires maximum assist with mobility and transfers. R5's care plan dated 2/4/2025 documents R5 is on pain medication, therapy related to neuropathy. Interventions include administer medication as ordered. R5's order sheet dated 1/27/2025 documents Pregabalin Oral Capsule 100 MG (Pregabalin) *Controlled Drug*Give 2 tablet by mouth every 8 hours for Seizures. R5's April MARS dated 4/1/2025-4/28/2025 documents Pregabalin Oral Capsule 100 MG (Pregabalin) *Controlled Drug*Give 2 tablet by mouth every 8 hours for Seizures. Start date 1/27/2025 at 1:00PM. Doses not documented as administered 4/12/2025 5:00AM dose, 4/16/2025 5:00AM dose, 4/20/2025 5:00AM dose, 4/23/2025 5:00AM dose and 9:00PM dose, 4/24/2025 5:00AM dose. On 4/29/2025 at 9:40AM R5 sitting up in chair in dining room. Stated I am out of my Lyrica all the time. I was out for 5 days in February. Got the Lyrica in and then out after a week. It took another 3 days to get more in. I ran out again yesterday and they did get it in and I got a dose this morning. If I don't get my Lyrica I feel like I am standing on shards of glass. I am to get Lyrica 3 times a day. On 4/29/2025 at 10:00AM Director of Nursing, DON, stated We have been having issues with a new system. Typically, the Doctor writes the script for 90 days. Pharmacy sends us 30 days or 1 blister pack at a time. When blister pack is getting low the nurse clicks refill and another card is sent. We are working with a new medical system. Sometimes narcotics have been an issue. We are in the process of getting a new medical director. We have a Nurse Practitioner but she does not have a Drug Enforcement Administration license. On 4/25/2025 at 2:00PM V4, Licensed Practical Nurse, LPN, stated she was unaware that R3 was missing her Lyrica. On 4/25/2025 at 3:00PM V17, Complainant, stated I just felt bad for the resident (R3). She was in pain and was out of her pain meds (medication) and I know what that is like. I have had surgery and been in pain. Facility policy dated 4/21 states All medications shall only be administered by licensed nursing personnel in accordance with their respective licensing requirement. All nursing personnel must have eighter appropriate training, experience, or both, if duties include administration of medications. PRN medication cards are to be ordered as needed not necessarily on a monthly basis. Do not wait until the card is empty to notify the pharmacy of a needed refill. 35156 3. R8's Physician Order Sheet (POS) for April 2025 documents a diagnosis of unspecified lack of coordination, abnormities of gait and mobility, hallucinations, insomnia, repeated falls, Parkinson's disease, other urticaria, hallucinations, mononeuropathy of right upper limb, including shoulder, generalized anxiety, major depression, restless leg syndrome, generalized skin eruption due to drugs and medicaments taken. The April POS also document Gocovri oral capsule extended release 24 hours 137 MG (milligrams) (amantadine HCL (hydrocholoride). Give 1 capsule by mouth at bedtime related to Parkinson disease without dyskinesia, without mention of fluctuations. The POS also documents, R8 has an order for amantadine (generic name for Gocovri). R8's Care Plan with a date initiated of 12/10/2024 document (R8) has Parkinson's disease. Interventions: Give medications as ordered by the Physician. Monitor/document side effects and effectiveness, dated initiated 12/10/2024. R8's Minimum Data Set (MDS) dated [DATE] document she is cognitively intact for decision making of activities of daily living. On 4/29/2025 at 1:11 PM, R11, Husband of R8 stated there were some issues with medications and (R8) did not receive all of her medications something to do with them not being at the Facility. R8's MAR dated April 2024 document R8 did not receive her Gocovri oral capsule extended release 24 hours 137 MG (milligrams) or (Amatadine) for seven out of 28 days, 4/2/2025, 4/20/2025, 4/24/2025, 4/26/2025 and 4/28/2025. R8's Progress Note dated 4/2/2025 at 6:28 PM, Gocovri Oral Capsule extended release 24 hour 137 MG, give 1 capsule by mouth at bedtime related to Parkinson's; disease without dyskinesia, without mention of fluctuations. Waiting for pharmacy. R8's Progress Note dated 4/20/2025 at 6:00 PM, Gocovri Oral Capsule extended release 24 hour 137 MG give 1 capsule by mouth at bedtime related to Parkinson's; disease without dyskinesia, without mention of fluctuations. On order. R8's Progress Note dated 4/24/2025 at 11:24 PM, Gocovri Oral Capsule extended release 24 hour 137 MG, give 1 capsule by mouth at bedtime related to Parkinson's; disease without dyskinesia, without mention of fluctuations, waiting on medication for delivery. R8's Progress Note dated 4/26/2025 at 8:04 PM, Gocovri Oral Capsule extended release 24 hour 137 MG, give 1 capsule by mouth at bedtime related to Parkinson's; disease without dyskinesia, without mention of fluctuations, Waiting on arrival on medication. On order. R8's Progress Notes dated 4/28/2025 does not document anything related to the Gocovri oral capsule. On 4/29/2025 at 1:11 PM, V2 stated, Gocovri is a medication that they use for (R8's) Parkinson disease. If the medication was given there should be a check mark on the MAR and an initial of whoever gave the medication. I see there are holes on the (R8's) MAR and she did not get the medicine every day. I know we had samples of that medication but if staff gave her the samples, they still should have marked it on the MAR. 4. R10's POS for April 2025 documents a diagnosis of Type 2 diabetes mellitus without complications, paraplegia, chronic pain, generalized anxiety disorder, major depression, cognitive communications deficit, abnormalities of gait and mobility. R10's Care Plan does not address her estrogen replacement. R10's MDS dated [DATE] document R10 was cognitively intact for decision making of activities of daily living. On 4/30/2025 at 1:30 PM, R10 stated she had missed a few doses of her estrogen R10's POS dated April 2024 document and order for Premarin Cream 0.625 MG/GM, (Estrogens, Conjugated), Insert 1 gram vaginally at bedtime every other day for hormone replacement -Start Date- 01/09/2025 7:00 PM. R10's April MAR document R10 missed four doses of Premarin Cream in April: 4/7/2025, 4/8/2025, 4/19/2025 and 4/20/2025. R10's Progress Notes does not document anything related to (R10) not receiving her estrogen cream. On 4/30/2025 at 11:12 AM, V2, Director of Nursing stated, We recently lost our Medical Director who use to come to the facility twice a week. We have a new company and have zoom meetings but there has been some delay in certain medications. I am not sure why (R10) did not get her estrogen. On 4/30/2025 at 2:49 PM, V18, Pharmacist stated, This is a specialty drug that (R8) is taking. It is important at all times to always follow the doctor's order. This drug it used to treat Parkinson's disease and if (R8) misses a dose it would not be ideal. By missing a dose it would increase her symptoms related to Parkinson's which would increase her tremors, and anything else related to her Parkinson. Ideally, we would not want to miss any doses.

Based on interview and record review, the facility failed to keep a resident free from misappropriation of property related to a staff member's use of a resident's money, for 1 of 3 residents (R3) reviewed for misappropriation in a sample of 8. This failure resulted in R3 having money stolen from bank account and feeling unsafe, like a fool, stupid and like a target. This past non-compliance occurred on 7/9/24 to 7/17/2024. Findings include: R3's Minimal Data Set, dated 5/30/2024, documents that R3 is cognitively intact. The facility's investigation documents On 7/16/2024, resident (R3), notified her bank of inconsistencies with her bank account. She filed a report with the bank. The bank did an investigation and determined that two staff members made several transactions using (R3's) (mobile payment application). The bank notified (Local) Police Department (PD) (report #) (Local) PD notified the facility. Upon receiving the initial concern on 7/17/2024, we initiated an internal investigation in accordance with our protocols. Our investigation involved interviewing residents, interviewing staff, reviewing the evidence and consulting our interdisciplinary team to ensure a thorough investigation. The findings of our investigation are as follows: 1. On 7/16/2024 (R3) reported to her bank that she had multiple charges to her account. The bank then reviewed the transactions with (R3) and they determined that these were fraudulent charges. The bank then notified (Local) Police Department of this incident. (Local) Police Department came to facility on 7/17/2024 and reported that the fraudulent charges were made by CNA (Certified Nursing Aid) (V9) and former employee (V8) (CNA). 2. Statements were collected from the staff that were working that night. a. (V9) (CNA) reports that (R3) had asked her to order pizza. V9 saved (R3's) card to her phone so she could place the order. She reports that she forgot to delete the card and that her cell phone made the debit card her default card. She reports that she didn't realize that it wasn't her card but when she did, she notified (R3) and they called the bank together. When questioned about (V8) charge, she reported that she sent him $100 because he asked her for $100 and that she gives him money all the time. 3. (R3) reports that she asked (V9) (CNA) to order pizza for the hall. R3 states she took her debit card out and laid it on her bedside table and then she thinks she must have fallen asleep. When she awoke, she changed her mind and decided it would cost too much to order pizza for the entire hall. It also documents 4. At the conclusion of our investigation, it was determined that the allegation of abuse was substantiated due to the evidence provided to both the resident and staff. We will be submitting a past non-compliance for misappropriation of resident's property. All information was taken into Consideration during this investigation. R3's bank Statement documents Current & Previous Cycle documents: multiple transfers from R3's Account to V9 (mobile payment application) totaling $678.70, $100 to V8 (mobile payment application) and additional store charges for total of $750. R3's Police Report, dated 7/17/2024, documents Initial Report Debit Card Fraud On 07/17/24 I (V13) was requested to (Local) Bank to speak with Branch Manager (V10). (V10) said she had a customer named (R3) with fraudulent activity on her account. R3 is currently living at (facility). (V10) had started the fraud dispute paperwork and she provided copies of the suspected transactions. (V10) said the suspects were (V8, CNA) and (V9, CNA). I then went to (facility). I spoke to (V14) and (V2, DON). They did confirm (V8) was a former employee with (facility) and (V9) is a current employee. I then went and spoke to (R3). (R3) said she did not give permission for (V8) or (V9) to use her debit card. (R3) said she did speak to one of the employees about buying pizza for some of the residents but the pizzas were never delivered. (R3) could not remember who she spoke to about the pizzas. (R3) was able to show me her debit card. Whoever obtained the debit card information would have had to have access to R3's room. I was able to review the paperwork provided to me by (V10). The debit showed multiple transfers to the financial application (mobile payment application) with the name (V9). On 07/14/24 a $50.00 dollar transfer was made to (V9). On 07/12/24 $350 was transferred to the (mobile payment application) under the name (V9). On 07/11/24 $449.86 was transferred through the (mobile payment application) to (V9). On 07/09/24 $300.00 was transferred to (V9) through the (mobile payment application). The total amount transferred to (V9) ls $1099.86. Charges were also made to (online retail store) on 07/09/24, 7/10/24, and 07/12/24 for a total of $283.05. On 07/09/24 $100.00 was transferred through the (mobile payment application) to (V8). It is believed Lock is short for (V8). On 8/21/2024 at 11:39 AM, R3 stated that some staff are rude, and others are nice. R3 stated that she has had an incident where she felt wronged. R3 stated that she wanted a debit card and with the help of the staff she was able to go to the bank and get a debit card. R3 stated that she had the card on her over bed table. R3 stated that (V9), was caring for her that day and had taken care of R3 for a long time. R3 stated that she informed (V9) that she wanted to buy pizza for the other residents on the hall. R3 stated that (V9) informed her that it would be close to $200. R3 stated that this was to much for her and did not want to do it and told (V9) this. R3 stated that later she was informed that (V9) had used R3's debit card, transferred money, made purchases and even given money to other people. R3 stated that she took at least $600. R3 stated that she did not given (V9) permission to use her card or save R3's information in her phone. R3 stated that she is not sure how (V9) got it. (V9) must have taken a picture. R3 stated that she feels sad and like a fool. R3 looking down and eyes [NAME] with water. I feel so stupid. I trusted her. How? Why would she do that to me? R3 stated that she does not feel safe and that she feels like she is being looked at as a target. On 8/19/2024 at 2:28 PM, V9, CNA stated that (R3) told her that she wanted to buy pizza for the residents. V9 stated that she was going to order it online. V9 stated that she entered (R3's) card information into her phone. V9 stated that she left the room and went to help other residents. V9 stated that when she returned (R3) was sleep. V9 stated that she did send money to her (mobile payment application), made purchases, and sent money to other people. V9 stated that she was not aware that she was using (R3's) card. V9 stated that the information must have gone to her electronic wallet. V9 stated that when (R3) told her this she and (R3) called the bank and tried to fix it. V9 stated that she has not returned the money. V9 stated that she does not know how much it is. V9 stated that she is waiting on the States's Attorney's office to contact her and tell her what she needs to pay. V9 stated that she thought she was using her own money but when she found out she did not tell the facility and that's her fault. V9 stated that she did use (R3's) money and when she found out she should have said something to her boss but she didn't and takes responsibility for what she did. On 8/22/2024 at 3:26 PM V10, Local Bank Manager, stated that the bank noticed that there were some fraudulent charges on (R3's) account. V10 stated that the bank investigated it and found the charges and transfer of cash was not authorized by the account holder. V10 stated at that time she notified the police. V10 stated that they were able to identify (V9) as the unauthorized user and this was notified to the police. V10 stated that the bank card was closed, and the account holder was notified. The facility's Abuse, Prevention and Prohibition Policy, dated 01/24, documents STATEMENT OF INTENT: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. POLICY: This facility prohibits mistreatment, neglect, or abuse of residents. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The facility also prohibits misappropriation of resident property. The residents must not be subjected to abuse by anyone. The facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect. Annually, the Administrator will contact local law enforcement to review the requirements for reporting to law enforcement. It also documents Misappropriation of Resident Property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Mistreatment Means inappropriate treatment or exploitation of a resident. Willful as defined in the definition of abuse, and means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The deficiency practice that began on 7/09/24 was corrected on 7/17/24 after the facility took the following actions to correct the noncompliance prior to the start of current survey: 1. Social Service Director provided residents with emotional support and reassurance. The Social Service Director provided Trauma Assessment 2. AD HOC QAPI meeting was held to discuss the investigations and theft of resident items. It was also determined that the facility would develop a past non-compliance to address the issue. 3. The Director of Nursing notified the Medical Director of the investigations and theft of resident monies. He was additionally notified that the facility would develop a past non-compliance to address the issue. 4. R3 was offered a lock box for their room to keep their valuables. 5. V9 and V8 employee files was reviewed. It was noted that pre-employee screening was done including reference checks and background checks. At the time the report was made, V8 was not employed at the facility. V9 employment was terminated following the outcome to the investigation. 6. AD HOC QAPI was held to discuss the conclusion of the investigation. The past non-compliance was also discussed, and it was determined that the facility would allege compliance on 7/17 /24 the Medical Director was updated as well. 7. The resident was notified by the financial institution that the money would be reimbursed to the account. 8. The Director of Nursing initiated all staff education on the Abuse policy with special focus on theft of resident items. All staff receive an education prior to working. 9. In servicing is ongoing with all staff on not using resident personal property. They need to report to the abuse coordinator if the resident is unable to keep personal items so we can supply a lockbox or give it to family for safekeeping. 10. Audits are in place related to the abuse deficiencies cited during the annual survey. The facility will continue to audit through the plan of correction and address any issues identified. 11. Compliance Achieved 07/17/2024.

Based on observation, interview, and record review, the facility failed to provide the Physician prescribed skin/wound treatments for 1 of 6 residents (R5) reviewed for wounds and quality of care in the sample of 44. Findings include: 1. On 06/25/24 at 10:00 AM, R5 stated that he does get cellulitis in his abdomen often. R5 was questioned if he gets a treatment to his abdominal folds. R5 stated that he gets nystatin powder to his folds and to his groin. R5 was questioned if he gets any type of barrier disposable cloth placed in his abdomen to collect the moisture, he stated that he does not. On 6/25/24 at 3:00 PM, V3, Assistant Director of Nurses, (ADON), entered R5's room to look at his abdomen. R5 was questioned if he gets a disposable cloth to absorb the moisture between his folds, R5 stated, You mean InterDry? I used to, but I don't anymore. It's been a while since I had one. R5 was questioned if he knew why. R5 stated, It is kind of hard to get it in the fold because the fold is so large and heavy. R5 stated that his abdominal fold does get moisture trapped in between the fold. On 6/25/24 at 3:03 PM, R5 stood up and exposed his abdominal folds. No InterDry moisture wicking sheet was observed. R5's abdominal fold was red and irritated. On 6/25/24 at 3:10 PM, V3, stated that since the Physician ordered InterDry for his abdomen the nurses should be doing it and not falsifying documentation that they are doing it when they are not. R5's Admission Record, print date of June 25, 2024, documents that R5 was admitted on [DATE] with diagnoses of morbid obesity and Panniculitis. R5's Physician Orders, dated 5/21/2024, documents, Cleanse posterior scrotum, inverted penis BID with mild soap and water, pat dry and apply barrier ointment. Apply InterDry moisture wicking sheets to abdominal fold and bilateral groin leaving wick at each end for moisture evaporation. Apply nystatin cream to bilateral groin rash. R5's Minimum Data Set, dated dated [DATE], documents that R5 is cognitively intact. R5's Treatment Administration Record, dated July 2024, documents, that R5's abdominal fold received treatment including InterDry on 6/23/24 day and night shift 6/24/24 day shift. On 7/1/24 at 11:40 AM, V18, Minimum Data Set / Licensed Practical Nurse, stated that the staff are expected to follow all Physician orders. The policy Wound Assessment, dated 3/21, fails to document to follow Physician Orders for treatment.

Based on observation, interview, and record review the facility failed to identify, assess, and implement interventions for pain for 1 of 6 residents (R129) reviewed for pain in the sample of 44. This failure resulted in R129 moaning in pain due to not being assessed and treated with pain medication for 44 minutes. Findings include: 1. On 6/24/2024 at 11:50AM R129 stated to V3 Assistant Director of Nursing (ADON) that her stomach was hurting. R129 was lying in bed groaning with facial grimacing. V3 told R129 that she would let her nurse know and left R129's room. On 6/24/24 at 12:10 PM R129 continued to groan while belching and stating, Oh God, I want to die. On 6/24/24 at 12:15 PM V7, Certified Nursing Assistant (CNA) entered R129's room to turn her on her left side. R129 stated, I'm hurting like I have to poop, please hurry for the nurse. V7, CNA stated she would notify R129's nurse now. V7 exited R129's room. V7 CNA was observed speaking with V6, Registered Nurse (RN) at the end of hall passing medications. V6 continued to do medication pass after being told R129 was in pain. On 6/24/24 at 12:25 PM, R129 stated her pain is a level is 10 on a scale of 1-10 with 10 being highest pain. R129 stated that her nurse has not been in to check on her yet. On 6/24/24 at 12:27 PM V37, CNA entered R129's room and took R129's vital signs which had not been taken. R129's blood pressure was 154/70, heart rate 68. V37 stated R129's temp was 98.4 and oxygen saturation 98%. V37 exited R129's room and reported readings to V6 RN who is still passing medications at the end of the hall. On 6/24/24 at 12:30 PM V6 entered R129's room and listened her lungs and stomach while asking Does it hurt when I press on your stomach anywhere? R129 stated she had pain when V6 pressed on her left lower abdominal quadrant. V6 stated R129 had active bowel sounds and did not feel any hard areas on her stomach. V6 stated, I can't remember when I was told she had pain, I've been busy it could have been 5 minutes ago. V6 stated she had not contacted the doctor about this. V6 left room without asking R129 to rate her pain. on 6/26/24 at 1:03 PM, R129 stated nobody likes to wait, I know they are busy and I'm not the only one, I'm just one of the people, regarding waiting for almost an hour on 6/24/24 after reporting she was in pain. R129's Care Plan, dated 6/192024 documents R129 is at risk for pain related to depression. R129's care plan documents to monitor, record/report to nurse resident complaints of pain or requests for pain medication. R129's care plan documents evaluate the effectiveness of pain interventions. Review alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and cognition. R129's Physician's Orders, PO, dated 6/12/24 documented Pain Scale: Record q shift: 0-1 No Pain; 2-3 Mild Pain; 4-5 Moderate Pain; 6-7 Severe Pain; 8-9 Very Severe Pain; 10 Worst Possible Pain. R129's Medication Administration Record (MAR) dated June 2024 documents Acetaminophen tablet 325mg (milligrams) give 2 tablets by mouth every 4 hours as needed for mild pain (1-4 on pain scale). R129's MAR documents that R129 was administered 2 Tylenol 325 mg at 12:44PM. R129's MAR does not document orders for any type of pain medication for any pain other than mild pain. On 7/1/2024 V18, MDS coordinator stated the facility does not have a pain policy. V18 stated it is expected that staff assess residents for pain and administer pain medication according to physician's order.

