Every finding on record at Carrier Mills NSG & Rehab CTR

Based on interview and record review the facility failed to ensure that residents who require assistance receive a shower for 2 (R20 and R1) of 3 residents reviewed for Activities of Daily Living in the sample of 20.This past non-compliance occurred between 4/1/26 and 5/26/26.1. R20's admission Record dated 6/2/26 documented an admission date of 2/18/26 and included diagnoses of fracture of left femur, dementia, lack of coordination, reduced mobility and generalized muscle weakness.R20's most recent Care Plan documents a focus area for self-care deficit dated 2/23/26. Interventions for this focus area include assisting with ambulation and transfers, assisting with toileting and showering/bathing both dated 2/23/26.R20's Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 3, indicating R20 has severe cognitive impairment. This MDS also documents R20 is dependent for showering/bathing, dressing and tub/shower transfers.R20's shower documentation from her Electronic Health Record as well as hand-written documentation from 4/1/26 - 5/31/26 combined show two separate six-day periods in April and May (4/1/26 - 4/6/26 and 5/16/26 - 5/21/26) where no shower was documented as provided for R20.The facility's staff schedule was reviewed and showed V18 (Certified Nurse Aide/CNA), V6 (CNA), V10 (CNA) and V17 (CNA) working during the time periods of 4/1/26 - 5/21/26. On 6/3/26 at 1:40 PM, V18 (Certified Nurse Aide/CNA) verified she worked some of the days during the time periods of 4/1/26 - 4/6/26 and 5/16/26 - 5/21/26 and said R20 was usually good about taking her showers routinely. V18 did not remember R20 refusing showers during those time periods. On 6/3/26 at 1:44 PM, V6 (CNA) verified she worked some of the days during the time periods of 4/1/26 - 4/6/26 and 5/16/26 - 5/21/26 and said R20 would usually shower when offered one. V6 stated sometimes they had to go back and ask a second time or re-engage R20 a little later, but R20 would usually take a shower. V6 stated those two time periods had been a while back, but did not remember R20 refusing a shower during those times. V6 stated all residents should be offered a shower at least two times per week and more often if needed or requested.On 6/3/26 at 1:50 PM, V10 (CNA) verified she worked some of the days during the time periods of 4/1/26 - 4/6/26 and 5/16/26 - 5/21/26 and stated R20 usually showered when offered one. V10 stated she never remembered R20 refusing a shower during those time periods above. V10 stated residents should be offered a shower at least twice weekly and more often if requested or needed.On 6/3/26 at 1:59 PM, V17 (CNA) verified she worked some of the days during the time periods of 4/1/26 - 4/6/26 and 5/16/26 - 5/21/26 and stated R20 usually showered when offered one. V17 stated she cannot remember R20 refusing one during those time periods.2. R1's Comprehensive MDS assessment dated [DATE] documents an admission date of 3/28/26 and a BIMS score of 15, indicating cognitively intact. Under Functional Abilities and Goals, this MDS also documents R1 is dependent for shower/bathe self (the ability to bathe self, including washing, rinsing, and drying self). R1's April and May 2026 shower documentation did not reveal any concerns with missing showers. On 6/2/26 at 8:56 AM, R1 was alert and oriented and stated he's been in the facility for about 2 months and he didn't get a shower for about the first three weeks he was in the facility. R1 stated, But I didn't speak up for myself. They're doing better now.On 6/2/26 at 1:32 PM, R1 stated he had a shower yesterday (6/1/26), but before that his last shower was on Saturday, 5/23/26. R1 stated he's changed rooms multiple times which has thrown off when his shower days are and believes that's part of the reason he's missed them a few times.On 6/2/26 at 12:47 PM, V4 (CNA) stated residents are supposed to have a shower at least two times weekly and more often if needed or requested.On 6/2/26 at 12:41PM, V3 (CNA) stated residents are supposed to have a shower/bath at least 2 times per week and more often if they request it or need one.On 6/2/26 at 12:52 PM, V5 (CNA) stated residents should have a shower/bath at least 2 times per week and as needed or requested.On 6/3/26 at 2:40 PM, when asked about showers, V2 (Director of Nurses/DON) stated since she has taken over the DON position, she has not had any complaints brought to her from residents or family about showers not being done. V2 stated however, when she was the MDS Coordinator, she did receive some complaints from a few residents and family about showers not being done. V2 stated it had been too long ago for her to