Based on interview and record review, the facility failed to answer call lights in a timely manner for 4 of 24 residents (R5, R22, R38, R50) reviewed for dignity in the sample of 44. Findings include: 1. On 06/24/24 at 12:30 PM, R38 was questioned if call light response is timely, R38 stated, Sometimes it takes hours for them to come. R38 was questioned how it makes her feel when she has to wait that long, R38 stated, Abandon like no one fxxxxxg cares. R38 was asked if she knew why it takes so long, R38 stated, They just say we are really backed up. R38's Admission Record, print date of 6/25/24, documents that R38 was admitted on [DATE] with diagnoses of Chronic Respiratory Failure and Chronic Kidney failure. R38's Minimum Data Set (MDS), dated [DATE], documents that R38 is cognitively intact, dependent on staff for toileting, bed mobility, and uses a wheelchair. 2. On 6/24/24 at 11:26 AM, R22 was questioned if her call light is answered timely, R22 stated, At night it can take over an hour. R22 was questioned as to how that made her feel waiting, R22 stated, You wait so long then you have an accident. It is beyond degrading to sit in something that should be in the toilet. It just makes me feel worthless. R22's Admission Record, print date of 6/25/24, documents that R22 was admitted on [DATE] with diagnoses of Major Depression Disorder and Edema. R22's MDS, dated [DATE], documents that R22 is cognitively intact, uses a wheelchair, is dependent on staff for toileting, requires partial / moderate assistance for hygiene, substantial / maximal assistance for bed mobility, and dependent on staff for bed to chair transfer. 3. On 6/24/24 at 12:35 PM, R50 was questioned about how timely the staff answer the call light, R50 stated, On the weekends, the staff can take hours for them to come in and answer the light because there is not enough staff. R50 was questioned how this makes her feel, R50 stated, I feel neglected. R50's Admission Record, print date of 6/27/24, documents that R50 was admitted on [DATE] with diagnoses of Obesity, Type 2 Diabetes and End Stage Renal Disease. R50's MDS, dated [DATE], documents that R50 is cognitively intact, uses a wheelchair, is dependent on staff for toileting, bed mobility, transfers, and is frequently incontinent of bowel and bladder. 4. On 06/25/24 at 10:00 AM, R5 stated, They don't have enough staff on night shift last night. I sat on the bedside commode for an hour and 15 minutes last night. R5 was questioned if the aides told him why it took so long, R5 stated, There was 2 CNA's for A and B hall. The one aide was working on both halls because the other aide was agency and she said, I am pregnant, and I am not doing a thing. R5 was questioned how waiting this long made him feel, R5 stated, It is what it is. R5's Admission Record, print date of June 25,24, documents that R5 was admitted on [DATE] with diagnoses of morbid obesity and Panniculitis. R5's Minimum Data Set, dated dated [DATE], documents that R5 is cognitively intact, uses a wheelchair, requires touch / supervision assist for toileting, hygiene, bed mobility, partial / moderate assistance for transfers. occasionally incontinent of urine, and frequently incontinent of bowel. On 6/26/24 at 4:05 PM, V18 MDS / Care Plan Licensed Practical Nurse, stated, The facility does not have a policy on call light answer times. V18 stated the expectation is that the light is answered in 3 to 5 minutes. The Resident Council meeting Minutes, dated 6/5/24, documents Call lights not being answered for 30 -45 minutes. The Illinois Long Term Care Ombudsman, dated 10/17, documents, The program strives to protect and promote the rights and quality of life for those who reside in long-term care facilities.

Based on interview, observation, and record review, the facility failed to provide complete incontinent care for 4 of 5 residents (R57, R59, R62, R128) reviewed for incontinence care in the sample of 44. Findings include: 1. On 06/26/24 at 2:35 PM, V38, Certified Nurse Aide, (CNA) and V39 CNA entered R57's room to provide incontinent care. R57's incontinent brief was moderately saturated with urine. V38 with disposable peri-wash cloths wiped the right groin, then left groin, and gently wiped over the labia twice. R57 was rolled over onto her right side and the rectal area and both buttocks were cleansed. V38 placed a new incontinent brief on R57. V38 failed to spread and cleanse the labia and cleanse the inner thighs. R57's Admission Record, print date of 6/26/2024, documents that R57 was admitted on [DATE] with diagnoses of Functional Urinary Incontinence, Paranoid Schizophrenia, and need for assistance with personal care. R57's Minimum Data Set (MDS), dated [DATE], documents that R57 is severely cognitively impaired, requires substantial / maximal assistance from staff for toileting, personal hygiene, Partial / moderate assistance with mobility, and is frequently incontinent of bowel and bladder. On 6/26/24 at 2:55 PM, V18, MDS / Care Plan Licensed Practical Nurse (LPN), stated, The facility does not have an incontinent care policy. We expect the nursing staff to follow standards of practice. On 6/27/24 at 11:20 AM, V41, Regional Directors of Operations, stated that the expectations of staff are that complete incontinent care will be provided. 40701 2. R62's MDS dated [DATE] documents R62 is cognitively intact. R62's Care Plan dated 6/27/2024, documents R62 has a catheter and a wound to the back of her right thigh. On 6/24/2024 at 10:30 AM, R62 stated she has open wounds and a urinary catheter. R62 stated she needs cleaned up (provided incontinent care). On 6/25/2024 at 10:40 AM, V29, CNA entered R62's room and R62 informed V29 that R62 needed incontinent care. R62 had a small soft bowel movement (BM). There was also BM on R62's catheter tubing. V29 began to provide incontinent care to R62 without donning a gown. V29 cleansed the area of R62's buttocks. R62's dressing to R62's open wound to R62's buttocks was soiled with BM. V29 removed R62's dressing with the same gloves used to cleanse the feces off R62's buttocks. V29 then cleansed R62's catheter tubing, without the benefit to hand hygiene or changing gloves. V29 then rolled R62 over and cleansed R62's groin area. At this time, R62 thanked V29 and stated, Usually they just clean my backside and not the front (peri/groin area) and I don't want any more infections. On 6/25/2024 at 10:55 AM, V8, Wound Nurse, entered R62's room to replace R62's dressing to her buttocks. V8 stated R62 also had an open wound to R62's right gluteal fold. When V8 lifted R62's right buttock cheek, there was still feces remaining in the crevice. V8 cleansed the remaining feces. 32874 3. On 06/24/24 at 11:54 AM V7, CNA, and V3, Assistant Director of Nursing (ADON) provided R59 incontinence care. V7 removed R59's pants and undid R59's adult diaper. V7 stated R59 has pooped and was incontinent of urine. V7 rolled the adult diaper under R59. V7 turned R59 to left side. V7 used disposable wipes and cleansed rectal area from front to back. V7 did not cleanse buttocks. V7 then placed R59 on back. V7 cleansed left groin, then right groin. V7 separated labia and made one swipe with disposable wipe from front to back. V7 did not cleanse inner thighs prior to drying R59. R59's Care Plan dated 2/21/2024 documents that R59 has bladder incontinence. R59's care plan documents wash, rinse, and dry perineum. 4. On 06/26/24 at 08:46 AM V22 CNA and V23, Certified Occupational Therapist Aide, COTA, went into R128's room transferred R128 from sit to stand to the toilet. V22 removed R128's adult diaper. R128's adult diaper was full of liquid stool. R128 stated he still needed to go to the bathroom. At 9:11 AM, V24 CNA and V22 with sit to stand lift lifted R128 to standing position. V24, with disposable wipes reached in from behind R59 and swiped from front to back using numerous wipes until no visual stool. At no time did V22 or V24 cleanse R128's scrotum or peri area during incontinent care. R128's Care Plan, dated 6/14/2024 documents R128 has bladder incontinence, and impaired m mobility. R128's Care Plan documents wash, rinse and dry perineum after incontinent episodes. On 7/1/2024 at 10:25AM V25, CNA, stated that when providing incontinent care on a male resident the scrotum is to be cleansed, the penis and the foreskin is to be pulled back and cleansed. 3

Based on interview and record review, the facility failed to provide enough staff to care for residents in a timely manner for (R38, R22, R50, R5) reviewed for sufficient nursing staff in the sample of 44. Findings include: 1. On 06/24/24 at 12:30 PM, R38 was questioned if call light response is timely, R38 stated, Sometimes it takes hours for them to come.R38 was asked if she knew why it takes so long, R38 stated, They just say we are really backed up. R38's Minimum Data Set (MDS), dated [DATE], documents that R38 is cognitively intact, dependent on staff for toileting, bed mobility, and uses a wheelchair. 2. On 6/24/24 at 11:26 AM, R22 was questioned if her call light is answered timely, R22 stated, At night it can take over an hour. R22's MDS, dated [DATE], documents that R22 is cognitively intact, uses a wheelchair, is dependent on staff for toileting, requires partial / moderate assistance for hygiene, substantial / maximal assistance for bed mobility, and dependent on staff for bed to chair transfer. 3. On 6/24/24 at 12:35 PM, R50 was questioned about how timely the staff answer the call light, R50 stated, On the weekends, the staff can take hours for them to come in and answer the light because there is not enough staff. R50's MDS, dated [DATE], documents that R50 is cognitively intact, uses a wheelchair, is dependent on staff for toileting, bed mobility, transfers, and is frequently incontinent of bowel and bladder. 4. On 06/25/24 at 10:00 AM, R5 stated, They don't have enough staff on night shift last night. I sat on the bedside commode for an hour and 15 minutes last night. R5 was questioned if the aides told him why it took so long, R5 stated, There was 2 CNAs for A and B hall. The one aide was working on both halls because the other aide was agency and she said, I am pregnant, and I am not doing a thing. R5's MDS, dated [DATE], documents that R5 is cognitively intact, uses a wheelchair, requires touch / supervision assist for toileting, hygiene, bed mobility, partial / moderate assistance for transfers. occasionally incontinent of urine, and frequently incontinent of bowel. On 7/1/24 at 8:23 AM, V44, CNA scheduler stated, The CNAs work on 8-hour shifts; 6 AM to 2 PM, 2 PM - 10 PM, 10 PM - 6 AM. Most CNA's work 8-hour shifts but I do have a few that work 12-hour shifts. Depending on the census, on day shift the highest is 9 which is 80 or above and the lowest 70 or less is 6. The evening shift, the highest is 8 and lowest is 5. The night shift highest is 5 and lowest is 3. 3 CNAs on night shift is not enough. The fall pod requires 1 CNA just for those 4 residents, then we need at least 3 other CNAs for the other residents. Before the fall pod R57 really needed one to one supervision because she was a fall risk. It is ridiculous for it to take the CNAs over an hour to answer the call lights. I come in and work that shift if we are shorthanded and there is no reason for that.

Based on interview and record review, the facility failed to monitor and treat a resident with the diagnoses of Diabetes Type 2 for one of 3 residents (R10) reviewed for quality of care, in the sample of 12. This failure resulted in R10 being hospitalized with Uncontrolled Diabetes Mellitus with an initial blood glucose of 614 in the emergency room (ER). Findings include: R10's Hospital emergency room (ER) Records, dated 5/22/24, documented that he had a history of insulin dependent diabetes mellitus and that he was admitted to the hospital on that date with the diagnoses of Acute on Chronic Renal Failure and Uncontrolled Diabetes Mellitus. Per the hospital records, R10's blood glucose level was 614 when he was in the ER. R10's Face Sheet, printed 5/23/24, documented that he was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus without complications. R10's Minimum Data Set (MDS) dated [DATE] documents he is moderately cognitively impaired and is dependent on staff for Activities of Daily Living (ADLs). R10's Care Plan, dated 9/26/21, documented, (R10) has Diabetes Mellitus. The goal for this care plan was, (R10) will have no complications related to diabetes through the next review date of 5/19/24. Interventions for this care plan included, Check all of body for breaks in skin and treat promptly as ordered by doctor. Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Dietary consult for nutritional regiment and ongoing monitoring. Discuss mealtimes, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, compliance with nutritional regimen. Don't use over the counter remedies for corns and calluses, refer to podiatrist to treat. Educate regarding medications and importance of compliance. Have resident verbally state an understanding. Educate resident/family/caregiver: Diabetes is a chronic disease, and that compliance is essential to prevent complications of the disease. Review complications and prevention with the resident/family/caregiver. Elicit a verbal understanding from the resident/family/caregiver, that nails should always be cut straight across, never cut corners. File rough edges with emery board. R10's Care Plan did not address monitoring blood glucose levels or signs and symptoms of hyper or hypoglycemia. R10's Care Plan, dated 9/26/21 and revised on 5/23/24, documented, (R10) has actual impairment to skin integrity related to (r/t) Diabetes, decreased mobility and urinary incontinence. (R10) had a pressure ulcer to the right trochanter, coccyx and right ischium, diabetic ulcer to left foot dorsal, and 2 arterial ulcers to RLE (right lower extremity). The goal for this care plan documented, (R10's) diabetic, pressure and arterial ulcers will show s/s (signs and symptoms) of healing through next review date of 5/19/24. R10's lab result, dated 5/8/24 at 7:05 AM documented that his blood glucose of 374, which is high, with normal limits being 74 to 106. R10's most recent Order Summary Report, dated 5/24/24 with order date range from 5/1/24 to 5/31/24, documented an order, dated 5/9/24, Draw TIBC (Total Iron Binding Capacity), Iron, Folate, A1C, Occult Stool x 3 one time only for 1 day. No A1C result was found for that date (5/9/24) in R10's Electronic Medical Record (EMR). R10's lab result, dated 3/7/24, documented his HGB A1C as 9.4, which was high, with the goal being less than 7 if a resident is diabetic. There was no documentation in R10's EMR that his physician was notified of this abnormal lab. R10's Physician Order Summaries were reviewed for April 2024, March 2024, February 2024, January 2024, December 2023, November 2023, October 2023 and September 2023. Review of these physician order summaries documented R10 was receiving both Humalog Insulin (Order dated 9/26/23: Humalog (Insulin Lispro) 15 units (u) subcutaneously (SQ) before meals for diabetes and Insulin Glargine 20 u SQ one time a day for diabetes). R10 continued to receive these medications with blood glucose monitoring before meals and at bedtime until he was hospitalized on [DATE]. R10's December 2023 physician order summary documented that he was readmitted to the facility on [DATE]. The December physician order summary documented the order dated 12/13/23: May obtain blood sugar prn (as needed) for signs and symptoms of hyper/hypoglycemia as needed. If blood sugar is less than 70 and able to swallow, administer food or juice. Recheck blood sugar in 15 minutes and notify MD as needed. If blood sugar remains less than 70 and able to swallow, administer glucose gel orally. Recheck blood sugar in 15 minutes. If blood sugar remains less than 70 and unable to swallow, administer Glucagon per manufacturer's instruction. Obtain from EDK (Emergency Drug Kit). Recheck blood sugar in 15 minutes. If blood sugar remains less than 70, notify MD as needed. R10 did not have an order to resume scheduled blood glucose monitoring. On 2/25/24 R10 received an order for Metformin 500 mg one tab in the morning and 2 tabs at bedtime. There was no order for routine blood glucose monitoring after R10 returned from the hospital on 12/7/23. R10's Hospital Discharge Instructions, dated 12/7/24, documented, Discharge Follow Up Appointments- Endocrinology, Call office for appointment in 3-5 days. We were not able to confirm if he takes insulin and he largely refused a lot of things in the hospital including blood draws. Blood sugars remained well controlled on Metformin 500 mg BID (twice a day). Please reassess. The discharge instructions did document that R10 was to stop taking Insulin Glargine and Insulin Lispro but did not address if R10 was to continue to have blood glucose monitored routinely as he had prior to hospitalization . No documentation was found in R10's EMR regarding notification of his MD for reassessment of blood glucose monitoring and if insulin should be resumed. On 5/24/24 at 11:07 AM V21, Licensed Practical Nurse (LPN), during phone interview, stated that she was R10's nurse on the day he was sent to the hospital. She stated he was having a change in condition since she saw him the previous week, as she only works prn. She stated the previous week R10 had some shortness of breath, and his pulse ox was a little low and she called his doctor, and a chest x-ray was ordered, and he was started on antibiotics. She stated when she saw him the next week, he was not any better and he had just finished his antibiotics. She stated that R10 was holding his pills in his mouth when she gave them to him and then started chewing them which was not normal for him. She stated R10 was normally grouchy and yelling at people and on that day, he was not talking. He was not being able to cough up his phlegm and was still drooling some of the chocolate health shake with little bits of his medication mixed in. V21 stated that she did not do an accucheck on R10 because she didn't think his change in condition had anything to do with his blood sugar. On 5/24/24 at 1:55 PM, V23, Registered Nurse (RN) in R10's Primary Care Physician's (V24's) office, stated that she couldn't find in R10's records at the physician's office that they ever received notification of R10's A1C result of 9.4 that was done on 3/7/24. V23 also stated that they would have definitely ordered accuchecks to be done if his A1C was 9.4, and probably would have started something else to treat his diabetes. She stated that R10's glucose level on 5/8/24 was 347 and V24 ordered an A1C to be done but they have not received those results yet. On 5/24/24 at 2:37 PM V25, MD, Hospitalist, stated that he has seen R10 during this hospitalization . He stated that R10's blood glucose was 614 when he first came to the emergency room , and it continued to be high for a while. He stated R10 should have been getting routine accuchecks to keep an eye on his diabetes. He stated that if R10 was on insulin, he would expect accuchecks to be done at least a couple of times a day and if not on insulin, he should have been receiving accuchecks at least once a day to monitor his diabetic status because of his history of diabetes. V25 also stated that he does think it would have made a difference if R10's blood glucose levels had been monitored and his high blood glucose levels had been caught and treated in that it would have helped prevent his hospitalization , infections and poor wound healing. V25 stated that he reviewed R10's medical records and they indicated R10 should have been taking insulin. He also stated it would have been appropriate to be checking R10's blood glucose levels to see if he needed to be back on insulin. On 5/24/24 at 3:12 PM, V2, Director of Nursing, stated that she has the fax confirmation page showing that the lab did fax R10's A1C result from 3/7/24 to the physician's office, but she does not think the facility followed up to make sure V24 saw it. She stated that going forward, the facility has educated the nurses to compare previous orders prior to hospitalization , or home medications to current or hospital discharge orders to check for any differences, and then notify the MD to see if he wants any previous orders, including accuchecks, resumed upon readmit to the facility. She also stated she just started this process about a month ago, so it probably did not happen when R10 was readmitted to the facility on [DATE]. V2 also stated R10's A1C was not drawn as ordered on 5/9/24 because he had one done within the last 3 months, so they will draw it in June. V2 stated that the facility does not have a specific policy regarding diabetic management, and stated they just treat according to physician's orders.