remember who brought those complaints to her. V2 said showers should be offered to residents at least two times per week and more frequently if needed or requested. V2 stated she could not explain the two time periods of 4/1/26 - 4/6/26 and 5/16/26 - 5/21/26 in which R20 did not have a shower documented. V2 stated R20 could have possibly refused due to not feeling well or simply did not want one, but admitted staff still should have documented something in her chart.The facility's Activities of Daily Living Policy dated revised March 2018 documents, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.Prior to the survey date, the facility implemented the following actions to correct the deficient practice:1. The facility held a Quality Assurance and Performance Improvement/QAPI meeting on 5/26/26 with V1 (Regional Director of Operations/Acting Administrator), V2 (DON), and V19 (Medical Director) in attendance. The QAPI Agenda/Meeting documents the following steps will be taken: 1. All ADL (Activities of Daily Living) care/showers will be reviewed and updated where appropriate. 2. Any issue identified will be addressed immediately. 3. Re-education of all staff responsible for showers and ADL care. 4. A QA/Quality Assurance tool has been created to monitor the effectiveness of education. Any issue identified will result in re-education and the QAPI process being re-initiated.2. The QAPI action plan includes the goal of improved compliance with ADL care/shower policy. The action is education with increased implementation of oversight.3. Inservice documentation for nursing staff (Registered Nurse/RN, Licensed Practical Nurse/LPN and CNA) shows that all nursing staff were educated on 5/26/26 on the following policies and procedures: ensuring residents are getting shower and ADL care.4. The Quality Assurance Audit Tool documents that 6 random residents will be audited three times per week for four weeks to assess the implementation of the corrective action. There is documentation showing that this Quality Assurance Audit Tool was conducted on the dates of 5/26/26, 5/28/26, 5/29/26, 6/1/26 and 6/3/26 for six random residents indicating the facility is monitoring as stated up through exit date of 6/4/26.

Based on interview and record review, the facility failed to ensure wound treatments were completed as ordered by the physician for 3 of 3 residents (R1, R19 and R20) reviewed for pressure ulcers in the sample of 20.This past non-compliance occurred between 4/1/26 - 5/26/26.1. R1's admission Record with print date of 6/2/26 documented an admission date of 3/28/26 and included diagnoses of infection and inflammatory reaction due to other cardiac vascular devices implants and grafts and end stage renal disease.R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 is at risk for developing pressure ulcers and that he has two unhealed pressure ulcers that are unstageable. The MDS documents treatments for these unhealed pressure ulcers include the application of ointments/medications and pressure ulcer care.R1's most recent Care Plan documents a focus area of actual alteration in skin integrity AEB: DTI (deep tissue injury) to right lateral foot and right 5th toe and healing surgical wound to right upper inner arm. See skin and wound tab for specific wound details (Date Initiated: 03/28/2026). A corresponding intervention for this focus area documents Treatment orders: see POS (Physician Order Sheet) and skin and wound tab (Date Initiated: 03/28/2026).R1's Order Summary Report with print date of 6/2/26 documents an order to cleanse right fifth toe with wound cleanser, then paint with betadine and leave open to air every day dated 3/28/26. This report documents another order to cleanse right outer foot with wound cleanser, apply TRIAD cream and then cover with dry dressing every day dated 5/29/26.R1's Treatment Administration Records (TAR) for March, April, and May 2026 document a physician ordered treatment to cleanse right 5th toe with wound cleanser, pat dry, apply betadine and leave open to air, every shift for skin healing with start date of 3/28/26. The March 2026 TAR was blank on 5 occasions: 3/28/26 (night shift), 3/29/26 (day shift), 3/30/26 (day shift) and 3/31/26 (day and night shift). The April 2026 TAR was blank on 8 occasions: 4/1/26, 4/10/26, 4/13/26, 4/14/26, 4/19/26, 4/20/26, 4/21/26 (all day shift), and on 4/23/26 (night shift). The May TAR was blank on 5/5/26 (night shift).R1's March, April, and May 2026 TAR's also document a physician ordered treatment to cleanse R1's right lateral foot area with wound cleanser, pat dry, apply betadine and leave the area open to air every shift for skin healing with a start date of 3/28/26. Out