Deficiency requires two deficient practice statements. A. Based on interviews and record review the facility failed to timely treat a urinary tract infection (UTI) for 1 of 6 residents (R17) review for urinary incontinent/(UTIs) in the sample of 42. This failure resulted in R17 having symptoms of UTI on 6/2/23, delay of physician notification and treatment, and subsequently being admitted to the critical care unit at the local hospital with diagnosis of UTI with septic shock. Findings include: R17's July 2023 Physician's Order Sheet (POS) documented R17 had diagnoses of long-term use of antibiotics, personal history of urinary tract infections, sepsis, unspecified organism, sever sepsis with septic shock, extended spectrum beta lactamase (ESBL). R17's Minimum Data Set, dated dated dated [DATE] documents that R17's Brief Interview of Mental Status score was a 14 which indicates R17 is cognitively intact. MDS documents that R17 is extensive assist of two people for toileting needs and is always incontinent. R17's Care Plan dated 4/26/2017 documents R17 will be free of complications from history of urinary tract infections with interventions of monitor/document/report to MD PRN (as needed) for signs/symptoms of frequency, urgency, malaise foul smelling urine, dysuria, fever, nausea and vomiting flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, behavioral changes. R17's Vital Sign records in the electronic medical record documents on 6/1/2023 at 8:31AM R17 had an elevated temperature of 99.1 degrees ( ) Fahrenheit (F). The Vital Sign Records document on 6/2/2023 at 11:56 PM R17 had an elevated temperature of 102.4 F. There was nothing in R17's Progress Notes that documented R17's physician was notified of R17 having an elevated temperature. R17's infection screening evaluation assessment dated effective 6/2/2023 documents R17 had a fever of >102 F and had new/marked increase in symptoms of urinary frequency, urinary incontinence, urinary urgency, acute dysuria, and abdominal pain with no notification of physician. R17's clinical record contains fax document to V19 (Physician) dated 6/4/2023 at 5:40 PM documented (R17) has been diaphoretic, clammy, pale, lethargic, has poor appetite on and off all weekend. She seems to be experiencing increased confusion today. She is disorientated and states she does not feel well. Afebrile. States she feels like she has a UTI. Incontinent of urine. States she is having dysuria. R17's Progress Note dated 6/4/2023 at 6:06 PM documents R17 has been diaphoretic, pale, clammy, and lethargic with poor appetite and fluid intake throughout the weekend. Encouraged oral hydration but she has been sleeping a lot. on 6/2/23 at 11:56 pm her temp was 102.4 but was alleviated with acetaminophen. She seems to be experiencing AMS /increased confusion today. She is disoriented and she states she does not feel well. C/o dysuria and vaginal discomfort. She also stated she feels like she has a UTI. Incontinent of urine. Notified (V19's) office. R17's Progress Note dated 6/5/2023 at 3:51 AM documents, Res remains pale, clammy, and diaphoretic. Res states that something is not right. Res has been very tearful this shift. Afebrile. C/o (complaints of) vaginal discomfort at times with dysuria. (Res) stated that she did not want to go to the hospital, she would wait for response from PCP (primary care physician) r/t (related to) lab orders. R17's Progress Note, dated 6/5/2023 at 10:58 AM documents @ (at) 1000 Call out to V19 (Physician) in regard to resident complaining of not feeling well, resident seems a little confused, complains of dysuria and just not feeling right. New orders received for CBC, CMP and UA with C&S obtained through straight cath. The Progress Note documented @ 10:15am Urine obtained per straight cath and call out to (Local hospital lab) lab, writer spoke with lab and lab is going to come out and draw CBC and CMP and pick up urine while here. R17's Progress Note, dated 6/5/2023 at 7:25 PM documents R17 was experiencing increase pain and Shortness of Breath. The Note documented Writer sent R17 to ER for further evaluation. MD aware. POA called but did not answer phone and unable to leave voicemail. R17 states she will call her husband at the hospital. Writer gave report to ER (emergency room ) RN (Registered Nurse). R17's Hospital records dated 6/6/2023 documents R17 was admitted to hospital on 6/5/2023 with diagnosis of Septic Shock due to UTI. R17's hospital records document that R17 was in distress from abdominal pain upon presentation at Local Emergency Department and became hypotensive not responding to Intravenous fluids bolus and was started on blood pressure support drug, R17 was admitted to critical care unit. On 07/26/23 at 3:17 PM, V3 (MDS/LPN) states she documented on the infections criteria assessment on 6/4/2023 about R17's temp on 6/2/2023 but did not notify the doctor of the fever or the frequency and urgency at that time. V3 states she does not have any documentation of R17 being monitored from 6/2/2023-6/4/2023 or of the doctor being notified on 6/2/2023 of fever of 102.4 F. V3 states V19 was notified on 6/4/2023 of R17's fever and urinary symptoms. On 07/26/23 at 3:26 PM, R17 states that she had a UTI on 6/2/2023 and that staff did not take care of it immediately. R17 states It took a few days for them to treat me and by then I was sick. I went to the hospital and just laid in the bed at the hospital and cried for days. It was very stressful. Facilities policy titled Significant Condition Change of Notification, undated, documents Purpose is to ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as onset of temperature of 101 degrees or higher with or without symptoms, when any of the situations exists the licensed nurse will contact the resident's representative and their medical practitioner. Prior to calling the medical practitioner the nurses will completer the SBAR assessment, charting will include an assessment of the resident's status as it relates to the change in condition and will be done each shift for 72 hours for residents with change of condition. 40650 B. Based on observation, interview, and record review, the facility failed to provide timely, complete incontinent care and urinary catheter care for 4 of 6 residents (R7, R17, R30, R41) reviewed for urinary incontinence and urinary catheter usage in a sample of 42. Findings include: 1. On 07/26/2023 at 10:15 AM, V18 (Certified Nurse Assistant/CNA) with the assistance of V5 and V13 (Certified Nurse Assistants/CNAs) performed indwelling urinary catheter care on R41. Using a different disposable wipe, she cleansed front to back of R41's left groin, right groin, and the down the center of labial folds. R41's indwelling urinary catheter was tightly secured to her right leg that was being supported by V5 (CNA). The indwelling urinary catheter was pulled tightly against her right thigh and was kinked at the point where the tubing connects to the drainage bag. V18 took a disposable wipe and cleansed from the outside of the labial fold towards the drainage tubing and did not cleanse from the meatus outward. R41's Physician order sheet, dated 07/27/2023, documented diagnoses of Neuromuscular dysfunction of bladder, unspecified and Urinary tract infection. R41's Care plan dated, 03/17/2023, documented, Catheter care every shift and (as needed). It continues, Check tubing for kinks each shift. On 07/27/2023 at 10:20 AM, V1 (Administrator) stated she would expect the staff to perform catheter care and incontinent care per the skills check off list. 40701 2. R30's MDS dated [DATE] documents R30 is cognitively intact and requires extensive assistance for toileting needs. R30's Care Plan dated 6/23/2023 documents, (R30) has bladder incontinence (due to) impaired mobility. Interventions include, Check (R30) every 2 hours and as required for incontinence. R30's Care Plan dated 6/23/2022 documents, (R30) has potential for impairment to skin integrity related to urinary incontinence and decreased mobility. It further documents, (R30) is on diuretic (medication that increases urination) therapy. On 7/25/2023 at 9:49 AM, R30 stated, I've sat soiled for 6 hours. I'm what they call a 'heavy wetter'. Staff will come in and say, 'I just changed you'. I don't want to get open areas (pressure ulcers). 3. R17's Face sheet dated 7/26/2023 documents R17 has a personal history of UTIs (Urinary Tract Infections), Vaginitis, Anxiety and Bed Confinement Status. R17's MDS dated [DATE] documents R17 is cognitively intact and requires extensive assistance for toileting needs. R17's Care Plan dated 7/26/2023 documents R17 is incontinent of bowel and bladder. R17's Care Plan dated 7/26/2023 documents R17 has ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) current medical condition. It further documents, Toilet Use: (R17) requires assist of 2 staff with toileting. She is inc (incontinent) and checked and changed every 2 hours or more frequently if needed. R17's Care Plan dated 7/26/2023 documents R17 has actual skin issues r/t urine incontinence and has MASD (Moisture Associated Skin Damage) to her buttocks r/t urine incontinence. It further documents R17 has bowel incontinence and interventions include, Provide peri-care after each incontinent episode. R17's Care Plan dated 7/26/2023 documents R17 has a history of renal failure and recurrent abnormal urinalysis with need for monitoring and treatment. On 7/25/2023 at 9:54 AM, R17 stated, They check on my roommate (R30) but then don't check on me. I feel ignored. One time my sheets were brown. I had urinated and had a bowel movement. I get UTI's very easily. I wasn't changed all afternoon that day. It sometimes takes 4-5 hours to get changed. The Facility's Resident Council Minutes dated 6/7/2023 documents cath (catheter) bags not being drained. It further documents, Peri (perineal) care not being provided with urine incontinence. 32874 4. On 7/24/2023 at 9:25 AM, during incontinent care for R7, V4 and V5 (CNAs) donned gloves and did not wash or sanitize hands. R7 was on his left side in bed. V4 and V5 removed R7's adult diaper. V5 with right gloved hand cleansed R7's rectal area from front to back with wipes. V5 did not cleanse R7's buttocks. R7 was repositioned to his back. V5 cleansed R7's right groin and left groin. V5 did not cleans R7's penis or retract R7's foreskin. R7's Care plan dated 11/20/2020 documents that R7 has bowel and bladder incontinence. R7's care plan documents to wash, rinse, and dry perineum. R7's Minimum data set (MDS) dated [DATE] documents that R7 requires extensive assistance and one-person physical assistance for toileting. The facility Skills Check List for Catheter care, undated, documents to separate labia or retract foreskin and maintain the positron throughout procedure, for female- use washcloth with warm water and soap to cleanse labia change the position of the washcloth for each downward stroke change position of wash cloth and cleanse around meatus with clean washcloth, rinse with warm water using same technique. The facility Skills Check List for Male Peri Care, undated documents pull back foreskin and wash tip of penis using circular motion beginning at urethra.

Based on observation, interview and record review, the facility failed to use the appropriate sling during a full mechanical lift transfer and failed to implement fall interventions in 3 of 4 residents (R1, R2, R3), reviewed for falls in the sample of 4. This failure resulted in R2 sustaining a left humerus fracture. Findings include: 1. R2's Face Sheet, undated, documents R2 has diagnoses of Unsteadiness on Feet, Muscle Weakness and Muscle Wasting and Atrophy. R2's Minimum Data Set (MDS), dated [DATE], documents R2 has moderate cognitive impairment and is dependent with 2 staff for transfers. R2's Care Plan, dated 12/29/21, documents R2 is at risk for falls with an intervention, dated 2/10/23, to provide education to staff on full mechanical lift transfers and R2 has an Activities of Daily Living, (ADL) self-care deficit with an intervention for use of a full mechanical lift and assistance of two staff for transfers. R2's Fall Risk Assessment, dated 7/27/22, documents R2 is at risk for falls. R2's Progress notes document the following: 2/10/2023 at 8:05 AM, staff came and got nurse, said resident was on the floor. Resident was lying on the floor on his left side, states he hit his head. When assessing resident, he said his neck and left arm hurt; 2/10/2023 at 12:40 PM, resident arrived back to facility per stretcher; left arm in sling due to left humerus fracture; 2/10/2023 at 3:15 PM, fall huddle with staff, immediate intervention was training with all staff. R2's SBAR assessment, dated 2/10/23, documents R2 sustained a fall related to a full mechanical lift transfer. Lift sling slipped of lift and resident fell to the ground. The facility's final report to the Illinois Department of Public Health (IDPH), dated 2/10/23, documents on 2/10/23 at approximately 7:45 AM, R2 was being transferred when the full mechanical lift sling slipped, causing him to fall. He was sent to the emergency room (ER) and was noted to have a left humerus fracture. He was transferred to the orthopedic doctor and had a hinged elbow brace to left upper arm, locked at 90 degrees, with sleeve placed under to prevent irritation, keep arm elevated to prevent swelling and therapy to work with him on left wrist and fingers for range of motion (ROM) to prevent stiffness. He will follow up with Orthopedics in 1 week. Pain medication was ordered, and staff continue to monitor his pain and give medications as needed. Care plan was reviewed and updated as needed. The facility's investigation into R2's fall documents the following: Occurrence Report: 2/10/23 at 7:45 AM - Nurse was called to resident's room, he was found lying on the floor on the left side, top half of sling was not connected to full mechanical lift, resident started complaining of neck pain and left arm pain, neuro's were initiated and within normal limits (WNL), fell out of full mechanical lift sling, complained of left arm and neck pain. 2/10/23 - Interview with V11, Past Certified Nursing Assistant (CNA) - resident slipped from full mechanical lift sling and she got help immediately and the nurse assessed resident. V11 put the sling under R2, hooked the sling to the full mechanical lift, hollered for V15 (Agency Certified Nursing Assistant/ Agency CNA) to come, V11 moved the full mechanical lift, and the sling came off the lift cross bar on the left side and R2 fell out of the left side of the sling. On 2/28/23 at 9 AM, R2 was observed with a sling and cast in place to the left arm. R2 stated they were using the lift to put him in bed, he ended up on the floor and isn't sure why. R2 stated he broke his arm but did not have to have surgery. On 2/28/23 at 8:20 AM, V5 (Maintenance Director) stated he checks the mechanical lifts weekly and anytime the staff reports a problem with them to him. V5 stated the lift that was used on R2 when R2 fell was a brand-new lift. V5 stated he checked it out and there were no mechanical issues identified. V5 stated it has been taken out of service and is in the garage. V5 stated that the staff were not using the right slings for that lift, so they have ordered new slings for it. V5 stated staff were in-serviced after the incident on appropriate use of the lifts and slings. On 2/28/23 at 9:30 AM, V2 (Director of Nursing/DON) stated V11 (Past CNA) and an Agency CNA (unsure of name, she was later identified as V15, Agency CNA) were the CNAs present when R2 fell from the lift. V2 stated there was a problem with the sling but she isn't sure what it was. On 2/28/23 at 1:30 PM, V10 (Agency Licensed Practical Nurse/LPN), stated she was passing medications in the dining room when the CNA (unsure of name), told her she needed help, R2 was on the floor. V10 stated when she entered the room, the sling was unattached to the top portion of the lift. States after the fall, they tested the sling with weight and each time the sling popped off of the ring that the sling attached to the lift with and the lift went sideways, the lift was dangerous, there was no safety mechanism in place if the lift shifted. V10 stated the facility had just gotten the lift and is unsure if had been used prior to R2's fall. V10 stated immediately after R2's fall, the lift was taken out of service because it needed special slings. V5 stated she is unsure if the CNAs or the facility knew that prior to R2's fall. On 2/28/23 at 2:55 PM, V5 (Maintenance Director) stated that he did not check to ensure the slings were compatible with the lift that was being used on R2 prior to it being put into use. V5 stated he put the lift together and made sure it worked, it went up and down and was working so he put it out on the floor for the staff to use. On 3/1/23 at 10 AM, V4 (LPN/MDS) the slings that they have were not compatible with the lift used during R2's transfer. V4 stated it was put out for use on 2/10/23, the day of R2's fall, and was taken out of service and placed in the garage immediately after R2's fall. V4 stated that the correct slings have been ordered, and prior to putting the lift back in the facility for use, V5 (Maintenance Director) will check the lift to ensure it is operating properly. They will also check the new slings to ensure they are safe for use prior to using them on residents. V4 stated she will also in-service all nursing staff on the new lift and slings prior to use. V5 stated the lift slings have also been color coded so it is easy to identify what type of sling it is and who it can be used on. The (Brand) Battery Operated Patient Lift Owner's Manual, lift used during R2's transfer, undated, documents the following: page 3: Warning, (Brand) slings are specially designed for use on (Brand) Lift equipment. For optimum performance use only genuine (Brand) 6-point slings on (Brand) Lift equipment. Use of non-(Brand name) slings is unsafe and may result in injury to the resident or caregiver. Page 8: Do not use a sling unless it is recommended for use with the lift. The Full Mechanical Lift Skills Checklist, undated, documents to gather the equipment, 2 staff must always assist with full mechanical lift transfers, place sling under resident and around the legs, position left near the resident and lower the four-point tilting frame making sure the resident's arms, legs and body are clear of the lift and frame, connect upper clips/loops to tilting frame, the connect lower clips/loops, make base of frame as wide as possible and slowly lift resident while applying pressure to tilting frame to keep it upright. Move lift to transport patient to new surface, making sure all body parts are clear of lift and frame, slowly lower the lift to position on new surface. 2. R1's Face Sheet, undated, documents R1 has diagnoses of Repeated Falls and Dementia. R1's MDS, dated [DATE], documents R1 has severe cognitive impairment, requires an assistance of 2 staff with transfers and has a history of falls. R1's Care Plan, dated 1/4/23, documents R1 is at risk for falls with the following interventions: 1/9/23 - toilet before and after meals, gripper strips on floor beside bed, 1/10/23 - Gripper socks on when in bed, 1/11/23 - Call light in reach, 1/12/23 - Call don't fall sign in room, therapy to do recliner evaluation. R1's care plan goes on to document R1 has an ADL self-care performance deficit and requires an assist of 2 staff and a full mechanical lift. R1's Fall Risk Assessment, dated 1/4/23, documents R1 is at high risk for falls. R1's Progress Notes document the following: 1/4/2023 at 4:04 PM, resident found on floor of room by CNA; this nurse and registered nurse (RN) assessed resident; no injuries to legs or arms; resident complained of pain to mid-back as well as the back of head; will not allow for staff to move her; made resident comfortable; contacted physician, emergency contact, 911, and hospital. 1/4/2023 10:51 PM, writer was alerted to resident's room at 10:25 PM by resident yelling out Help Help. Writer entered resident's room and found resident lying flat on her back facing her bed, with body/legs extended in front of her in alignment. It appeared to writer that resident was returning from the bathroom trying to walk towards her bed and fell . There were no witnesses to the fall. Resident was alert and oriented x 2, no complaints of pain or discomfort, no bruising or swelling noted to her head, contusions were noted to bilateral lower extremities (BLE) in various states of healing from previous falls. While assessing resident, writer noted that the resident had drawn both BLE into 90-degree angles with feet flat on the floor and did not complain of any pain or discomfort. Resident was able to move all extremities x 4, grip strength was equal. With the assistance of CNAs and the use of a gait belt, resident was assisted to a standing position and then transferred to bed. Resident requested the use of a bed pan. At this time, while the CNA was placing the bed pan under resident, she complained of both right and left hip pain. Writer called appropriate personal and discussed residents' condition, and due to complaints of pain after the fall, writer was instructed to send resident to ER for further evaluation. At 10:27 PM, writer called 911. At 10:45 PM, resident left facility via stretcher, 1/5/2023 at 12:10 AM, Writer spoke with V17 (R1's Granddaughter), V17 voiced her concerns regarding the frequent falls. She stated that she would like her grandmother to have an alarm on her bed as well as in a chair, also to have side rails placed on both sides of the bed. Writer stated that her concerns would be given to the appropriate personal. 1/5/2023 1:21 AM, resident returned to facility with Impression Recurrent falls. Discharge instructions given to resident for contusions and fall prevention, follow up with provider within 2 days. Resident is currently resting in bed; at this time, she is not voicing any signs of pain or discomfort and has fluids and call light within reach. 1/9/2023 9:08 AM, patient was found sitting on the floor in her room. R1 stated she had slid out of her recliner while trying to get up to use the restroom. Skin tear noted to right forearm. No other injuries noted. No complaints of pain or discomfort. Neuro checks initiated. Power of Attorney (POA) and Physician notified. 1/10/2023 4:12 AM, at approximately 4:00 AM, a staff LPN, while making rounds, found resident sitting on her buttocks on the floor directly in front of the recliner. Resident had her legs extended forward. Resident did not have any clothing on and was barefoot. Writer noted a slightly wet (Brand) absorbent, disposable underwear on was tossed aside by the bathroom door. Writer assessed resident, resident was able to move all extremities x 4 without pain or discomfort. No apparent injuries were noted. Resident denied pain and denied hitting her head. Resident has equal grip strength and was alert and oriented x 2. When questioned where she was trying to go, R1 stated, I was trying to get to the bathroom. Writer with the assistance of CNA and the use of a gait belt, assisted resident to a standing position and transferred to wheelchair and into the bathroom to toilet per resident's request. Fall huddle was conducted with staff with the intervention of frequent visual checks. Resident's physician was notified as well as V17. At this time, resident is resting in the recliner with fluids and call light within reach. Vital signs and neuro checks will continue for the next 72 hours per facility policy. 1/11/2023 2:14 AM, at 2:00 AM, staff was alerted to resident's room by a loud sound. Writer entered room and found resident lying on her left side near the foot of her bed. Her head was not touching the floor. Resident denies hitting her head. Resident is able to move all extremities x 4 without pain or discomfort. When writer asked about the fall, resident stated I was going to the bathroom. Room was adequately lit, and no obstacles were on the floor. Residents incontinent brief was wet. Writer and staff CNA, with the use of a gait belt, placed resident in a standing position and then placed her in wheelchair. Resident requested to use the bathroom. Resident did void at this time. Resident was then assisted back to bed. V17 was notified of fall as well as her physician. Vital signs stable at this time, and neuro check are WNL. Fall huddle conducted with staff. At this time, the resident is resting in bed with fluids and call light within reach. Vital signs and neuro checks are to continue for the next 72 hours per facility protocol. R1's SBAR assessment, dated 2/26/23 documents R1 was found lying in the floor beside bed. Range of motion was performed with pain to back. Unable to move resident without crying out in pain. Resident said that she did hit her head. On 2/28/23 at 10:35 AM, R1 was observed in her room in a reclining wheelchair with the feet elevated. Full body mechanical lift sling was under the resident, no rips/tears noted. R1's call light was not within reach, there was not a Call don't fall sign in the room and no gripper strips were beside the bed. 3. R3's Face Sheet, undated, documents R3 has diagnoses of Parkinson's Disease, Abnormalities of Gait and Mobility, Dementia, Unsteadiness on Feet and Muscle Weakness. R3's MDS, dated [DATE], documents R3 has severe cognitive impairment, requires a limited assistance of 2 staff with transfers and has a history of falls. R3's Care Plan, dated 2/10/17, documents R3 is at risk for falls related to Parkinson's Disease with Dementia, personal choice is to remain as independent in all ADLs despite poor safety choices and history of falls with need for monitoring. The care plan lists the following interventions: 10/30/22 - ensure he is not left unattended in the dining room; 12/21/19 - call light within reach; 2/28/23 - do not lock wheelchair when at dining room table; 12/31/19 - Non-skid material in wheelchair to prevent sliding; 12/28/22 - Education done with staff on fall interventions; 12/29/22 - Ensure he has a soda with every meal; 12/25/22 - Ensure resident is one of the first to be taken out of the dining room; 1/8/23 - Frequent monitoring to assure proper positioning while in bed; 1/6/23 - gripper socks; 2/20/23 - Remove mat from floor and place wheelchair next to his bed; 12/22/22 - low bed; 6/1/22 - scoop mattress to bed; 4/22/22 - place non-skid strips in front of closet and wear non-skid socks to bed; 1/26/23 - Staff educated to ensure they are doing rounds and offering toileting every 2 hours. There were no interventions listed on the care plan for the falls on 12/5/22, 12/6/22, 12/22/22, 1/17/23, 2/9/23, 2/10/23 and 2/16/23. R3's Fall Risk Assessment, dated 11/1/22, documents R3 is at high risk for falls. R3's Progress Notes document the following: 12/5/2022 8:32 PM, resident had been sitting near nurse's station and another resident hollered that resident was on floor; this nurse assessed resident and no apparent injuries were found; CNAs assisted resident from floor and neuros were started; POA and doctor notified. 12/6/2022 11:28 AM, this nurse entered resident's room with another nurse and resident was leaning out of bed; this nurse and other nurse assisted resident back into bed and assessed for injuries; no injuries found; neuros started; notified POA and doctor. 12/22/2022 5:36 PM, this nurse was heading back to nurse's station and was notified by another nurse and CNA that resident was on floor in another resident's room; when this nurse went to assess and assisted resident up, it was noticed that resident's right shoulder appeared to be protruding out and swollen; resident was very tender in response to any touch in that area; this nurse contacted Administrator and contacted on-call doctor for an order to send resident to ER for evaluation and treatment. 12/22/2022 10:30 PM, resident returned to facility from ER visit. Impression: Contusion of right shoulder initial encounter, contusion of right hip initial encounter, and right rib contusion. At this time, the resident is not voicing any complaints of pain or discomfort. Resident is resting in bed with fluids and call light within reach. 12/25/2022 9:40 PM, writer requested into dining room at roughly 8:35 PM on 12/25/2022. Resident observed sitting on his buttock with bilateral arms resting at each side, bilateral legs straight out in proper alignment. Environment was well lit, quiet and floor dry. Writer approached resident and began assessment. Fall huddle initiated. Neuro checks initiated. Resident placed in a standing position without difficulty, assisted into wheelchair and taken to his room. Physician notified at roughly 8:50 PM. POA notified at 8:54 AM. Currently resting in bed, with call light/fluids within reach. Vitals continue to be obtained/charted under neuro assessment. 12/25/2022 10:16 PM, when writer spoke with resident regarding what he was doing at the time of the fall, stated he was getting up to go to his room. 1/6/2023 6:48 PM, approximately 4:10 PM, resident found by housekeeping manager sitting on the floor. Resident fully dressed in socks only and no shoes on. Resident sitting on the floor facing the door beside roommate's bed. Resident denied pain and denied hitting head. R3 said he was trying to get roommates side table to use. Resident able to perform active range of motion with no pain. Able to come to a standing position with writer. Resident's skin assessed with no new areas. POA called and message left. MD made aware at 4:36 PM. 1/8/2023 12:17 AM, at roughly 9:40 PM on 1/7/2023 writer was requested into resident's room. Writer approached room and observed resident sitting on the floor mat, next to his bed, with bilateral legs straight out in proper alignment, right hand holding onto bed rail and left arm resting next to left side. Environment was dark, floor dry with call light within reach. Resident was wearing gripper socks. During assessment, resident was asked what had happened during the time of the fall, stated to writer he was trying to roll over. Fall huddle initiated, fall witnessed by additional staff. MD notified at 10:00 PM. POA called with message left at 10:22 PM. Call back received from POA at 10: 56 PM, aware of situation/agrees with steps being taken. Fall intervention in place. Call light/additional materials within reach of resident. 1/17/2023 9:20 AM, resident was found on floor laying in wheelchair in dining room; assessment was done and no complaints of pain or injury; staff assisted resident and wheelchair to upright position; neuro checks started, physician and POA notified. 1/25/2023 4:49 PM, CNA approached this nurse and advised resident was on the floor of his room; upon arrival in his room, this nurse found resident on floor between his bed and wheelchair; resident had no complaints of pain or discomfort; this nurse and CNAs assisted resident from floor; vitals were started, doctor notified and POA notified. 2/9/2023 6:47 PM, CNA was walking, passed resident's room, and found him on floor with wheelchair next to him; CNA notified this nurse and this nurse assessed resident; no apparent injuries were found; resident was assisted into another wheelchair and neuros were started; MD and POA notified; nursing supervisor/DON/Administrator notified. 2/10/2023 4:38 PM, resident witnessed ambulating and going to door frame and slowly sitting himself on the floor. Resident yelled for writer. Skin assessed; active range of motion performed with no pain noted. POA, MD, and DON aware. Resident fully dressed in anti-skid socks. Incontinent brief is dry, drink and snack at bedside. Fall mat on the floor. Resident was unable to tell writer what he was doing ambulating. 2/16/2023 2:49 PM, Resident slid out of chair by nursing station according to staff, who helped resident up from the floor. Witness stated there was no injury to resident. Resident appears relaxed and in no pain and or distress. Vitals were taken and updated into the resident's chart. Currently, the resident is on neuro checks from previous fall on night shift. This appears to be a normal thing for the resident, will continue to monitor for and change in condition or level of consciousness of the resident. 2/20/2023 4:00 PM, Patient fell . Fall was unwitnessed. Patient did not state how he fell . Writer was passing evening medications on A-Hall. Writer looked down the hall and saw staff gathered around patient. When writer approached, patient was sitting upright, knees to chest. Patient was relaxed. Upon assessment patient had a bump on the back of his head. Skin intact. Patient was sent to ER per staff request. 2/20/2023 7:20 PM, resident returned to facility from the ER, resident has no new orders. Nothing found in test at hospital. Neuros continued. 2/25/2023 2:52 PM, see SBAR assessment for further information and family/physician notification. The change in condition the resident is currently experiencing is a fall. CNA said that they heard a loud noise and found resident laying on the floor with back against the wall next to head of bed. On 2/28/23 at 1:40 PM, R3 was observed in bed, pleasantly confused, unable to provide any details of his falls. There was no non-skid material in R3's wheelchair and R3 was wearing regular socks, not gripper socks. The facility Resident Council Notes, dated 12/7/22, documents call lights were being put out of reach. The Fall Policy, dated 9/17/19, documents Following any falls, the facility staff completes an occurrence report. Details of the fall will be implemented, and the care plan will be updated.