of 7 opportunities, the TAR was blank on 5 occasions: 3/28/26 (night shift), 3/29/26 (day shift), 3/30/26 (day shift) and 3/31/26 (day and night shift). The March 2026 TAR was blank for this treatment order on 5 occasions: 3/28/26 (night shift), 3/29/26 (day shift), 3/30/26 (day shift) and 3/31/26 (day and night shift). The April 2026 TAR was blank on 8 occasions: 4/1/26, 4/10/26, 4/13/26, 4/14/26, 4/19/26, 4/20/26, 4/21/26 (all day shift), and on 4/23/26 (night shift). The May TAR was blank on 5/5/26 (night shift).On 6/2/26 at 8:56 AM, R1 stated he was not getting his dressing/treatment to his right foot and toe as often as the doctor ordered it when he first got here, but now the staff are doing it almost every day.On 6/2/26 at 2:28 PM, V11 (Registered Nurse/RN) stated R1 has complained to them of not getting his dressing change/treatment to his right foot and right fifth toe, but V11 states the problem is R1 wants the treatment done on his time or R1 wants it done differently than the doctor ordered it.On 6/2/26 at 2:40 PM, V12 (Licensed Practical Nurse/LPN) stated R1 has voiced complaints a couple of times saying he did not get his dressing changes/treatments to his right foot and right 5th toe on a couple of V12's days off.On 6/3/26 at 10:22 AM, V14 (RN) verified she worked some of the days R1's treatments were not marked as completed. V14 said she cannot remember why R1's treatments were not marked as completed. V14 stated they are usually able to complete all their ordered treatments in her shift period. V14 stated they may have forgotten to initial the TAR.A facility grievance dated 5/24/26 filed on behalf of R1 documented R1 was not getting his dressings/treatments to his wounds every day like he should. This grievance documents it was reviewed by V1 (Regional Director of Operations/Acting Administrator) and the grievance was unfounded. 2. R19's admission Record with print date of 6/2/26 documented an admission date of 5/5/26 and included diagnoses of acute kidney failure, dementia and cerebral infarction.R19's MDS assessment dated [DATE] documents BIMS score of 00, indicating R19 was not interviewable. This MDS also documents R19 is at risk for pressure ulcers.R19's most recent Care Plan documents a focus area of R19 is at risk for alteration in skin integrity (initiated 5/6/26). Corresponding interventions for this focus area include incontinence care and applying barrier cream; turn and reposition every two hours; pressure reducing device for wheelchair and treatment orders: see POS and skin and wound tag (all initiated 6/3/26).R19's Order Summary Report with print date of 6/2/26 documents an order to cleanse right hip wound with wound cleanser, pat dry, apply calcium alginate and cover with dry dressing daily, every day shift for wound care with a start date of 5/17/26.R19's TAR for May 2026 documents a treatment order to clean area of right hip with wound cleanser, pat dry, apply calcium alginate and cover with dry dressing daily with a start date of 5/17/26. This TAR was blank on 5 occasions on 5/18/26, 5/19/26, 5/23/26, 5/26/26, and 5/27/26.3.) R20's admission Record with a print date of 6/2/26 documented an admission date of 2/28/26 and included diagnoses of Alzheimer's disease, chronic kidney disease, pressure induced deep tissue damage of left heel and reduced mobility.R20's MDS assessment dated [DATE] documents a BIMS score of 3, indicating severe cognitive impairment. This MDS also documents R20 is a substantial/maximum assist for rolling left and right, R20 is at risk for pressure ulcers, and has at least one unhealed pressure ulcer.R20's most recent Care Plan documents a focus area of R20 has an actual alteration in skin integrity (initiated 2/23/26). Corresponding interventions for this focus area include treatment orders see POS and skin and wound tab, and turn and reposition every 2 hours (both initiated on 2/23/26).R20's May TAR documents a physician order for Betadine External Solution apply to right heel topically every day shift related to pressure induced deep tissue damage of right heel. Paint discolored area with betadine and cover with silicone foam bordered dressing - leave compression sock off right leg, with a start date of 3/27/26 and discontinue date of 5/7/26. This TAR was blank on 4 occasions on 5/3/26, 5/4/26, 5/5/26, and 5/7/26. R20's May TAR then documents a physician order for Betadine External Solution, apply to right heel topically every day shift related to pressure induced deep tissue damage of right heel. Paint discolored area with betadine and cover with white bordered foam dressing - leave compression sock off right leg, with a start date of 5/8/26 and discontinue date of 5/28/26. This TAR was blank on 7 occasions on 5/9/26, 5/10/26, 5/15/26, 5/18/26, 5/19/26, 5/26/26, and 5/27/26.On 6/3/26 at 10:25 AM, V13 (LPN) verified she worked on the dates of 5/5/26, 5/26/26 and 5/27/26, and stated she was not sure why R19 and R20's treatments were not marked off as completed those days. V13 stated they are usually able to complete all their treatments in their shift period. V13 stated they might have forgotten to initial them.On 6/3/26 at 10:36 AM, V11 (RN) verified she worked on the following dates of 5/4/26, 5/19/26, and 5/27/26 and stated she usually does the treatments and does not remember a reason why she would not have done the ordered treatment on R20. V11 gave the same response in relation to the days worked of 5/19/26 and 5/27/26 for R19 and dates of 4/1/26, 4/19/26, 4/20/26 and 4/21/26 for R1 and treatments not being marked off as completed those days. V11 stated if she was here, she did her treatments. She further stated she might have forgotten to initial them though.On 6/3/26 at 11:01 AM, V12 (LPN) stated she did not remember any specific reason why they would have missed doing the treatments on R19 on dates of 5/18/26, 5/19/26 and 5/23/26. V12 stated it's possible they might have been extremely busy with admissions or emergencies and did not have time to complete all the treatments. V12 stated that does not happen very often but does on occasion. V12 gave the same response in relation to R20's treatments not being marked as completed on 5/3/26, 5/4/26, 5/5/26, 5/9/26, 5/10/26, 5/18/26, and 5/19/26.On 6/3/26 at 11:42 AM, V15 (LPN) stated, in relation to R19's treatments not being marked as completed on 5/23/26 and 5/27/26, there was one day in May they were unable to complete R19's treatment/dressing order due to being busy and not having enough time. V15 stated they do remember passing it on to the night shift nurse (can't remember who) R19's treatment still needed to be completed, but they were not sure if it was completed or not. Regarding R20's treatments not marked as completed on 5/9/26, 5/10/26 and 5/26/26, V15 stated she cannot remember missing any of the ordered treatments and simply might have forgotten to initial them.On 6/3/26 at 2:40 PM, V2 (Director of Nurses/DON) stated wound care should be performed at the time and direction of the physician's orders. V2 stated treatments and dressing changes are documented on the TAR. V2 stated if the treatments are not documented as completed on the TAR it could mean one of two things: either the nurse forgot to document it on the TAR, or they did not do the treatment. She stated, You know the old saying, if it wasn't charted, it wasn't done. V2 stated R1 had mentioned to her last week there were some nurses not performing wound care on his foot, but when she asked him who it was, he stated he didn't want to get anyone in trouble. In relation to the treatments/dressing changes not documented as completed on R1, R19 and R20's TAR's, V2 stated she could not explain it away, and it potentially signaled the treatment/dressing change was not being completed which could cause a wound to worsen.Prior to the survey date, the facility took the following actions to correct the deficient practice:The facility held a Quality Assurance and Performance Improvement (QAPI) meeting on 5/26/26 with V1 (Regional Director of Operations/Acting Administrator), V2 (DON), and V19 (Medical Director) in attendance. The QAPI Agenda/Meeting documents the following steps will be taken: 1. All skin assessments will be reviewed and updated where needed. 2. Any issue identified will be addressed immediately. 3. Re-education of all staff responsible for skin assessments and treatments for wounds. 4. A QA/Quality Assurance tool has been created to monitor the effectiveness of education. Any issue identified will result in re-education and the QAPI process being re-initiated.The QAPI action plan includes the goal of improved compliance with wound care policies. Action is education with increased implementation of oversight. Inservice documentation for nursing staff (RN, LPN and CNA) shows that all nursing staff were educated on 5/26/26 on the following policies and procedures: performing skin assessments, wound care, treatments and reporting new wounds.The Quality Assurance Audit Tool documents that 6 random residents will be audited three times per week for four weeks to assess the implementation of the corrective action. There is documentation showing that this Quality Assurance Audit Tool was conducted on dates of 5/26/26, 5/28/26, 5/29/26, 6/1/26 and 6/3/26 for six random residents indicating the facility is monitoring as they stated they would up through exit date of 6/4/26.