Based on interview and record review, the facility failed to ensure continuity of care by failing to secure follow up appointments and testing for 2 of 3 residents (R3, R6) reviewed for quality of care in the sample of 13. This failure resulted in R6 being admitted into the hospital with a Urinary Tract Infection. Findings include: 1. R6's Face Sheet, print date of 2/2/23, documents R6 was admitted on [DATE] with diagnoses of Acute Kidney Failure, Atrial Fibrillation, Anemia, History of Malignant Neoplasm of Prostate and muscle weakness. R6's Hospital After Visit Summary, dated 12/9/22, documents, Discharge instructions: Please hold Eliquis for one month - can resume first week of [DATE] need CT (computerized tomography) head prior to monitor resolution of bleed f/ u (follow up) with NS (neurosurgery) in 3 weeks. What's Next: Follow up with (V9, Neurosurgeon). Please call our office to schedule a follow - up in about 4 weeks with a repeat CT head prior to your follow - up to assess if the small bleed on the surface of your brain has resolved. Follow up with (V6, Urology Nurse Practitioner) in 2 weeks. Our office will call to schedule (indwelling urinary catheter) removal and starting Lupron. R6's Health Status Note, dated 1/31/23 at 10:00 AM, documents, Discharge Summary Note Text: Pt. (patient) d/c'd (discharged ) with medications and belongings. Writer educated pt. on medications times, taking meds (medications) as prescribed, and some side effects to report to PCP (Primary Care Provider). Pt. given copy of order summary. R6's Hospital Emergency Department Phys (Physician) Chart, dated 2/2/23, documents R6 was admitted on [DATE] with diagnoses of Acute Cystitis with Hematuria (blood in urine), Dehydration and Anemia. On 2/8/23, V12 (Nurse Practitioner) stated, V13 (R6's daughter) brought R6 in to be seen after leaving the nursing home. I saw him on 1/31/23. He just looked awful. He was so weak he could not stand by himself. I did a quick assessment and took him down to the emergency room for an evaluation. My office is in the hospital. He then was admitted to the hospital. When I saw him, he had a very high heart rate, and I was worried he was septic. The hospital admitted him and diagnosed him as being septic with an UTI (Urinary Tract Infection). I cannot say if leaving the (indwelling urinary) catheter in longer and not getting him started on the Lupron did him harm but he was admitted to the hospital with a UTI, which is harm. I think he deteriorated from being septic from the UTI and his low Hemoglobin and Hematocrit. I did not remove his (indwelling urinary) catheter while he was in my office. I left it for the hospital to address. V12 further stated, R6 not getting his CT scan and follow up neurology appointment and the delay of restarting his Eliquis put R6 at risk. When I saw him, he had a very fast heart rate with the sepsis, and he has atrial fibrillation. This puts him at high risk for developing a blood clot. He was definitely at a high risk of harm, but to my knowledge, the hospital did not find a blood clot. 2. R3's Face Sheet, print date of 2/7/23, documents R3 was admitted [DATE] and has diagnoses of Acute Respiratory Distress Syndrome, Emphysema and Congestive Heart Failure. R3's Hospital After Visit Summary, dated 11/17/22, documents, What's Next: Jan (January) 23, 2023 (Regional Hospital) Vascular Ultrasound at 8:00 AM and Follow-up with (V10), Cardiology Advanced Practice Nurse, on Monday [DATE] at 9:00 AM. On 2/6/23 at 1:39 PM, V3 (Interim Assistant Director of Nursing/ Interim ADON) stated that when a resident is admitted to the facility, if there are any appointments that need to be made, they go to V8 (Transport Driver) and she sets up the appointments. V3 also stated that all discharge orders that document a doctor's office will call with an appointment should be followed up on to ensure that the resident gets the needed appointment scheduled. On 2/6/23 at 2:20 PM, V8 (Transport Driver) stated that she was not aware that R6 needed an appointment for a CT of the brain or a follow up appointment for removal of an indwelling urinary catheter. V8 also stated, R3 is too large to go in the facility van. We usually try to set him up with a bariatric transport out of [NAME]. I just found an envelope in last year's book stating that R3 missed an appointment on 1/23/23 for the cardiologist. I need to talk to the Administrator and see if we can do that as a possible telehealth visit. When asked if she was aware of the appointment that R3 had for 1/23/23 at 8:00 AM for a vascular ultrasound, V8 stated, I was not aware of that. I guess I need to talk to the Administrator about getting him to [NAME]. Usually, the nurses give me the discharge paperwork with all appointments on it or any appointments that need to be made for the residents, and I will call and set them up. I did not get R6's or R3's discharge paperwork with those appointments on it. On 2/6/23 at 3:15 PM, when asked about the missing appointments of R3 and R6, V3 (Interim ADON) stated that she will have to come up with a better system to track appointments and make sure they get made. On 2/7/23 at 11:35 AM, V3 stated that the facility does not have a policy and procedure on setting appointments or transcribing hospital discharge orders.

Based on interview and record review, the facility failed to provide care and follow physician orders for an indwelling urinary catheter for 1 of 5 residents (R6) reviewed for indwelling urinary catheter care in the sample of 13. This failure resulted in R6 having an indwelling urinary catheter longer than ordered and being admitted to the hospital with a diagnosis of acute cystitis with hematuria. Findings include: R6's Face Sheet, print date of 2/2/23, documents R6 was admitted on [DATE] with diagnoses of Acute Kidney Failure, Atrial Fibrillation, Anemia, History of Malignant Neoplasm of Prostate and muscle weakness. R6's Hospital After Visit Summary, dated 12/9/22, documents, Discharge instructions: Follow up with V6 (Urology Nurse Practitioner) in 2 weeks. Our office will call to schedule (indwelling urinary catheter) removal and starting Lupron. R6's Electronic Medical Record (EMR) was reviewed for documentation of the care and observation of R6's indwelling urinary catheter. R6's EMR had 2 notes available for review related to R6's indwelling urinary catheter were on Admission and on 12/28/22. The catheter is not mentioned anywhere else. There were no orders regarding the indwelling urinary catheter, no care plan regarding it, and nothing on Treatment Admission Record (TAR) regarding the performance of catheter care or monitoring for R6. R6's Admission Assessment, dated 12/9/22, documents that R6 was admitted with an indwelling urinary catheter. R6's Health Status Note, dated 12/28/22, documents that R6 has an indwelling urinary catheter. R6's Health Status Note, dated 1/31/23 at 10:00 AM, documents, Discharge Summary Note Text: Pt. (patient) d/c'd (discharged ) with medications and belongings. Writer educated pt. on medications times, taking meds (medications) as prescribed, and some side effects to report to PCP (Primary Care Provider). Pt. given copy of order summary. R6's Hospital Emergency Department Phys (Physician) Chart, print date of 2/2/23, documents R6 was admitted to the (local hospital) on 1/31/22 at 4:05 PM with diagnoses of Acute Cystitis with Hematuria (blood in urine), Dehydration and Anemia. R6's Hospital Complete Blood Count with Differential, dated 1/31/23 at 4:31 PM, documents that R6 had a white blood cell count of 19.6 which is high (This is indicative of an infection). The normal range is 4.8 - 10.8. R6's Hospital Urinalysis, dated 1/31/23 at 4:17 PM, documents that R6's urine was obtained from an indwelling urinary catheter, and it was slightly turbid, had leukocytes, protein, red blood cells and white blood cells present in the urine. All of these are abnormal to be in urine. R6's Hospital Inpatient Discharge, dated 2/7/23, documents, Diagnoses: 1. Sepsis 2' (secondary to) UTI (urinary tract infection). Specimen did not qualify for a culture. ABS (antibiotics) given anyway. SIRS (Systemic Inflammatory Response Syndrome) criteria resolved on IV (intravenous) Rocephin. No other source found. On 2/8/23, V12 (Nurse Practitioner) stated, V13 (R6's daughter) brought R6 in to be seen after leaving the nursing home. I saw him on 1/31/23. He just looked awful. He was so weak he could not stand by himself. I did a quick assessment and took him down to the emergency room for an evaluation. My office is in the hospital. He then was admitted to the hospital. When I saw him, he had a very high heart rate, and I was worried he was septic. The hospital admitted him and diagnosed him as being septic with a UTI. I cannot say if leaving the (indwelling urinary) catheter in longer and not getting him started on the Lupron did him harm, but he was admitted to the hospital with an UTI, which is harm. I think he deteriorated from being septic from the UTI and his low Hemoglobin and Hematocrit. I did not remove his (indwelling urinary) catheter while he was in the office. I left it for the hospital to address. On 2/6/23 at 2:20 PM, V8 (Transport Driver) that sets up appointments, stated that she was not aware that R6 needed an appointment for a follow-up appointment for removal of an indwelling urinary catheter. V8 stated, Usually the nurses give me the discharge paperwork with all appointments on it or any appointments that need to be made for the residents, and I will call and set them up. I did not get R6's discharge paperwork with those appointments on it. On 2/8/23 at 2:30 PM, V3 (Interim Assistant Director of Nursing/ Interim ADON) stated, When a resident is admitted with an (indwelling urinary catheter), orders are written for the care of the catheter like if the catheter needs to be changed because it is not working (blocked), if it needs to be irrigated or if the drainage bag needs to be changed. Those would all be prn (as needed) orders. Those orders would be placed on the TAR so the nurse know that there is a (indwelling urinary) catheter and that it needs to be monitored. The nurses should be checking and documenting on the catheter. We are a (corporation name) home, and we do not have a policy on (indwelling urinary) catheter care. We expect our nurse to follow the nursing standard practice of nursing care for (indwelling urinary) catheters. V3 was told that R6 only had documentation of R6 having an indwelling urinary catheter on 2 notes, the Admission Assessment from 12/9/22 and Health Assessment note of 12/28/22, V3 stated that R6's indwelling urinary catheter should have been charted daily in the TAR.

Based observation, interview and record review, the facility failed to assess for risks of weight loss by monitoring weights and failed to implement interventions to prevent weight loss for 4 of 7 residents (R6, R7, R8, R9) reviewed for nutrition in the sample of 13. This resulted in R8 losing 13.8 pounds (lbs.) in 25 days resulting in a 11.2 % weight loss, R6 losing 9.9 lbs. resulting in a 6.1% weight loss in 30 days, and R9's losing 22.46 lbs. resulting in 17.5% weight loss in 24 days. Findings include: 1.R8's out of state Regional Hospital Progress Notes, dated 11/29/22, documents, Wt. (weight) readings from last 3 Encounters are 11/25/22 123 lb. (pounds) 7.3 oz (ounces), 10/04/22 123 lb. 7.3 oz, and 6/30/22 134 lbs. 0.6 oz. R8's Facility's Face Sheet, print date of 2/7/23, documents that R8 was admitted on [DATE] from an out of state Regional Hospital with diagnoses of a Stroke, Dementia and Severe Protein - Calorie Malnutrition. The facility had no documentation R8's weight was taken upon admission. R8's Physician Orders, dated 12/12/22, documents, Weekly weight every day shift every Thur (Thursday) for 4 weeks. Stop date of 1/12/23. R8's Minimum Data Set (MDS), dated [DATE], documented he had severe cognitive impairment, required limited assistance of one staff for eating. R8's February 2023 Physician Orders documents, Regular diet, Mechanical Soft texture, Regular Liquid Consistency, health shakes with meals, whole milk and large portion protein with meals. R8's Dietician Nutrition assessment, dated 12/28/22, documents, Most Recent weight 123.0 Date: 12/12/22 Scale: wheelchair. Usual body weight unknown. Goal weight 154. Comments: IBW (Ideal Body Weight) 139 - 169 lbs. Weekly weights ordered. Appearance Malnourished. Skin issues Pressure Ulcers (unstaged) R (right) Trochanter. Nutrition Summary: 72 y/o (year old) male - admitted with multiple medical issues including malnutrition, skin breakdown, kidney disease, dysphagia. He is on a Regular Mechanical Soft diet - speech therapy is ordered. Intake is reported 75-100% - occasionally eats less at times. Mechanical Soft diet (may be changed with speech therapy). Health shakes @ (at) meals along with extra foods as above. May need to make restrictions depending on renal function issues. Goal - gradual weight gain, intake >75%, wound healing. He is underweight, and extra calories and protein are warranted. Do not want to overdo the protein d/t (due to) to compromised kidney function. Suggest adding health shakes TID (three times a day) @ meals, large portions of protein and whole milk @ meals. Suggest adding a multivitamin/mineral supplement. Staff aware of food preferences. Nutrition Plan: Mechanical Soft diet (may be changed with speech therapy). Health shakes @ meals along with extra foods as above. May need to make restrictions depending on renal function issues. Goal - gradual weight gain, intake >75%, wound healing. R8's Weight and Vitals Summary documents that on 12/12/22, R8 weighed 123 lbs. (pounds) using a wheelchair scale. This same report documents that on 1/6/23 R8 weighed 109.2 lbs. using a mechanical lift scale, indicating that R8 had a 13.8 lbs. weight loss, indicating that R8 has had a significant weight loss of 11.2% in 25 days. R8's Dietary Note, dated 1/14/23, documents, Skin and weight issues - Unstageable area on medial L (left) foot and 2 areas on R trochanter - improving. Last update added health shakes TID @ meals, large portions of protein and whole milk @ meals, as well as a multivitamin/mineral supplement. Weight loss noted from admission - 123# to 109.2# - 13.8# (11/2%). Continue with current interventions and will follow. The facility had no other documented weights recorded for R8. There was no documentation that the facility implemented any additional interventions to address R8's weight loss after he lost 13.8 pounds. R8's Dietary Note, dated 2/4/23, documents, Skin issues - Stage 4 area on medial L(left) foot and Stage 3 areas on R trochanter - improving noted on both by nursing. Recently added health shakes TID @ meals, large portions of protein and whole milk @ meals as well as a multivitamin/mineral supplement. Weight loss noted from admission - 123# to 109.2# - 13.8# (11/2%). No February wt. (weight) at this time. Continue with current interventions and will follow. There was no documentation that the facility implemented any additional interventions to address R8's weight loss or if he had experienced any further weight loss. The facility supplied document Need w/c (wheelchair) Dec (December) is a handwritten notebook piece of paper that documents R8 weighed 109.6 lbs. On 2/7/23 at 9:30 AM, V3 (Interim Assistant Director of Nursing/ Interim ADON) stated that the weight aide found a handwritten notebook piece of paper with weights on it that had been taken in December, but they had not been documented. On 2/7/22 at 2:01 PM, R8 was observed eating lunch with the assistance of V11 (Certified Nursing Aide/CNA). R8 was not served a health shake with the noon meal. 2. R6's Face Sheet, print date of 2/2/23, documents R6 was admitted on [DATE] from a Regional Hospital with diagnoses of Acute Kidney Failure, Atrial Fibrillation, Anemia, History of Malignant Neoplasm of Prostate and muscle weakness. The facility had no documented admission weight for R6. R6's MDS, dated [DATE], documents that R6 is cognitively intact and requires set up for meals. R6's Weight and Vital Summary, printed on 2/7/23, documents, R6's weight was 159.8 lbs. on 12/15/22. R6's Care Plan, dated 12/22/22, documents, Diet to be followed as prescribed. Interventions. Food dislikes are: none noted at this time. I prefer snacks between meals. I would like anything for a snack. My favorite beverages are: variety of beverages. My favorite foods are: none noted at this time. R6's Treatment Administration Record (TAR), dated 12/1/22 - 12/31/22, documents, Weight every day shift every Sat (Saturday) for 4 weeks. Start date of 12/10/22. This TAR fails to document R6's weight on 12/10/22, 12/17/22 and 12/23/22. R6's Weight and Vital Summary dated 12/31/22 documents R6 weighed 161.6 lbs. R6's Physician Orders, dated January 2023, documents, Regular Diet Regular texture, Regular Liquid Consistency, 2000 cc (cubic centimeters) fluid restriction avoid ham, bacon, sausage, sauerkraut, salted crackers, chips, oj (orange juice), bananas, baked potatoes, tomatoes juice, avoid saltshaker and salt at table. R6's Hospital Emergency Department Phys (Physician) Chart, dated 2/2/23, documents that R6 was admitted to the hospital on 1/31/23 and R6's initial weight at the Emergency Department presentation was 151.7 pounds. This indicates R6 lost 9.9 lbs. in 30 days resulting in a 6.1 % weight loss which is classified as a significant weight loss. 3. R9's Hospital Progress Note, dated 12/18/22, documents that R9 weighed 58.3 kg (128.6 lbs.) R9's Face Sheet, print date of 2/7/23, documents that R9 was admitted on [DATE], with diagnoses of Parkinson's Disease, Dementia and limitation of activities due to disability. There was no documentation the facility obtained R9's weight upon admission. R9's MDS, dated [DATE], documents R9 is severely cognitively impaired and requires limited assistance of 1 staff member for eating. R9's Dietician Nutrition Assessment, dated 12/28/22, documents, Most Recent Weight: 134.0 (Lbs.), Date: 12/5/2022, Scale: Wheelchair. BMI 20.4. Goal weight 154. IBW - 139-169 lbs. Weight was obtained from hospital admission record. Appearance: Well nourished. Comments on appearance: thin. Nutritional Plan: 92 y/o male - admitted after hospitalization for UTI (Urinary Tract Infection) - has Parkinson's and dementia. On a Pureed diet - eats with assistance. He is below IBW standards. Suggest adding calories to promote some wt. gain. Suggest super cereal and double protein @ breakfast, whole milk @ meals, ice cream and extra dessert @ lunch and supper. Need to obtain a current wt. on facility scale. Nutritional Goal: Provide extra foods as above. Goal - intake >75%, gradual wt. gain. R9's Health Status Note, dated 1/1/23, documents, New diet order received per dietary recommendation add super cereal whole milk ice cream and extra dessert. R9's Weight and Vital Summary documents that R9 weighed 105.8 lbs. on 1/11/23. R9's weight calculations of 12/18/22 at 128.6 lbs. and 1/11/23 at 105.8 lbs. document a 22.46 lbs. weight loss or 17.5% weight loss in 24 days, indicating R9 sustained a significant weight loss. R9's Dietary Note, dated 1/14/23, documents, Weight loss noted - 105.8# BMI-16.09. Admission wt. was recorded as 134 (taken from hospital admission records. He is on super cereal & 2x protein @ breakfast, whole milk @ meals, ice cream & extra dessert @ lunch and supper. He has been working with ST (Speech Therapy) -to be advanced to Mechanical Soft - waiting on MD (Medical Doctor) order to confirm. Yesterday at lunch, he was given some ground chicken and ate about 50% of it with supervision. Dietary staff will check with nursing before providing anything other than pureed foods for now and if he gets this, it must be with close supervision. He does need additional calories - will suggest adding Health shake or 2.0 supplement at med pass - 90 ml TID (milliliters three times a day). R9's Physician Orders Summary, dated 2/7/23, documents, Regular diet Mechanical soft texture, Regular Liquid Consistency, offer Kennedy cups only when shaking with straws, return to regular silverware. Continue ice cream x (extra) dessert lunch and supper offer 2 x protein @ Breakfast offer super cereal @ breakfast whole milk with meals with assist with feeding. R9's Physician Orders fails to document, Health shake or 2.0 supplement at med pass - 90 ml TID that was recommended on 1/14/23. On 2/8/23 at 12:50 PM, R9 was not served milk or ice cream with the noon meal. 4. R7's Face Sheet, print date of 2/7/23, documents that R7 was admitted on [DATE] from a Regional Hospital with diagnoses of Orthopedic aftercare following surgical amputation (left below the knee amputation). R7's Physician Orders, dated 2/7/23, documents, Regular diet Regular texture, Regular liquid consistency. R7's MDS, dated [DATE], documents that R7 is cognitively intact and R7 is independent with eating. R7's facility Weights and Vitals Summary, documents R7 was only weighed one time and that was on 2/6/23 and his weight was 289.6 Lbs. R7's Hospital Discharge Plan, dated 1/17/23, documents on 1/10/23 R7 weighed 152.3 kg (kilograms) or 304.6 lbs., and R7 had a left below-the-knee amputation. On 2/7/23 at 2:30 PM, R7 stated, I had my surgery on 1/14/23. I do think I am losing weight, and my shorts are a little looser. On 2/6/23 at 1:45 PM, V3 (Interim ADON) stated, New admissions are weighed upon admission and then once a week for 4 weeks. If the resident's weight is stable, then they will be weighed once a month, if not, then the weekly weights will continue. Residents that are experiencing weight loss will be weighed weekly until they stabilize. I do not know why R9's updated dietary recommendation is not in the system. On 2/7/23 at 9:02 AM, V3 stated, I have figured out what happened with the dietary recommendations, the Administrator walked out about January 8th, 9th or 10th. I just got all these recommendations that V1 (Administrator) just got yesterday afternoon via email. I think what happened is they were going to the old Administrator, and they were not getting forwarded to the new Administrator. The process is the Dietician will make a note in the computer about recommendations. She then goes back to her office and makes up the orders, which is then emailed to the Administrator. The Administrator then forwards them to me to put into place. The facility Weight Assessment and intervention policy, dated 1/2017, documents, Weight Assessment. 1. The nursing staff will measure resident's weights on admission, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly. 2. Weights will be recorded in the individual's medical record. 3. The threshold for significant unplanned and undesired weight loss will be based on the following criteria. It continues, a. 1 month 5% weight loss significant; greater that 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10 % weight loss is significant; greater than 10% is severe.

Based on observation, record review, and interview, the facility failed to provide supervision to prevent falls and wandering for 2 of 8 residents (R14, R34) reviewed for accidents and supervision in the sample of 46. This failure resulted in R34 having multiple falls resulting in a nasal fracture, head contusion and hip fracture. Findings include: R34's Face Sheet, printed on 8/4/21, documents R34 has diagnoses of unsteadiness on feet, muscle weakness, other abnormalities of gait and mobility, anterior dislocation of left humerus, displaced intertrochanteric fracture of the right femur, lack of coordination and history of falling. The Face Sheet documented these diagnoses had onset dates prior to 8/16/21. R34's Care Plan, not dated, documents (R34) is at risk for falls related to a hx (history) of falls and impaired mobility. R34's Care Plan interventions document Encourage (R34) to be patient and wait for help after asking for help. R34's Care Plan Intervention documents Encourage resident to remain in high traffic area when up in w/c (wheelchair). R34's Care Plan Intervention (R34) will be last up and down first after meals. When resident becomes restless staff to take him for a walk. R34's Minimum Data Set (MDS), dated [DATE], documents R34 has severe cognitive impairment. MDS documents R34 requires extensive assistance of two staff persons for transfers. MDS documents R34 is not steady and is only able to stabilize with staff assistance when moving from seated to standing position, walking, turning, facing the opposite direction while walking, moving on and off toilet, and surface-to surface transfers. R34's Fall Risk Assessments, dated 5/2/2021, 6/13/2021 and 6/16/2021, document High Risk for falls. R34's Occurrence Report, dated 6/1/2021 at 2:40 PM, documents Nurse was sitting at desk observed resident lying face first on the floor. CNA said she had just taken R34 to the bathroom. The Follow up report section documented Resident was sitting by nurse's desk while nurse was documenting. Nurse heard resident state 'Girls I hurt myself bad.' R34 was noted lying face down on the floor with a bleeding nose and hematoma to left forehead. Resident sent to (Local Hospital) ER (emergency room ). Dx (diagnosis) with (fractured) nasal bone and hematoma on forehead. On 8/9/2021 at 9:12 AM V16, Licensed Practical Nurse (LPN), stated R34 has poor safety awareness. V16 stated on 6/1/2021, R34 was placed in front of the nurse station against the wall. R34 stated she was charting and heard R34 say he hurt himself. R34 stated when you are sitting at the nurse station and documenting you can't see the residents in front of the desk unless they are right next to you. V16 stated R34 was supposed to lie down after lunch but things happen. R34's Health Status Note, dated 6/15/2021 6:41 PM, documents Note Text: Resident on I and A (incident and accident) for witnessed fall. Continues to need reminders to let staff assist with all transfers. R34's Fall Occurrence Report, dated 6/16/2021 at 7:30 PM, documents Writer notified to come to nurse's station by UA (unit aide). Resident observed on floor in front of wheelchair. Had landed on his buttocks then laid down. Resident had recently been toileted and given a shower. Resident kept wanting to stand up therefore was being 1 on 1 by staff at the nurse station. The Follow-up Report section documented R34 was talking with the Task Aide and stated he was going to stand up. Task Aide asked R34 to remain seated so she could get some help, but resident stood up and fell to the floor, landed on his buttocks. Task aide then informed the nurse R34 was on the floor. R34 complained of pain to left leg, and hip area. R34 was sent to (local hospital) ER (emergency room ). Resident was transported to (another hospital) in (nearby city). Resident has poor safety awareness, poor eyesight, and hard of hearing. R34's Health Status Note, dated 6/16/2021 18:37, documents Note Text: I &A (incident and accident document) for witnessed fall with no injuries. R34 continues to attempt to self-transfer. resident involved with activities throughout the day, R34's Health Status Note, dated 6/16/2021 23:40, documents Note Text: Writer received call from (Local Hospital) ER (emergency room ). R34 is reported to have Left Hip Fracture. R34 is being transferred from (Local Hospital) to (Regional) hospital in (nearby city). On 8/6/2021 at 7:40 AM V26, LPN, stated R34 has poor safety awareness. V26 stated when R34 gets his mind set on something he is going to do it. V26 stated on 6/16/2021 R34 was making attempts to stand, and she placed R34 across from the nurse's station so she could watch him. R34 stated that she had V25, Unit Aide, sitting there to perform one on ones with R34 as she went down hall to pass her medication. V26 stated that V25 can't touch him so she couldn't prevent his fall. V26 stated she assessed R34 while on the floor and he had no internal or external rotations. V26 stated that R34 was lifted off the floor with 2 CNA's and placed in bed. V26 stated that this is when R34 complained of hip pain. On 8/9/2021 at 9:15 AM V25 stated she works throughout the building. V25 stated her job consists of passing ice, passing trays, taking the smokers out, making beds and wheelchair cleaning. V25 stated she cannot perform any hands-on care for the residents. V25 stated on 6/16/2021 R34 was sitting across from the nurse station against the wall. V25 stated R34 kept trying to stand up, pushing up from the wheelchair. V25 stated R34 told her he was going to stand up. V25 stated she left R34, across from the nurse station, went to the top of the hall and yelled for help. V25 stated No one came. V25 stated while she was trying to get help R34 took a couple of steps and grabbed hold of the table lost his balance and fell backwards hitting his head, and buttocks on the floor. V25 stated she can't provide hands on care, so she had to leave R34 to get help. On 8/9/2021 at 12:20 PM, V2, Director of Nursing (DON, stated one on one interventions would be when a staff is next to the resident. On 8/9/2021 at 12:22 PM, V4, MDS Coordinator, stated one on one is when staff is sitting next to the resident. V4 stated that a unit aide would not be appropriate to provide one on one care because they can't do hands on care. V4 stated if the resident is getting up and down the unit aides would not be appropriate for one-on-one care. V4 stated They (unit aides) can call for help but they can't do any hands-on care. On 8/9/2021 1:50 PM V4 stated residents that are identified as high risk require increased supervision and placed on the S.A.F.E. program. V4 stated if there would have been a CNA or person that could provide hands on care then R34's fall, on 6/16/2021, would have been prevented. The Facility's Fall Prevention Policy (S.A.F.E.) documents Definition: The S.A.F.E. program promotes Safety Assessment, Fall prevention and Education of both staff and residents. 2. R14's Admission Record, print date of 8/4/21, documents R14 was admitted on [DATE] with diagnoses of [CONDITION(S)], [CONDITION(S)], Cognitive Communication Deficit, Dementia and Profound Intellectual disabilities. R14's Minimum Data Set (MDS), dated [DATE], R14 is severely cognitively impaired. R14's Care Plan, undated, documents, R14 is an elopement risk/wanderer. The Care Plan documents R14 wanders the halls and goes into other people's rooms as well as touch doors with her foot to get herself turned around. The Care Plan interventions document that staff should redirect R14, get R14 out of the room if by herself, because she is gets stuck, and can't turn around, and refer to social service. On 8/2/21 at 1:45 PM, R14 was propelling herself in her wheelchair on B-hall with no supervision. R14 went into and came out of room B12. On 8/3/2021 at 8:40 AM, R14 was propelling herself in her wheelchair through the hall. At 8:44 AM R14 entered R20's room. R20 began to yell get out, get out. On 8/3/21 at 8:56 AM staff intervened and removed R14 from R20's room and placed R14 in the hall. R14 continued to self-propel through the hall. On 8/5/2021 at 1:15 PM, R20 stated R14 comes in her room all the time. R20 stated she yells for her (R14) to get out. R20 stated (R14) goes through her roommate's stuff. It scares me. R14 stated sometimes she is asleep, and this happens waking her up and startling her. R20 stated she went to the resident council meeting yesterday and told them they needed to do something about residents coming in and out of her room. R20 stated she guesses they are harmless but how does she know they are harmless. R20 stated It's scary. On 8/2/21 at 11:43 AM, R35 stated R14 steals her things like pens and hairbrushes because she wanders around. On 08/04/21 at 09:46 AM, V9 Certified Nurse's Aide (CNA), stated, (R14) just wanders around and goes into other people's rooms. We have to redirect her. On 8/5/21 at 8:00 AM, V2, MDS/LPN, stated, (R14) does wander in her wheelchair. She goes all over the facility and she is quick. Staff should be redirecting her and giving her something to do. On 8/9/21 at 9:15 AM, V25 Unit Aide, stated R14 does wander around the building in her wheelchair, and she requires supervision to get her out and keep her out of other residents' rooms. R14's Nurses Note, dated 3/4/2021 at 2:37 AM, I&A (incident and accident) R14 as being struck by another Resident in her head. There is no injury noted. The facility final incident report, undated, documents, (R109) [AGE] year-old white male with diagnosis of [CONDITION(S)] (post-traumatic stress disease), CHF (congestive heart failure) was heard yelling Get out of my room followed by a tapping noise. ADON (Assistant Director of Nurses) went to see what noise was and saw (R109) hitting (R14), a [AGE] year-old white female with diagnosis of dementia on the head with a Reacher. The facility Resident Council Meeting, dated 8/4/21, documents, Issues / Concerns: wandering residents. The facility policy Elopements, dated 2/2021, documents, It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible.

Based on observation, interview, and record review, the facility failed to perform catheter care and complete incontinent care for 7 of 10 residents (R1, R2, R6, R8, R14, R34, R44) reviewed for incontinence care, catheter care in a sample of 46. This failure resulted in R44 not given supra pubic catheter care as ordered and being hospitalized for urosepsis. Findings include: 1. R44's Care Plan, not dated, documents (R44) has supra pubic catheter: [CONDITION(S)]. R44's Care Plan Interventions document catheter care every shift and PRN (as needed), monitor for signs and symptoms of discomfort on urination and frequency, and monitor/document for pain/discomfort due to catheter. R44's Treatment Administration Record (TAR), dated June 2021, documents Supra pubic catheter care, wash catheter site with soap and water every shift for catheter care. R44's TAR does not document R44 received supra pubic catheter care on the following dates and shifts: Days shift on 6/7, 6/8, 6/10 and 6/17/21; Evening shift on 6/2, 6/3, 6/6, 6/7, 6/8, 6/10 and 6/11/21; and Midnight shift on 6/10/21. R44's TAR also documents Monitor for signs and symptoms of infection, notify MD of any signs or symptoms of infection every shift. R44's TAR does not include documentation that R44 was being checked for infection on the following dates and shifts: Day shift on 6/7/21, 6/8/21 and Evening shift on 6/3/21, 6/6/21, 6/7/21, and 6/8/21. R44's order was discontinued 6/10/21. R44's Progress Notes, dated 6/23/2021 at 2:45 PM, documents Resident complains of pain keeping him awake at night. Has a decrease appetite and complains of nausea? New orders received to increase [MEDICATION(S)] to 900 mg (milligrams) TID (three times a day), CBC (complete blood count), CMP (comprehensive metabolic panel), and abdominal Xray. R44's Progress Notes, dated 6/23/2021 at 10:38 PM, (X-ray company) here to complete ABD (abdominal) Xray earlier this evening. Results received and faxed to MD (doctor). R44's Progress Notes, dated 6/24/2021 at 10:20 AM, Situation-Background-Assessment-Recommendation (SBAR) Note documents Text: resident is experiencing a change in condition. Resident is currently experiencing Drainage to suprapubic site. Labs from a.m. sent with Ambulance. R44's Progress Notes, dated 6/24/2021 at 10:30 AM, documents Resident with moderate amount drainage on brief. R44's Supra pubic catheter with some drainage. Attempted to change catheter. Once balloon was deflated very large amount purulent drainage from site. Attempted to place new 18 Fr (French). 10 cc (cubic centimeters) balloon, unsuccessful, no drainage of urine into tubing with attempt by DON (Director of Nursing) as well with no success. Upon this process call received from Lab with elevated WBC (white blood cell) 25.4. (V22, Medical Director/Physician) also was called. New Orders from doctor to send to ER (emergency room ). ER was contacted by phone. 911 contacted, for transport to (Local) Hospital ER. All paperwork completed. Lab results sent with ambulance. Bed hold/and transfer also sent upon transport via ambulance with 2 EMTs (Emergency Medical Technicians) transporting. R44's Progress Notes, dated 6/24/2021 at 3:28 PM, documents Call received from (local hospital) ER (emergency room ) RN (registered nurse). Resident is being transported out to a (regional hospital) with low B/P (blood pressure) and placed on [MEDICATION(S)]. WBC (white blood count) at 25.8. R44's Progress Notes, dated 6/25/2021 at 2:08 AM, documents Call placed to (regional) hospital. Writer spoke with a hospital nurse. R44 was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/5/2021 at 10:35 AM V22, Medical Director, stated not performing supra pubic care could have caused this infection and caused R44 to be hospitalized . 2. R2's Care Plan, not dated, documents R2 has bladder and bowel incontinence. R2's Care Plan Interventions documents Check (R2) every 2 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes. R2's Minimum Data Set (MDS), dated [DATE], documents frequently incontinent of urine, always incontinent of bowel and requires total assistance of two staff with toileting. On 8/2/2021 at 10:51 AM V8, Certified Nurse's Assistant (CNA), assisted R2 with incontinent care. V8 left the room and obtained a stack of wash cloths. V8 wet the washcloths with water in the sink. V8 placed washcloths in a plastic bag on the foot of the bed. V8 then pulled back R2's cover and unfastened R2's incontinent brief. R2 was incontinent of urine and small amount of bowel. V8 assisted R2 over onto his left side and using the wet washcloth wiped R2's anal area. Using another wet washcloth V8 again wiped R2's anal area. V8 then rolled R2 onto his right side and placed a clean incontinent brief on R2. V8 did not apply soap or cleanser to the washcloth or clean R2's buttocks, peri area, penis or scrotum. 3. R34's Care Plan, dated 6/13/2021, documents R34 has bladder incontinence. R34's Care Plan Interventions document Incontinent: Check and change every 2 hours and more frequently if needed, give good skin care. R34's MDS, dated [DATE], documents R34 requires extensive assist of 2 persons for toileting. R34's MDS documents R34 is occasionally incontinent of urine and frequently incontinent of bowel. On 08/02/21 at 12:04 PM, V8 and V9, CAN's, assisted R34 with toileting. V8 and V9 assisted R34 to stand, pulled R34's urine soaked depend down to his knees. R34 was incontinent of urine which was verified by V9 and blue stripe on the depend. While sitting on the toilet, V9 applied a clean incontinent brief. R34 urinated and had a bowel movement while sitting on the toilet. V9 wet the wash clothes, sprayed the washcloths with cleanser and wiped the left side of R34's groin. V9 folded the washcloth and wiped down the right side of the groin. V8 and V9 assisted R34 to stand and wiped his anal area with a wet washcloth. V8 and V9 pulled up R34's incontinent brief and assisted R34 into the wheelchair. V9 did not wash R34's penis, scrotum, buttocks and inner thighs. On 8/4/2021 at 10:15 AM V9 stated she knew she was supposed to wash R34's penis, scrotum and buttocks. V9 stated that it's hard to clean R34 when he is on the toilet. On 8/4/2021 at 12:00 PM V3, Assistant Director of Nursing (ADON), stated she expects staff to provide incontinent care using soap or no rinse cleanser when providing incontinent, and peri care. V3 stated that she expects all areas of incontinence including labia, penis, scrotum, buttocks, and thighs to be cleansed during incontinent care. On 8/4/2021 at 2:45 PM, V4, Minimum Data Set / Licensed Practical Nurse, stated, We do not have a policy on incontinent care we expect staff to use their scope of practice. V4 was further questioned on what that means and V4 stated the facility expects the staff to do the correct actions according to the staff's education. 4. On 8/4/21 at 3:20 PM, V12 CNA performed incontinent care for R1. R1 was lying on her left side. R1 has an indwelling urinary catheter. R1 was incontinent of stool. V12 washed R1's buttocks and rectum with soap, rinsed the areas and dried the area. With assistance from V6, Licensed Practical Nurse (LPN), V12 rolled R1 over to the right side and positioned R1 for comfort. V11 failed to cleanse R1's groin, pubic area, spread the labia, cleanse the meatus or cleanse the urinary catheter. On 8/4/21 at 1:30 PM, V4, MDS/LPN, stated she would expect the staff to cleanse the peri-area, all areas that encountered urine or feces and the indwelling urinary catheter. R1's Admission Record, print date of 8/4/21, documents R1 was admitted on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R1's MDS, dated [DATE], documents R1 is severely cognitively impaired and is totally dependent on two staff members for toileting and personal hygiene. This MDS also documents R1 is always incontinent of bowel and has an indwelling urinary catheter. R1's Care Plan, undated, documents, (R1) is dependent on staff for all ADL's r/t (related to) (stroke) and contractures. Toilet use: (R1) is dependent on staff incontinent of urine, R1 is checked and changed every 2 hours and more frequently if needed good skin care given. 5. On 8/3/21 at 2:41 PM, V11 CNA, stated, R14 was gotten up at 7:00 AM and has not been laid down yet. We usually lay her down after lunch, but we just haven't had time yet. V11 further stated R14 has not been given incontinent care either but, she has been checking her in the common bathroom. V11 and V12 CNA laid R14 down utilizing the mechanical lift. V12 removed R14's pants which had a wet spot the size of orange on the buttocks. V11 removed the incontinent brief which was saturated with urine. The incontinent brief also had bowel movement and dried to her buttocks. R14 was lying on her right side. V11 wiped R14's buttocks and rectum with a soapy washcloth and then rinsed. V11 dried the rectum and buttocks. V11 with the same gloves placed a new incontinent brief under R14. V11 and V12 fastened the incontinent brief. V11 and V12 positioned R14 for comfort. V11 failed to wash R14's perineal area, groin, spread the labia and cleanse the meatus. R14's Face Sheet, print date of 8/4/21, documents R14 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's MDS) dated [DATE], documents R14 is severely cognitively impaired and is totally dependent on 2 staff members for hygiene, toileting and is always incontinent of bowel and bladder. R14's Care Plan, undated, documents, (R14) has ADL Self Care Performance Deficit related to decrease mobility. Toilet Use: total dependence of 2. 6. R6's Care Plan, dated 07/29/2021, does not document R6 is incontinent. R6's MDS, dated [DATE], documents R6 is occasionally incontinent of bowel. On 08/04/21 at 10:15 AM, R6 was laying in his bed on his right side. He remained in bed from 10:30 AM through 12:45 PM based upon 15-minute observations. At 12:50 PM, during a skin check on R6's buttocks, V9, LPN, pulled his gown away from his buttock and R6 had dried BM covering entire anus. V9 laid R6 back down on his back. V9 did not do incontinent care on R6. V9 covered R6 up with his sheet and left R6's room. On 8/4/2021 at 2:35 PM, V4 MDS Coordinator stated she would expect staff to clean residents immediately and do full patient care. On 8/5/2021 at 12:24 PM, V8 LPN stated if she came across a resident and noticed they had dried BM on their buttocks, she would do all patient care needed immediately. 7. On 8/3/21 at 8:50 AM, R8 was lying in bed. R8's pants and incontinent brief were pulled down to his knees. R8's bed and clothes were soaked in urine. There were multiple flies on and around R8. V7 LPN entered and pulled up R8's incontinent brief that was around his ankles and put new pants and shirt on R8. V7 did not put a new incontinent brief on R8, do any perineal care or cleanse R8 after his incontinent episode. On 8/4/21 at 9:00 AM, R8 was resting in bed. R8's pants were down to his ankles, incontinent brief on. R8's bed and clothes appeared wet. When questioned if he was wet, R8 stated, Yep, it's wet. At 9:05 AM, R8 stated, They help me whenever I ask them. They haven't been in yet today. On 8/4/21 at 11:54 AM, V11, CNA, stated, The night shift said they changed him (R8) at 5:00 AM this morning. We just changed him around 9:30 AM because he was wet. He (R8) usually lets us know when he is wet. On 8/3/21 at 3:00 PM, V4 stated, I would expect the staff to do proper incontinent care when caring for an incontinent resident and changing their clothes if soiled. R8's Care Plan dated 5/14/21 documented that R8 required assistance from one to two staff members for toileting. R8's MDS dated [DATE], documented R8 has moderate cognitive impairment. R8 MDS documents R8 requires extensive assistance from two staff for toileting and extensive assistance from one staff for dressing, personal hygiene and bathing.

Based on observation, interview, and record review, the facility failed to identify, assess, monitor, and provide treatment for [REDACTED]. This failure resulted in R4's pressure ulcer first identified at stage 2 and worsening to a stage 4 in less than 2 weeks and R2 developing a facility acquired stage 3-4 pressure ulcer. Findings include: 1. R4's Electronic Medical Record (EMR) documents R4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R4's Pressure Ulcer Weekly Wound Evaluation dated 1/6/21 documents Stage 2 Pressure Sore, Facility Acquired on 1/6/21 distal left buttock, measurements 0.5 X 0.2 X 0.1. Stage 2 Pressure Sore middle left buttock facility acquired 1/6/21. Measurements 0.5 X 1 X 0.1. Stage 2 Pressure Sore proximal left buttock, facility acquired 1/6/21. Measurements 0.5 X 1 X 0.1 cm. R4's Physcian Order Sheet (POS) dated 1/6/21, documents an order for [REDACTED]. R4's Physician order [REDACTED]. Orders written on 1/14/21 document, [MEDICATION NAME] Skin Protectant Paste (Skin Protectants, Misc.) Apply to open area on coccyx topically as needed for open area. [MEDICATION NAME] Skin Protectant Paste (Skin Protectants, Misc.) Apply to open area on coccyx topically every shift for open area. R4's Pressure Ulcer Weekly Wound Evaluation dated 1/19/21 documents Proximal left buttock, facility acquired 1/6/21 Original Stage 2. Highest Stage 4. Measurements 2 X 1.5 X 0. Worsening Wound Bed now has 80% slough. Left Buttock distal Stage 2, measurements 1.2 X 1 X 0. On 1/20/21 at 2:02 PM, V17, Acting Administrator, stated, I have called the Wound Specialist office to see if they got the order for a consult for (R4), but they cannot find the order. As of 1/20/21 the Wound Specialist had not seen R4. On 1/13/21 at 9:55 AM, V10, Registered Nurse (RN) stated, (R4) has new pressure sores to her left buttock. V10 rolled R4 over to her right side. R4 had bordered foam dressing on pressure areas dated 1/13/21. R4's POS had no orders for bordered foam dressing on pressure areas. R4's Care Plan revised on 1/19/2021 documents, (R4) has the potential for pressure ulcer development r/t (related to) immobility and hx (history) of pressure ulcers. Has Stage IV on left buttock proximal. Has Stage II on left buttock distal. (R4) will have intact skin free from redness blisters thru next review. Administer treatments as ordered, and monitor for effectiveness. (R4) needs assistance to turn/reposition every 2-3 hours, more often as needed or requested. use wedge or pillow for positioning. Low air loss mattress. Pressure reducing cushion to wheelchair when up in wheelchair. Treat pain as per orders prior to treatment/turning etc. to ensure (R4)'s comfort. 2. R2's EMR documents R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2's Care Plan dated 12/14/20 documents, (R2) has actual impairment to skin integrity r/t fragile skin. Moisture Associated Skin Damage (MASD) Posterior Rt thigh. (R2) will have no complications r/t abrasion post Rt thigh thru next review date. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Follow facility protocols for treatment of [REDACTED]. Use lotion on dry skin. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp, or hard surface. (R2) has potential for pressure ulcer development r/t limited physical mobility and occasional episodes of incontinence and history of pressure areas has areas to coccyx times two, and sacrum. Date Initiated: 11/20/2018 Revision on: 01/14/2021. (R2)'s areas of skin impairment will show signs of healing and remain free of infection through the review date. Float heels while in bed as he will allow. Inform (R2)'s caregivers of any new area of skin breakdown. (R2) needs assistance to turn/reposition at least every 2-3 hours/use wedge or pillow for positioning. more often as needed or requested. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Pressure reducing cushion to wheelchair when up in wheelchair. while in recliner, shoes off, heel floating device in place with heels floated, and legs elevated while in bed. If he refuses educate him on risk vs benefits of non-compliance. Pressure reduction mattress on bed. Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. R2's POS dated 12/14/20 documents Wound Specialist to consult and treat wounds as indicated. R2's Wound Evaluation and Management Summary by wound specialist dated 12/14/20, documents, Alginate Calcium with silver, apply once daily for 22 days. Gauze Island with border apply once daily for 22 days for Stage 3-4 pressure ulcer to coccyx. Measurements 0.1 X 0.3 X 0.3. R2's wound specialist Physician documents on 1/11/21, Stage 3-4 pressure ulcer to coccyx 1.0 X 0.5 X 0.2 cm with orders for Alginate Calcium with/silver, apply once a day for 17 days, Gauze Island dressing once a day for 17 days. R2's January 2021 TAR documents, Cleanse coccyx with wound cleanser, apply sure prep periwound, place small amount calcium alginate to wound bed. Cover with bordered foam dressing. Change q3d (every 3 days) et (and) as needed (PRN) every day shift every 3 day(s) for stage 2 coccyx. R2's TAR documents dressing changes done every 3 days, not every day as ordered. R2's Last wound assessment done 1/6/21 documents facility acquired Stage 2-3 pressure ulcer Healed. On 1/13/21 at 10:50 AM, V11, Licensed Practical Nurse (LPN), provided wound care for R2. With assist from V12, Certified Nurse Aide (CNA), rolled R2 over to his left side. No dressing was on the pressure sore to his coccyx. V11 stated, there should have been a dressing on the wound. V11 cleansed the wound with wound cleanser, sure prep applied, Calcium Alginate placed on wound, covered with bordered foam dressing which was dated, 1/13/21. On 1/13/21 at 11:00 AM, V11 stated, The nurses working on the floor are responsible for doing weekly skin checks. The wound nurse does skin checks on every resident in the building every month. The floor nurse is responsible for making sure the dressings are intact every shift. On 1/13/21 at 4:51 PM, when asked why the facility was not following the wound specialist orders for wound care, the orders are for dressing changes every day, V3, Corporate Registered Nurse, stated, I don't know, the wound nurse is out sick. 3. R1's EMR documents R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's Braden Scale for Predicting Pressure Sores dated 11/18/20 documents (14) Moderate Risk. R1's Minimum Data Set ((MDS) dated [DATE] documents R1 is cognitively intact and requires extensive assist of 2 persons for bed mobility. R1's Care Plan dated 8/26/20 documents, (R1) has pressure ulcer or potential for pressure ulcer development Immobility. (R1) will have intact skin, free of redness, blisters or discoloration by/through review date. Float heels while in bed as tolerated. Pressure reducing cushion to wheelchair when up in wheelchair. Pressure reduction mattress on bed. Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. (R1) has an ADL Self Care Performance Deficit related to decreased mobility and weakness. (R1) will improve in at least Activity of Daily Living (ADL) care areas through next review. BATHING: (R1) is dependent on staff with bathing assist of 1 staff. BED MOBILITY: (R1) is extensive assist of 2 with bed mobility. DRESSING: (R1) is extensive to dependent on staff for dressing 1-2 staff participation. EATING: (R1) is independent with set up. PERSONAL HYGIENE: (R1) is extensive assist of staff 1-2 for personal hygiene. Praise all efforts at self care. SIDE RAILS: 1/2 SR (side rail) x 2 for bed mobility rails up as per Dr's order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition PRN to avoid injury. TOILET USE: (R1) is extensive assist of staff for toileting 2 staff participation. TRANSFER: (R1) is a (full body mechanical) lift transfer and assist of 2 staff. R1's Nurses notes dated 12/21/20 at 2:51 PM document, Note Text: Resident was receiving bed bath this AM and the CNA (Certified Nurse Aide) giving the bath noticed dark purple areas to bilateral arm, right leg, right upper back and right buttocks and an open area to coccyx. Nurse was asked into the room to evaluate. Upon evaluation residents right arm has dark purple bruising/petechia from right below elbow to his wrist, dark purple bruising/petechia on left arm above elbow to wrist, a dark purple bruise/petechia to right upper back measuring 2.0 X 7, a dark purple bruise/petechia to right buttocks measuring 7.8 X 7.7, a dark purple bruise/petechia to right lower leg measuring 11.8 X 8.8 and a stage 2 pressure ulcer to coccyx measuring 4.6 X 1.2 X 0.1 (100% granulation tissue). N.O. (New Orders) to cleanse coccyx with wound cleanser apply [MEDICATION NAME] change Q (every) 3 days and prn (as needed) until healed, mx all bruising/petechia q shift until healed and over right wrist scab with foam dressing change Q 3 days and PRN until healed. It also documents, Spoke with (R1's) Doctors Nurse new orders for 2 view CXR (Chest X-Ray), CMP (Comprehensive Metabolic Panel), CBC (Complete Blood Count) with peripheral smear and UA (Urinalysis) with C&S (Culture & Sensitivity) if indicated. R1's Nurses notes dated 12/22/2020 at 12:54 AM, document, Note Text: Biotech called for STAT (as soon as possible) CXR results. Large amount of Right sided pleural effusion. Call placed to on call for R1's doctor. Call returned by on call medical doctor (MD). MD was informed of CXR results and order received to send to local hospital for treatment. R1's local hospital visit documents, On 12/22/20 at 4:00 AM, R1 was transferred from local hospital per helicopter with Registered Nurse (RN) to larger hospital, out of town, diagnosis, Septic Shock, Urinary Tract Infection [MEDICAL CONDITION], Metabolic [MEDICAL CONDITION]. R1's hospital records on 12/22/20 document, Wound 12/22/20 6:00 AM, Coccyx Medial, Pre-existing: Yes. Wound Type: Pressure Ulcer. Wound Bed Assessment: Full Thickness; Fragile; Light purple; Pink. Wound Length 6 cm, Wound Width 4 cm, Wound Depth 0.3 cm. Unstageable. Wound Right Heel, Left Heel Pressure ulcer/injury Deep Tissue injury. Wound Bed Assessment: Dusky; Fragile. The facility's undated Skills Checklist for changing dressing/treatment documents, Verify order, gather and set up equipment, explain procedure to resident, wash hands, apply gloves, position resident where only area for dressing change is exposed, remove old dressing and dispose of it in approved container, remove gloves, wash hands, apply new gloves, cleanse wound as ordered, apply treatment as ordered, cover with dressing that is ordered, reposition resident for comfort, remove gloves, wash hands, put supplies away, clean table surface, remove trash with soiled dressings from room, wash hands, document procedure in etar (Electronic Treatment Administration Record), date. The facility Policy and Procedure for Pressure Ulcer/Pressure Injury Prevention Revised 4/2018 documents, PREVENTION OF PRESSURE ULCERS/INJURIES A pressure ulcer/injury (PU/PI) can occur wherever pressure has impaired circulation to the tissue. A facility must: Identify whether the resident is at risk for developing or has a PU/PI upon admission and thereafter; Evaluate resident specific risk factors and changes in the resident's condition that may impact the development and/or healing of a PU/PI; Implement, monitor, and modify interventions to attempt to stabilize, reduce or remove underlying risk factors; and If a PU/PI is present, provide treatment to heal it and prevent the development of additional PU/PIs. The first step in the prevention of PU/PIs, is the identification of the resident at risk of developing PU/PIs. This is followed by implementation of appropriate individualized interventions and monitoring for the effectiveness of the interventions.

Based on observation, interview, and record review, the facility failed to supervise to prevent injury for 1 of 3 residents (R3) reviewed for falls in the sample of 6. R3 sustained a laceration to the back of head, resulting in 4 staples. Findings include: R3's Care Plan dated 6/27/20, documented, R3 is at risk for falls, and impaired balance. R3 requires frequent visual checks when R3 is in room and staff to toilet R3 more frequently, continues to document to toilet every two hours, assure appropriate foot wear, fall prevention mattress. On 8/25/20, an intervention was implemented to re-locate R3 closer to the nurse's station related to frequent falls. Care Plan dated 7/06/20, documented to encourage R3 to remain in high traffic area while awake. R3's Minimum (MDS) data set [DATE], documented, severe impaired cognition, requires physical assistance from staff with transfers on and off toilet, uses wheelchair, self-propels, always incontinent of bowel, diagnosed with [REDACTED]. R3's Fall Risk Data Collection Fall assessment dated [DATE], documented R3 at a high risk for falls, unable to independently come to a standing position, exhibits loss of balance while standing and requires staff to participate with R3's mobility. The Facility's Fall Occurrence Log, documented R3 to have had 6 falls due to self-attempt transfers to her bathroom for the following dates: 6/30/20, 7/06/20, 7/07/20, 8/17/20, 8/24/20 and 8/25/20 and 9/03/20. 2 of the 6 falls resulted in minor injuries and a fall that occurred 9/03/20, resulted in treatment at a local medical hospital for treatment. R3's Progress Note dated 9/03/20 at 6:50 PM, documented V5, Certified Nurse Aide, CNA found R3 on the floor lying flat on back with head touching floor lying between R3's roommates bed and bathroom. R3 was profusely bleeding from back of head. R3 was transferred to local hospital for evaluation and treatment. R3's Emergency Department Impression Report, dated 9/03/20, documented, accidental fall, scalp laceration, skin tear right hand, head injury. R3's re-admission progress note dated 9/04/20, documented R3 received 4 staples to the back of head because of the fall. On 9/02/20 at 2:50 PM, R3 was in her room, door opened, sitting in a wheelchair, self-propelling herself to her bathroom toilet. R3 had made multiple attempts, rocking back and forth, to raise up from her wheelchair towards the toilet. R6, standing adjacent from outside R3's room, stated, to reviewer that he was looking for a staff but could not find anyone that could assist R3. R6 continued to state, that (R3) is not to get up from her wheelchair without staff assistance, she will fall. R3's self-attempts to transfer from wheelchair to toilet was monitored from 2:45 PM to 2:55 PM, when V4, CNA came out from another residents room and approached R3 at 2:56 PM. R3 stated, I have to poop. On 9/02/20 at 3:00 PM, V4, CNA stated, that R3 is not to get up by herself without help. On 9/15/20 at 11:37 AM, V1, Administrator, stated, she would expect staff to monitor residents identified as a high fall risk more frequently and to follow residents specific Care Plan interventions. The Facility's Policy, entitled, Fall Policy, dated 9/17/19, documented the facility shall ensure that a Fall Management Program will be maintained to reduce the incidence of falls and risk of injury's to residents and promote independence and safety.

Based on interviews, observations and record review, the facility failed to identify, assess, monitor and prevent new pressures sores from developing for 5 of 8 residents (R1, R6, R8, R9 & R10) reviewed for pressure ulcer treatment and prevention in the sample of 15. This failure resulted in a decline of the ulcer for R9 evidenced by an increase in size and 90% slough wound bed in one week. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], identifies R9 as having severe cognitive impairment who requires extensive to total assist of two staff for all activities of daily living except eating. The MDS documents R9 to be always incontinent of bowel and bladder. The Braden Scale, dated 5/17/16, scores R9 at high risk for pressure ulcers. The Care Plan, dated 5/17/16, identifies R9 to have an in-house acquired sacral pressure ulcer with interventions directing staff to assess skin with all cares and report, air flow mattress and wheelchair cushion, (offloading) boots, float heels in bed and turn/reposition every two hours and more frequently if needed in part. R9's June 2016 physician's orders [REDACTED]. R9's Registered Dietician Evaluation, dated 5/5/16, documents R9's [MEDICATION NAME] is low at 3.1 (normal 3.4-5.) On 6/7/16 at 9:15 AM, R9 was transferred to bed by E4, Certified Nurses Aide (CNA), and E6, Registered Nurse (RN). R9 had been incontinent of bowel/bladder and had deep creases across both buttocks, upper thighs and hips. R9 had a folded top sheet in between his knees and protective boots bilateral. R9's dressing (undated) on his coccyx was loose on the bottom edge and had bowel movement inside. The wound base was visible without moving the dressing and the base was pink, very sloughy with irregular edges. R9 had a dressing (dated 6/6/16) on his mid left buttock, and an open blister looking area on inner right knee that did not have the dressing on it as ordered. R9 was provided poor incontinent care and left on his right side. R9's deep creases remained at 9:50 AM. R9 was observed every 15 minutes through 11:57 AM to remain on his right side without repositioning. The soiled loose coccyx dressing had not been changed as of 11:57 AM according to E4 who was in the room getting him up for lunch. The Pressure Ulcer Weekly Wound Evaluation, dated 5/31/16, documents R9's sacral ulcer was acquired on 2/8/16, had light drainage, granulation present (beefy red), stage II 2 cm (centimeter) x 3 cm x 0.1 cm, no tunneling, wound edges attached and flat, no infection suspected, no inflammation and no treatment change. The Weekly Wound evaluation dated 6/7/16 documents decline - measuring 3.8 cm x 2.6 cm x <0.2 cm slough tissue present (90% slough covered), serosanguinous purulent moderate drainage with macerated reddened periwound tissue, no infection/inflammation present. The physician was notified and treatment orders were changed. Under the comments section of the evaluation, it documents area to sacrum has worsened. MD (medical doctor) is aware staff was educated on turning/repositioning, Resident is last up, first to go down. R9's Care Plan was not revised according to the evaluation. The Weekly Wound Evaluation for R9's knee, dated 6/10/16, documented the knee ulcer acquired in house 5/9/16 as a blistered area, dry, closed measuring 1 cm x 1 cm. On 6/8/16 at 9:07 AM, R9 was in bed on his right side. R9 remained on his right side throughout the morning until after 12:00 PM based on every 15 minutes observations. R9 remained in bed for lunch on his right side. The facility's policy/procedure entitled Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated 2/2014, documents that staff will attempt to identify cause contributing to skin breakdown and implement appropriate preventative measures. The Policy documents the physician will document pertinent orders to be carried out for pressure ulcers. 2. The MDS, dated [DATE], identifies R1 has cognitive impairment and requires extensive to total assistance of staff for bed mobility, transfers and bathing/hygiene. The MDS documents R1 is always incontinent of urine and occasionally incontinent of bowel. The Care Plan, dated 5/20/16, documents R1 is at risk for pressure ulcers due to immobility with the goal to have intact skin, free of redness blisters and discoloration. Interventions include: assess skin with all cares, weekly skin assessments, cushion to chair, incontinent care as needed, turn and reposition every 2 hours and more often if needed. The Weekly Skin Assessment, dated 6/2/16, documents no new skin issues and no pressure ulcers. On 6/7/16 at 7:55 AM, R1 was in the wheelchair in the dining room for breakfast. R1 was under constant observation throughout breakfast and at 9:18 AM, E3 Assistant Director of Nurses (ADON) propelled R1 to the hallway outside his room. At 9:50 AM, R1 was taken to the shower room to be repositioned by E4 and E5, Certified Nurse Aides (CNA), who just grabbed the straps of the lift pad and pulled him up in the chair. No off loading was done. R1 was then taken to his room. R1 had regular socks on with no shoes. At 10:05 AM, R1 was lifted to bed via a mechanical lift. R1 had deep creases throughout his hips, buttocks and upper thighs. R1 had a deep red area inner left buttock and a broken blister at the base on his fifth toe which was the size of a dime. R1 grimaced when the foot was moved. There was no dressing on the toe. E4 and E5 positioned R1 on his right side with no padding or protection on his feet and nothing between his knees which were held together. The Progress Notes, dated 6/7/16 at 10:33 AM, documents R1 to have a new area noted to left pinky toe - appears to be a blister that has popped et (and) res stated his toe rubbed on his shoes, new order received for Hydrogel et dry dressing daily. No changes were made to the Care Plan to include preventative measures on his feet. On 6/8/16 at 9:07 AM, R1 was in bed on his right side. He had regular socks on his feet and no treatment/dressing on the blistered area on the base of his small toe as ordered the previous day. R1 grimaced when E3 removed his sock. E3 looked in his sock and in his bed and was not able to locate the dressing. R1 laid on his right side with the head of the bed elevated throughout the entire morning with observations done every 15-20 minutes until 11:30 AM when he go up for lunch. R1 was taken to lunch without wearing shoes. On 6/9/16 at 12:30 PM, E2, Director of Nurses (DON), provided the wound weekly evaluation that identifies R1's toe wound as a non-pressure sore even though E1 identified it from rubbing on his shoe. The eval was dated 6/7/16 and documents the area as acquired during stay, moist, popped blister, no drainage, measuring 1 cm (centimeter) x 1 cm. The facility has not implemented any prevention measures for his feet or regarding shoes in an effort to prevent further breakdown. 3. The MDS, dated [DATE], identified R6 as being cognitively intact requiring extensive assist of one to two staff for all activities of daily living. The MDS documents R6 is always incontinent of bowel and bladder. R6's June 2016 Physician order [REDACTED]. Interventions include treatment as ordered, weekly skin checks, turn/reposition every two hours and more often if needed, and pressure relieving devices to wheelchair and bed. On 6/8/16 at 1:19 PM, R6 was transferred to bed via a mechanical lift by E5 and E7, CNA. R6 stated she had been in the chair since her shower at 7:00 AM. E5 stated she had toileted R6 at 11:30 AM, but R6 did not recall that. E5 and E7 rolled R6 to her right side. The back of her pants were wet throughout the buttocks area and upper thighs. Her incontinent brief was saturated with urine and was soiled with bowel movement. R6's coccyx had a small pea size open area directly on the coccyx that was covered with cream. E5 stated the facility had identified that earlier and documented it. On 6/8/16, E2 provided the Wound Weekly Evaluation, dated 6/8/16, which identifies R6's coccyx ulcer, but does not include measurements. The description of periwound has none checked with no infection or inflammation present. The comment section documents red area to coccyx and peri area and posterior thighs continuing on to document that R6 is being treated with an antibiotic and has had an increase urinary output as she receives [MEDICATION NAME] daily. The evaluation failed to include staging on the small open area noted on her coccyx. 4. On 06/07/16 from 6:45 AM to 10:15 AM, under constant observation, R8 was observed sitting up in a high back wheelchair in a tilted back position. At 9:37 AM, E14, CNA was observed telling E15, Licensed Practical Nurse (LPN), that R8's wheelchair had been stuck in the same position and could not be repositioned. R8 was taken down to the dining room via wheelchair to an activity without being toileted or checked for incontinence. On 06/08/16 at 9:45 AM, E5 and E18, CNAs, were observed during transfer for R8. A skin check was done. R8's buttocks were reddened and deeply creased with a new, unidentified open area near the coccyx/sacral region, measuring approximately 1.0 cm x 1.0 cm. The area was partially denuded with some redness in the center. E3 used skin prep around the open area and placed a [MEDICATION NAME] foam dressing on the open area. No wound cleanser was used and no perineal care was performed at this time. E5 and E18 stated that they work with R8 often and had not noticed any skin breakdown until now. E3 stated R8 has an order to apply a barrier cream to the buttocks on every shift or as needed. The POS, dated 06/01-30/16, documented R8 had the following diagnoses, in part as, [MEDICAL CONDITION], Mental Disorders due to known physiological condition. The MDS, dated [DATE], documented R8 is severely cognitively impaired with short and long term memory deficits. It documented R8 requires total assistance of at least two staff for transfers, dressing and toilet use. It also documented R8 requires total assistance of at least one staff for locomotion, hygiene and bathing. The MDS also documented R8 had no pressure ulcers as of this date. The Care Plan, dated 06/06/16, documented R8 was identified as potential for developing a pressure ulcer, incontinent of bowel and bladder and immobility. The interventions were listed, in part as, assess, record and monitor wound healing and turn and reposition every two hours and more often as needed. The Braden Scale for predicting pressure ulcer development, dated 03/08/16, documented R8 was at high risk for developing a pressure ulcer. The Weekly Pressure Ulcer Report, dated 05/30/16, did not have R8 listed as having a pressure ulcer. The Weekly Pressure Ulcer Report, dated 06/09/16, listed R8 as having a facility acquired Stage II pressure ulcer of the coccyx/sacral region measuring 1.0 cm x 1.0 cm x 0.1 cm. The Weekly Skin Check, dated 06/08/16, documented R8 had no new areas of skin impairment or no new changes this week. 5. R10's Care Plan Initiated 06/17/2016 documents R10 is at risk for pressure ulcers and needs turned and repositioned every 2 hours and as necessary. On 6/7/2016, R10 was sitting in a geriatric chair with bilateral feet slightly [MEDICAL CONDITION] and dangling without support starting at 6:45 AM in dining room. At 9:20 AM, E13, Registered Nurse (RN), pushed R10 over to television area where she remained until removed by E4, CNA, at 12:07 PM. At 12:07 PM, E4 and E5, CNA, took R10 to her room. E5 stated that they were going to reposition R10. R10 was pushed into her room with E4 and E5 grabbing the straps on the mechanical lift pad under R10 and pulled upwards only and E3 was present during this time. On 6/9/2015 at 10:20 AM, E3 was asked if just lifting up on mechanical lift pad under a resident is considered repositioning? E3 stated she didn't agree with repositioning a resident with just using the mechanical lift pad straps being lifted up by staff and resident being put back down. The Nursing Services Policy and Procedure Manual (Revised April 2013) documents Intervention/Care Strategies #4. Residents who are in a chair should be on an every hour (q 1 hour) repositioning schedule. Preparation documents #1. Review the residents care plan to evaluate for any special needs of the resident.

Based on interview, observation and record review, the facility failed to ensure that appropriate treatments and services including correct Passive Range of Motion (PROM) and splints are provided as needed for 3 of 7 residents (R1, R8, R10) reviewed for range of motion and positioning in a sample of 15. This failure resulted in R1 developing further contracture and skin breakdown. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], identifies R1 to have cognitive impairment and requires extensive to total assistance of staff for bed mobility/transfers and has limitations upper/lower on one side. The MDS documents R1 gets PROM (Passive Range of Motion) 5 days a week. The Care Plan, dated 5/20/16, identifies R1 to have contractures on the left side since a [MEDICAL CONDITIONS] with an intervention for staff to do PROM to left side 5-10 repetitions to each joint BID (twice daily.) On 6/7/16 at 7:45 AM, R1 was in the dining room in his wheelchair. There were no pedals on his wheelchair and his legs were dangling off the seat of the chair with no support to his feet. R1's left arm was contracted up against his chest and his hand was contracted into a ball. He had no protector in his hand. R1 had a elbow protector on his left arm which had slid down into the anticubital area. R1 was poorly positioned and repeatedly leaned over to his right side with his head off the wheelchair. At 10:05 AM, E4 and E5, Certified Nurses Aides (CNA), transferred R1 to bed via a mechanical lift. R1 appeared to have foot drop. E4 stated R1's left hand does not open, but E5 stated he can open it and assisted R1 in stretching out his fingers. R1's fingernails were very long. R1 moaned when his fingers were opened. R1 laid on his right side throughout the rest of the morning with his left arm drawn up to his chest. On 6/8/16 at 9:15 AM, R1 was in bed and had a palm protector in place on his left hand. R1 wore it throughout the day. On 6/9/16 at 10:00 AM, R1 again had his palm protector on. At 2:20 PM, E8, CNA, removed the protector and stated she only does PROM on R1's left side. E8 attempted PROM on R1's hand with no range done on his fingers and no opposition of the thumb was done. E8 failed to do abduction/adduction on the left hand fingers, no range was done for the toes at all and no internal/extension or abduction/adduction of the hip was done. E8 stated she has worked with R1 for about 7 months and has seen some improvement. A progress note, dated 6/8/16, documents PT (Physical Therapy) is to evaluate and treat left AC (anticubital) Fossa laceration and flexion contractor [MEDICAL CONDITION] open the area, increase range of motion and more air. On 6/9/16 at 2:49 PM, E2, Director of Nurses (DON,) stated the hand device is not a splint, but a palm protector as a nursing measure and that she ordered it about a month ago. E2 stated R1 should have the palm protector in daily. A Joint Mobility Assessment completed by E9, Occupational Therapist (OT), dated 9/9/15, documents daily Left side PROM's per facility protocol. Measurements document all left side joints as having severe limitations of 1-25% range. On 3/23/16, the joint mobility assessment shows severe for all left side joints except the left knee improved from moderate/severe to minimal. On 6/9/16, an additional occupational plan of care was completed and documents R1 presents with flexion contracture, as did appear on admission to this facility on 7/8/14. Patient was previously place on left upper extremity PROM and hygiene program with restorative at time of OT dc (discontinued) in August 2014. Patient not always compliant with restorative and patient refusing to allow caregiver staff to provide daily, adequate ROM (Range of Motion) to let elbow to prevent further contracture and skin breakdown. Patient now presents with increased flexion contracture, such that he is developing skin breakdown in the anticubital fossa. The Care Plan fails to show R1's refusals nor does it include a plan to ensure R1 receives the ROM when he does refuse and the palm protector daily. Documentation for PROM from 5/25/16 through 6/9/16 shows R1 did not receive ROM at all 5/31/16 and was documented as done one time per day for 4 of 15 days. The facility's policy/procedure entitled Range of Motion, dated 10/2010, documents it purpose it to exercise the resident's joints and muscles. The Guidelines document staff are to support the extremity at the joint as it is being exercised, move each joint through its range of motion three times unless otherwise instructed, move each joint gently, smoothly, and slowly through its range of motion, and remember to stop at point of pain. The steps in the procedure documents staff are to position resident in the supine position, if permitted remove the pillow. The steps then go through each joint including the toes and fingers. Documentation should be recorded in the medical record and include if and how the resident participated in the procedure or any changes in the resident's ability to participate, any problems or complaints made by the resident, documents refusals and interventions taken to address refusals. 2. On 06/07/16, R8 was observed to have severely contracted hands. On 06/07/16 and 06/08/16, R8 was observed at varying times throughout the day with no preventative measures to help maintain or improve the range of motion in her hands. The June 2016 Physician order [REDACTED]. The Care Plan, dated 06/06/16, documented R8 was to have Passive Range of Motion exercises and after place either carrots or posey hand rolls in R8's hands while awake and can tolerate. The MDS, dated [DATE], documented R8 was severely cognitively impaired and required total assistance with dressing, hygiene, bathing and toilet use. It also documented R8 had limited Range of Motion in both the upper and lower extremities. On 06/09/16 at 4:20 PM, E2 stated that R8 was to have devices in her hands to prevent further decline of the hand contractures, and that R8 had been known to remove splints after staff had applied them to her hands. 3. Intermittent observation on 6/7/2016 starting at 6:45 AM through 11:25 AM of R10 sitting in geriatric chair with bilateral slightly [MEDICAL CONDITION] feet dangling in space. On 6/7/2016 at 11:25 AM, E12, CNA, was asked about R10's feet being unsupported. E12 stated we can elevate feet when we put the reclining back of the chair back. R10's Care Plan, Revision date 09/02/2015, documents the intervention to elevate feet as much as possible.

Based on record review and interview the facility failed to evaluate hazards and risks and implement interventions including adequate supervision to prevent falls for 2 of 6 residents (R2, R5) reviewed for falls in the sample of 6. This failure resulted in R2 sustaining a right hip fracture. Findings include: 1. R2's face sheet documents R2 was admitted to the facility on [DATE] with the following partial [DIAGNOSES REDACTED]. R2's Minimum (MDS) data set [DATE] documents R2 is totally dependent on 2 staff for bed mobility, transfers, ambulation. R2 has range of motion impairment on bilateral upper and lower extremities. R2 has no speech and is rarely/never understood. R2 usually understands. R2 has severely impaired vision. R2 has both short and long term memory problem and has moderately impaired cognition. The Facility's Occurrence Log for 3/1/15 through 4/21/15 documents R2 had a fall at 3:23 a.m. on 4/12/15. Fall Details Report documents E5, Certified Nursing Assistant (CNA) found R2 parallel to bed on right side on floor. The Report documents bed rails and alarm were not in use for R2 at time of fall. E6, Registered Nurse (RN), documents E5 turned and repositioned R2 at 3:00 a.m. on 4/12/15. The Report documents E6 gathered dressing supplies for R2's dressing changes. E6 was called to R2's room and found R2 lying on her right side parallel to her bed. The Report documents R2 assessed and found to have right iliac crest is pushed upwards as well as protruding outwards towards her skin more than usual. The Report documents R2 has a hematoma beginning to show at her right eyebrow. E2, Director of Nursing (DON) documents the following conclusion: Based on investigation and staff interviews, (R2) with voluntary and involuntary movement of extremities, was positioned for dressing changes, as a result of movement, resident rolled from bed onto floor. On 4/22/15 at 10:00 a.m., E2 stated R2 was assessed by E2 and E4, Licensed Practical Nurse/Restorative Nurse, for a specialty mattress due to multiple pressure sores. In addition, E2 stated the facility uses side rails for residents that need them for mobility. During this interview, E4 said it is the admitting nurse's judgment as to whether a resident receives side rails on their bed. E4 also said she re-assesses residents side rails quarterly for continued use, but she does not do an initial assessment for side rails upon admission. Review of Proper Use of Side Rails policy and procedure on 4/23/15 documents Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). (Note: The side rails may have the effect of restraining one individual but not another, depending on the individual resident's condition and circumstances.) Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. An assessment will be made to determine the resident's symptoms or reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a) Bed mobility; and b) Ability to change positions, transfer to and from bed or chair, and to stand and toilet. Review of the (Low Air Loss Bariatric Mattress) Owner's Manual on 4/23/15 documents Indications for use: The above mattress is a flotation therapy mattress that provides pressure management to assist in the prevention and treatment of [REDACTED]. The alternating pressure and low air loss mode provided with this mattress is indicated for use as a preventive tool against further complications associated with critically ill residents of immobility. The mattress Air Cells: There are 20 air-filled polyurethane air cells are divided into two separate, every other cell alternating pressure zones. These air cells inflate to a height of 8 inches. Specific cells are designed with holes which allow the (Air ) mattress to provide low air loss. The Side Perimeters: There are two air-filled side perimeter to help contain the resident with the mattress system. The Mattress Height: The total pressure-management surface height is 10 inches, 13 inches with optional raised perimeters. Warnings for this mattress documents This product is designed to assist in the prevention and treatment of [REDACTED]. This may include, but is not limited to: 1. Bed rails for repositioning and fall prevention. Observation of the (Low Air Loss Mattress) was completed at 12:00 p.m. on 4/23/15. The bed frame that holds the mattress is 18 inches from the floor and the mattress itself is approximately an additional 10 inches high. On 4/23/15 at 2:10 PM , E6 stated that she never saw R2 attempt to turn herself or move independently prior to R2's fall from bed on 4/12/15. E6 said R2 was non-verbal except when E6 changed R2's pressure ulcer dressings. E6 stated that she heard R2 say ow and stop when she was in pain during dressing changes. On 4/23/2015, at 10:50 AM, E7, Licensed Practical Nurse (LPN), stated she never saw R2 move prior to her fall on 4/12/15, but after R2's fall she observed R2 to turn herself independently to her right side while waiting for the ambulance to arrive. E7 said R2 had many contractures and was shocked R2 could move herself. On 4/22/2015, at 2:45 PM, E5, stated that R2 seemed to become more alert during the late evening or night shift and would answer Yes/No questions. In addition, when she wanted her television channel changed she pointed with her toes. E5 said he turned and repositioned R2 on her left side with pillows behind her back and a pillow between R2's knees. E5 said he did not have any positional devices in front of R2 and R2's bed did not have side rails at 3:00 a.m. on 4/12/15 to prevent R2 from rolling out of bed. In addition, E5 said R2's bed height was pretty high and there were not any mats on the floor to soften a fall if R2 fell out of bed. E5 said that R2 had changed position in bed on one night (date unknown) before the 4/12/15 fall. E5 said he checked with all of his co-workers to see if they had repositioned R2 and forgot to tell him, but they had not. He asked R2 if she turned herself onto her right side and she indicated Yes to him. E5 said he found R2 on the floor at 3:23 a.m. on 4/12/15 when he went back into R2's room to assist E6 with R2's pressure ulcer dressing changes. E5 informed the nurse and rolled R2 onto a bath blanket to make her more comfortable while they waited for the ambulance. E5 said while they waited for the ambulance, R2 turned on to her right side independently. R2's nurse's notes dated 4/12/15 at 5:45 a.m. completed by E6 document that R2 is being transferred from the local emergency room to a local city hospital emergency room due to a right hip fracture. 2. R5's admission face sheet documents that R5 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE] documents that R5 is mildly cognitively impaired, requires extensive assistance for transfers and ambulation, and has poor balance. The MDS documents that R5 uses a walker and a wheelchair for locomotion, with one assist. R5's Progress Nursing notes dated 3/27/15 document that R5 was found unresponsive due to low blood sugar and was transferred to the emergency room . While there it was determined that R5 also had a urinary tract infection. R5's Nurse's notes on 3/29/15 document that R5 was still weak and being monitored when she fell on [DATE]. On 4/23/15, at 1:50 PM, E10, Certified Nurses Aid (CNA), who was the documented caretaker at the time of the fall on 3/29/15, stated I was taking (R5) to the bathroom. She was walking with her walker and I was walking next to her. I noticed the toilet was dirty so I went in to clean off the toilet and left (R5) to stand with her walker while I did that. I thought she was stable with the walker, but I guess she wasn't. She tried to walk without it. and then fell back and hit her head on the floor. Review of policy and procedure for Assisting a Resident to Walk to the Bathroom dated October 2010 documents the following: After resident done using toilet, assist the resident to stand. Allow the resident an opportunity to maintain his or her balance. Reposition the resident's clothing. Allow the resident to wash his or her hands. Assist the resident back into a comfortable position. Place the call light within easy reach of the resident. Clean the bathroom as necessary (i.e. flush commode, wipe up spills, etc.) The facility Occurrence reports for 3/29/15 and 4/1/15 were reviewed. The Report documented on 3/29/15, as a result of the fall, near the bathroom, R5 had a large hematoma with bleeding that required transfer to the emergency room , and a pressure dressing and pain medication for 4 days afterwords.

Based on interview, observation and record review, the facility failed to identify, develop and manage pain effectively for 1of 7 residents (R3) reviewed for pain management in a sample of 15. This failure resulted in R3 exhibiting pain during care and treatments. Findings include: 1. The Admission Sheet indicates R3 was readmitted to the facility on [DATE] from the hospital. According to the MDS (Minimum Data Set) dated 3/10/14 and 7/9/14, R3 has cognitive impairment and requires extensive assist of two for activities of daily living. According to the POS (Physician order [REDACTED]. The July 2014 POS documents dressing changes to be done twice daily and has an order for [REDACTED]. The Pain assessment dated [DATE] identifies R3 as having no pain. The care plan dated 6/23/14 does not reflect a pain management plan. On 7/22/14 at 11:45am, R3 had just returned from the wound clinic. R3 stated "I'm hurting... they took out a lot of bones" on her bottom when she went to the wound clinic. E7 LPN (Licensed Practical Nurse) was giving noon medication and asked R3 if she wanted a pain pill. R3 stated yes, it was "bad" and asked for two. R3 was given pain medication without identifying where the pain was or how it rated on a pain scale of 0-10 scale with 10 being the worst. E7 stated she did not give R3 pain medication prior to her visit to the wound clinic because she denied pain at the time. The Medication Administration Record (MAR) documents she gave 1 tab of [MEDICATION NAME] 50mg at 11:15am and Tylenol tabs ii at 1719 (5:19PM) on 7/22/14. On 7/24/14 at 1:10pm, E4 and E12 CNA's (Certified Nurse Aides) transferred R3 to bed via a mechanical lift. She cried out as she was lifted from her wheelchair and grimaced and moaned as she was transferred to the bed. E7 stated at 12:30pm, she had just given R3 a pain pill and would do her treatment afterwards. At 2pm, E7 did R3's treatment on her coccyx pressure ulcer. She complained of pain during the treatment. According to the July MAR (Medication Administration Record), R3 has only received the [MEDICATION NAME] 7 times since 7/10/14 even though she's been going to the wound clinic weekly (7/15 and 7/22/14). The Controlled substance proof of use sheet for [MEDICATION NAME] shows it's not been given prior to wound clinic visits and that R3 receives it randomly. The pain scale recorded on the MAR documents R3 rating her pain as 7, 6 and 9 with the other 4 times given, no score documented. The Tylenol is documented as being given one time on 7/22/14 since 7/10/14. There is no evidence the facility adequately assessed R3 for pain especially during treatments and/or trips to the wound clinic. On 7/24/14 at 3pm, E15 CNA was asked if R3 complains of pain during her shift and stated she doesn't complain directly but she sees it when she does care or anything with her. E15 stated R3 has facial grimacing. E15 stated R3 used to do a lot for herself like propel herself back in her chair from the dining room and now is a mechanical lift. The MDS dated [DATE] compared to the one dated 7/9/14 shows a decline in outside room mobility, eating, and transfer. On 7/24/14 at 3:20pm, E16 LPN stated she doesn't really complain of pain but she can tell by the expression on her face. E16 states she asks if she wants Tylenol or a pain pill. E16 said "yes" when asked if her ADL's (Activities of Daily Living) declined explaining R3 used to be a slide board transfer and now is a lift but also used to do more of her care too. The Policy entitled Pain Management dated 8/27/01 documents the policy is to maintain a resident as free as it is possible with the least amount of medication possible. The policy indicates residents are to be assessed based on complaints of pain, diagnosis, non-verbal communication of pain such as facial grimace, body posturing, affirmation by nodding, eye contact, written confirmation, or selecting on of the 1-10 scale, verbal, or non verbal, or 1-5 facial expression, "faces", pain scale.

Based on interview, observation and record review, the facility failed to identify, assess and treat pressure ulcers in a timely manner for 2 of 4 residents (R2 and R3) reviewed for pressure ulcer prevention in a sample of 15. This failure resulted in R3 developing an unstageable pressure sore that was not timely identified, assessed and treated and failed to follow recommendations for treatment and supplements that would aide in healing the pressure sore. Finding include: 1. According to the MDS (Minimum Data Set) dated 3/10/14 and 7/9/14, R3 is a double [MEDICAL CONDITION] readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicates she requires extensive assist of two staff for mobility, bathing and hygiene. The MDS also documents her to have a [MEDICATION NAME] and be always continent of bowel. The July 2014 POS (Physician order [REDACTED]. According to the POS, she is also being seen by the wound clinic weekly for a in house acquired pressure ulcer to her right ischium. The order dated 7/19/14 was for a Mesalt Rope, cover with [MEDICATION NAME] border daily and PRN (as needed.) The Weekly Pressure Ulcer Assessments document the date R3's ulcer was initially found was 4/27/14. It was first assessed/measured on 4/30/14 as being unstageable and measured 7cm x 7cm x 0.5cm deep with slough/eschar, necrotic tissue 90% granulation 10%, moderate amount of pink/yellow exudate. The treatment order was obtained on 4/29/14, two days after it was found. There is no documentation as to why the facility staff did not find this pressure ulcer until it measured 7cm x 7cm with eschar/slough. On 7/22/14 at 11:45am, R3 had just returned from the wound clinic. Her dressing was intact but drainage soaked. The Wound Clinic's note dated 7/22/14 documented that the wound still had necrotic tissue that is not improving and "really needs a wet to dry" dressing. The measurements were 2.2cm x 5.5cm x 5cm deep with 75% slough. The treatment was changed to wet to dry changes BID (twice daily.) The wound clinic also checked "continue with current vitamin therapy." Review of R3's POS as of the morning of 7/24/14 shows no vitamins and/or nutritional supplements to aid healing. The Registered Dietician's (RD) E11 notes document "Second Request" - Resume MVI (Multiple Vitamin) daily for general support. Some decline noted in wound. Being seen in wound clinic also rec (recommend) Prostat AWC 30ml TID (three times a day) for wound support due to size." On 7/24/14 at 1pm, E7 LPN stated she did not see any vitamins on R3's Medication Administration Record [REDACTED]. On 7/24/14 at 10:15am, E2 DON (Director of Nursing) stated she could not explain why staff did not identify it sooner but agreed that was a problem. On 7/24/14 at 11:45am, E7 LPN (Licensed Practical Nurse) was asked if she'd done R3's treatment yet and responded that she didn't know if she needed to do one or not but after looking, stated no. At 1pm, E7 stated she had premedicated R3 so she could do the treatment. At 1:10pm, E4 and E12 CNA's (Certified Nurse Aides) transferred R3 to bed via a mechanical lift. Her dressing over the left thigh was loose on two sides with the some of the packing hanging out of the wound. The wound had an odor. The dressing was dated 10-6 7/24. There is no indication the nurse on duty, E7, LPN checked and/or was informed that the dressing wasn't intact and in good condition when R3 was transferred to the wheelchair for lunch. At 2pm, E7 LPN had R3 roll to her right side. R3's dressing was still loose. E7 pulled the loose dressing off and then removed two pieces of packing that were still wet from inside the gaping wound at the right gluteal fold. E7 kept holding R3's left buttock up and holding the wound open with her left hand. E7 rolled the dirty dressing into her gloves and applied alcohol gel to her hands and regloved. E7 then sprayed wound cleanser into the interior of the wound patting the exterior parameters of the wound but did not cleanse the wound bed itself. E7 sprayed it twice then packed the wound with saline soaked 4 x 4 gauze dressings and covered it with a larger dressing. E3 Wound Nurse/Assistant Director of Nursing agreed that the wound bed was not cleansed afterward at 2:10pm. On 7/24/14 at 2:20pm, E13, Corporate Nurse also agreed in interview that the interior of the wound or the wound base needed to be cleansed with the cleanser and 4x4 gauze. 2. The MDS dated [DATE] identifies R2 to be a [AGE] year old female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS documents that she requires extensive assist of two staff for transfers and bed mobility. The MDS also documents R2 as having a suprapubic catheter and [MEDICAL CONDITION]. R2's care plan dated 7/23/14 indicates R2 has a history of pressure ulcer due to immobility with interventions for staff to turn/reposition every two hours and more often if needed, assess skin with all care and report problems to nurse as needed (PRN), encourage to lay down between meals, and obtain orders as needed. The July 2014 POS includes an order dated 7/9/14 for skin prep to upper left anterior thigh every shift for prevention. R2 is on a regular diet. There are no current labs for Protein and/or [MEDICATION NAME]. On 7/22/14 during initial tour of the building at 9:30am, R2 was sitting in her wheelchair at bedside and asked if someone could look at the sore on her upper left thigh as it was "hurting real bad." R2 stated she had told the nurses and the CNA's about the sore several times but no one had done anything about it.. R2 was transferred to bed via a mechanical lift by E4 and E5, CNA's with E6, Licensed Practical Nurse (LPN) present. R2 had an elongated irregular shaped open sore on her upper posterior left thigh which was beefy red. E4, CNA, stated in interview that R2 was gotten out of bed into her wheelchair at 7am, 2 1/2 hours prior. At 1:35pm on 7/22/14, R2 stated she still had no treatment to her thigh and that she wanted to lay down but staff told her she had already laid down earlier that day. Progress notes fail to reflect this area even though R2 stated she had informed and asked staff to look at it previously. At 3:50pm on 7/22/14, E8 LPN was asked if the facility had previously identified R2's sore and stated there was no documentation on it but the wound nurse was looking at it. At 3:55pm on 7/22/14, the Administrator, E1 also stated the wound nurse was looking into it. On 7/22/14 at 20:18pm (9:18pm) a telephone order was received to cleanse upper left thigh with wound cleanser, apply [MEDICATION NAME] then [MEDICATION NAME] every day til healed every evening. The progress notes refer to the same information. Weekly Pressure Ulcer assessment dated [DATE] documents R2's left buttock as measuring 5.4 centimeter (cm) x 0.8cm wide x < 0.1cm depth, stage II, Pink. On 7/24/14 at 10:20am, E2, DON agreed that the CNA's and/or nurses doing the skin prep every shift for prevention should have picked up the area more timely before R2 complained of pain associated with it. The facility policy entitled "Wound healing and treatment" dated November 2010 under assessments indicates that weekly skin checks will be done for all residents, "Daily observation of skin and identification during routine care giving by CNAs, findings will be given to the licensed Nurse for assessment and further follow up.", Licensed Nurses will assess and document skin problems initially, upon admission or identification, The assessment should include specific findings on each wound, location, size, depth, stage, exudate, odor, pain, presence of necrotic tissue, wound bed, wound margins and periwound skin condition.", in part. The Wound Assessment policy dated November 2010 also documents that each wound will be assessed initially either at time of admission or at the time the wound is identified.

Based on record review, observation and interview, the facility failed to identify the difference between pressure ulcers and vascular wounds; reposition residents; and implement aggressive nutritional care, treatment and change of treatments for 1 of 1 residents (R7), reviewed with wounds in the sample of 9 . This failure resulted in R7 developing gangrene of his foot. R7 was hospitalized for [REDACTED]. R7's family chose not to have his foot amputated, R7 was placed on Hospice and given only comfort measures. The findings include: R7 was admitted to the facility on [DATE] with diagnoses, in part, of subdural hematoma, altered mental status, difficulty walking, end stage [MEDICAL CONDITION] with [MEDICAL TREATMENT], dementia, and diabetes mellitus. physician's orders [REDACTED]. The treatment for [REDACTED]. The "Weekly Pressure Ulcer Report's", dated 2/25/13 - 3/14/13, document R7's foot wounds measured 2.0 x 2.0 cm for the left heel, and 2.0 x 4.5 cm for the right heel through 3/14/13. The reports document R7's left heel wound increased to 4.0 x 2.0 cm on 3/21/13, and to 17.2 x 7.5 cm on 3/29/13. This report documented R7's right heel increased to 2.5 x 5.0 cm on 3/21/13 and to 11.0 x 6.0 cm on 3/29/13. The "Weekly Pressure Ulcer Assessment" for R7 was completed by E5, Restorative/Wound Nurse, on 2/25/13 for the left heel and on 2/28/13 for the right heel. There are no other "Weekly Pressure Ulcer Assessment" completed until 3/29/13 when E7, Registered Nurse, completed the assessments. On 3/29/13 E7 documented the left heel was 17.2 x 7.5 cm and 100% necrotic. E5 documented the right heel was 11.0 x 6.0 cm and 100% necrotic. There was no documentation for the toes. The "Weekly Pressure Ulcer Report", dated 2/28/13, documented R7 had a 2.0 x 2.0 centimeter (cm) unstageable "E/S (Eschar/Slough)" ulcer on the left heel, and an area on right heel measuring 2.0 x 4.5 cm E/S. Both of R7's heels were documented as 100% necrotic with light exudate and no odor. The report does not identify the heels as "SDTI (Suspected Deep Tissue Injury)". There is no documentation on the "Weekly Other Skin Condition Report" regarding R7's toes or the heels. On 3/1/13, R7's "physician's orders [REDACTED]. The same treatment was ordered for the right heel. R7's physician's orders [REDACTED]. Apply [MEDICATION NAME] gel, cover (with) [MEDICATION NAME] and tape. (Change) BID (twice a day) and PRN (as needed)" and "skin prep L (left) foot 5th toe every shift". R7's nurses notes, dated 3/17/13, documented that R7's family was at the facility and notified staff that there was "drainage coming from between his toes". R7's Nurses Notes document a 1.8 by 0.2 by 0.6, Stage 3 open area on his left foot. The nurses note documented the area was "at left foot inner aspect between 4th and 5th toe. Small amt (amount) of clear with very slight red tinged drainage, slight purple color also around wound bed. Left foot 5th toe purple and very mushy". On 3/18/13 the order was changed to "Cleanse L ft (foot) 4th and 5th toe stasis ulcer with skin integrity, apply maxsorb extra AG (aquagel) rope, secure with [MEDICATION NAME] tape". There is no documentation on the "Weekly Pressure Ulcer Report" or the "Weekly Pressure Ulcer Assessment" report regarding R7's toes. A telephone order, dated 4/1/13, documents an order for [REDACTED]. E2, Director of Nursing, stated in an interview on 4/18/13 at 1:05 PM that E5, Wound Nurse, was supposed to do the weekly pressure ulcer assessments but didn't do them as required. E2 stated E5 quit on 3/28/13 but had not done what was required with the pressure sores for a few weeks prior to that. E2 stated E5 was not following the pressure sores in the facility. E2 stated as the wound nurse, E5 was supposed to implement the policies of the facility regarding pressure sores, monitor and educate the staff. E2 said that the Facility staff nurses now assess and document pressure sores. E2 stated R7 had a regular mattress but all the mattresses in the facility were pressure redistributing mattresses. E2 also stated R7 went to [MEDICAL TREATMENT] three times per week for 6 hours each time. E2 stated the [MEDICAL TREATMENT] staff would not allow R7 to be turned and repositioned even though they sent a staff from the facility to [MEDICAL TREATMENT] with him. E2 stated they had sent a special cushion with R7 when he went to [MEDICAL TREATMENT]. E2 stated R7 did wear pressure relieving boots on both of his feet. R7's Care Plan, dated 2/26/13, documents: "Focus - The resident has multiple pressure ulcer and potential for pressure ulcer development r/t (related to) Disease process". There is no documentation where the pressure sores are located on R7's body. "Interventions" include, in part, "Administer treatments as ordered and monitor for effectiveness; assess/record/monitor wound healing weekly, monitor nutritional status. Monitor/document report to MD (Medical Doctor) PRN (as needed) changes in skin status. Pressure reduction mattress on bed". There was no documentation regarding R7's pressure relief boots. R7's Care Plan, dated 3/7/13, documents: "Focus - The resident has potential for pressure ulcer development r/t immobility and incontinence". There are no pressure ulcers identified. The "Interventions" included, in part, "Nurses to complete weekly skin assessment" and "Turn and reposition every 2 hours and more often if needed". R7's "Weekly Skin Assessments" document the following: On 3/5/13 and 3/12/13, "Mild Risk" is documented in the area on the form which states "B" or "Bruise noted - describe color and size, and if there is induration noted. Indicate if this is a new finding or existing by checking the "N" box for New and "E" box for existing bruise". The "Findings/Initial Assessment" section is not completed and there are no descriptions of the bruise or where the bruise was located. On 3/19/13 and 3/26/13, "Mild Risk" is documented in the area on the form which states "existing B and O". The "O" code is defined as "Open areas noted. Indicate if this is a new finding or existing by checking the "N" box for New, "E" box for existing wound". Both the B and O are checked as an existing wound. There is no description under the "Findings/Initial Assessment" section. There is no documentation where the bruise or open area is located. On 4/2/13, "Mild Risk" is documented on the form. An X is written in. X is defined as "Other noted skin issue: rash, etc. Indicate if this is a new finding or existing by checking the "N" box for new, "E" box for Existing skin condition." The form does not designate if the area is new or existing. Under the "Findings/Initial Assessment" section states "new tx (treatment) for heels and coccyx (4-1-13)". R7's "Weekly Pressure Ulcer Assessments" document the following: 2/25/13, left heel wound measures 2.0 x 2.0 cm "unstageable P/U (pressure ulcer)". The wound was described as 100% necrotic with "slough/eschar" and "clear". There was a small amount of pink/yellow exudate. There was no documentation of any wounds with the toes. 2/28/13, right heel wound measures 2.0 x 4.5 cm "Unstageable pressure ulcer". The wound was described as clear with slough/eschar. The tissue was 100% necrotic with a small amount of pink/yellow exudate. There was no odor. 3/29/13, left heel wound measures 17.2 x 7.5 cm with 100% necrotic tissue and "slough/eschar". The wound was described as [DIAGNOSES REDACTED]tous with a moderate yellow, pink color exudate and a mild odor. There was no documentation of the toes. 3/29/13, right heel wound measures 11 x 6 cm "unstageable pressure ulcer". The wound was described as 100% necrotic tissue with slough/eschar. The wound was macerated with a small amount of pink/yellow exudate and a mild odor. There was no documentation of any toe wounds. E7, Registered Nurse (RN), stated in an interview on 4/18/13 that E5 had been the Wound Nurse but had quit on 3/24 or 3/25/13. E7 stated she had been filling in for E5. E7 stated she could not find any measurements for R7's wounds from 2/25 and 2/29/13 until she did the measurements on 3/29/13 on the "Weekly Pressure Ulcer Assessment". The Braden Scale For Predicting Pressure Sore Risk dated 2/25/13 assessed R7 as a 16 or "Mild Risk". On 3/4/13 and 3/11/13, R7 was assessed as a 13 or "Moderate Risk" for the development of pressure sores. On 3/18/13, R7 was assessed as a 9 or "Very High Risk". On 3/8/13 the "Dietitian's Progress Record" documented a recommendation by Z3, Registered Dietitian (RD), of Nephro Vites or renal multivitamins and to obtain labs to better evaluate nutritional status. The record documents the areas on R7's right and left heel. There is no mention of the wounds on R7's toes. The Nephro Vites were not started until 3/13/13. There is no further documentation by the Registered Dietitian. There was no nutritional assessment of R7's [MEDICATION NAME] level. The "Nutrition Report" from the [MEDICAL TREATMENT] center dated 3/7/13, documents R7's [MEDICATION NAME] at 3.1 g/dl (grams/decaliter) with the requirement at 4.0 or higher. The report documented R7's protein was "VERY LOW". The report documented "It is important for you to increase your protein intake to help with healing and feeling well". Past values of R7's [MEDICATION NAME] level was 3.4 g/dl on 2/28/13. The nurses notes written by E5, LPN, and dated 3/21/13, document "Called placed to dietician to notify of new wounds. Awaiting call return." On 3/22/13 the nurses notes document "RD returned call-notified of new stage 2 pressure ulcers to coccyx. Recommendations made to start [MEDICATION NAME] Renal 1 can PO (passing orally) BID (twice a day) and to consult [MEDICAL TREATMENT] unit to see if starting Prostat AWC would be contraindicated". R7's coccyx pressure ulcer was identified on 3/15/13. The Physicians' Orders document an order, dated 3/22/13, for the spplement [MEDICATION NAME] Renal 1 can twice a day and Prostat 30 cc (cubic centimeters) twice a day for wound healing. The "Medication Record" documented the [MEDICATION NAME] Renal and Prostat were not started until 3/23/13. When R7 was admitted to the hospital on [DATE], his [MEDICATION NAME] level was 1.6 g/dl. The "Dietitian's Progress Note" documented on admission R7's diet order was regular, low concentrated sweets. E20, Food Service Supervisor, documented on 3/18/13 R7's diet was changed to mechanical soft. On 3/26/13, R7's diet was changed to puree. There was no documentation of the Nepro Vite recommendation or any other supplements. R7's "physician's orders [REDACTED]. On 3/13/13 the Nephro Vites were ordered. On 3/15/13 the physician ordered a divided plate for R7. On 3/18/13 the physician ordered a pureed, low concentrated sweets diet for R7. R7's Physician Progress, written by Z1 and dated 3/28/13, did not document any information regarding the area on R7's bottom, coccyx or heels. E4, Licensed Practical Nurse, stated in an interview on 4/23/13 at 1:50 PM that Z1 did not see R7's wounds that day because R7 was going to [MEDICAL TREATMENT]. E4 stated there were no treatment changes to R7's heels or toes on 3/28/13. R7's physician progress notes [REDACTED]. We note that he has black eschars on both heels which is a new finding. He also has some necrotic appearing [MEDICAL CONDITION] on the lateral toes on the left foot which are somewhat foul smelling. He is otherwise not much changed. Pressure sores of the heels, Possible Gangrene Left Foot. We will set him up with wound clinic and see about getting him evaluated". There is no mention of the pressure ulcer on R7's coccyx. Z1 stated in an interview on 4/22/13 at 1:35 PM that he had seen R7's wounds one time when there was eschar and gangrene in his foot. Z1 stated the heel ulcers were due to pressure and vascular insufficiency. Z1 stated the area on the coccyx was due to pressure, but R7 wouldn't stay off his back. Z1 stated "beats me" when asked if using a air overlay mattress sooner than 3/27/13 would have helped. Z1 stated R7 had end stage [MEDICAL CONDITION] and severe [MEDICAL CONDITION] disease. On 4/24/13, the facility submitted a written statement by Z1. Z1 documented that R7 had a [DIAGNOSES REDACTED]. It is my conclusion that the area to (R7's) feet were unavoidable and due to his condition and [DIAGNOSES REDACTED]." E4, Licensed Practical Nurse (LPN), stated in an interview on 4/23/13 at 1:50 PM that Z1 did not see R7's foot wounds on 3/28/13. E4 stated R7 was on his way to [MEDICAL TREATMENT] at that time. E4 stated that on 4/5/13, R7's left foot "was nasty". E4 stated it had a necrotic smell - "like dead tissue". R7's 4/5/13 nurses notes, written by E4, documents that Z1 was at the facility and examined R7's feet. Z1 wrote an order for [REDACTED]. The nurses notes document That R7's family was upset and requested R7 be sent to the emergency room . According to the nurses notes, R7 was sent to the local emergency roiagnom on [DATE]. The local emergency room "Emergency Department Record" documented "Positive for redness and wounds. Coccyx decubitus approx. (approximately) 10 cm; also significant pressure sores on both heels; ?necrotic looking left 4 th toe". R7's [MEDICATION NAME] level was 1.6 G/L (grams/Liter) normal (3.4-5.0). The emergency department record documented "Multiple Decubitus, [MEDICAL CONDITION] and IDDM (insulin dependent diabetes mellitus). The emergency room record documented R7 was transported to a large metropolitan hospital. The History and Physical from the large metropolitan hospital, dated 4/5/13, documents "early decubitus on the sacrum". On 4/6/13 a "Wound Consult" documents R7 was admitted to the hospital with [REDACTED]. The hospital "MD Progress Note" dated 4/6/13 document "left 4th and 5th toes necrotic and foul smelling. Both heels with ulcers about 6 cm in diameter, skin necrotic, previous ABI noncompressible and 0 toe pressure". The physician recommended a left below knee amputation. On 4/8/13 the "MD (Medical Doctor) Progress Notes" documented the plan was for comfort measures and to not have the amputation. The Facility Policy and Procedure titled "Pressure Ulcer Prevention and Healing Program" documents the following requirement: "The facility has a designated Wound Care Nurse, who completes weekly assessment and documentation. Nutritional support is used as needed for those at risk or those who have wounds or nutritional deficits. The physician and family are notified timely when wounds are identified and with any significant change in status. Care Plans and MDS (Minimum Data Set) reflect the current wound status, risk factors and individualized approaches. Support Surfaces according to resident's risk level and specialty beds appropriate for existing wounds".