Based on interview, observation, and record review the facility failed to provide the identified level of supervision and assistance required to prevent an accident for 1 of 3 (R1) residents reviewed for accidents in a sample of 9. This failure resulted in R1 falling and having multiple rib fractures.This past noncompliance occurred on 05/06/26.The findings include:R1's admission Record documents an admission date of 08/02/25, with diagnoses in part of unspecified dementia, bursitis of unspecified shoulder, unilateral primary osteoarthritis right hip, primary generalized osteoarthritis, unsteadiness on feet, unspecified abnormalities of gait and mobility, repeated falls, cognitive communication deficit, and other reduced mobility.R1's MDS (Minimum Data Set) dated 02/27/26 documents in Section C a BIMS (Brief Interview for Mental Status) score of 7, which indicates moderately impaired cognition. Section GG documents toileting as partial/moderate assistance. Sit to stand and chair/bed to chair transfers documents partial to moderate assistance. Toileting transfers documents partial to moderate assistance.R1's Care plan documents a focus area with a date initiated of 08/04/25, that states I am at risk for falls r/t (related to) decreased mobility, episodes of incontinence. Interventions include 1. Assist with transfers and ambulation. 2. Staff to remain with resident during ambulation and transfers, PT (Physical Therapy)/OT (Occupational Therapy) to eval (evaluate) and treat, and medication review (05/06/26).R1's fall risk evaluation dated 02/10/26 documents a score of 15 which indicates R1 is at risk for falls.R1's fall risk evaluation dated 05/06/26 documents a score of 5 with the category marked at NA (Not Applicable).R1's Fall report dated 05/06/26 documents under Nursing description: CNA (Certified Nurse Assistant) came and got this nurse, stating that the resident had fallen in her bathroom. Upon entering bathroom resident was sitting on the floor beside the toilet. Asked her what happened and she stated she fell, landing on her bottom. CNA concurred with statement stating resident let go of her walker and fell. Resident's house shoes are too big and may have contributed to the fall. This nurse assessed resident and no apparent injuries. No bruising was noted and resident was able to move all extremities. Neuro checks were WNL (Within Normal Limits). This nurse got another CNA to help and the two CNA's used a gait belt to get resident up and back to her recliner. Resident was walking. C/O (complained of) a sore bottom. In the notes section of the fall report it was documented upon IDT (Interdisciplinary team) investigation it was found on 05/06/26 at approximately 5:11AM CNA entered residents room to assist her to get up in preparation to go to the dining room for breakfast. CNA placed walker in front of residents recliner and resident stood up from the recliner and ambulated to the bathroom with her walker independently with the CNA walking with her as a standby assist which is her baseline status for ambulation for short distances. When resident finished using the bathroom the CNA placed her wheelchair near the bathroom door as resident uses a wheelchair for long distances and was getting ready to go to the dining room for breakfast. CNA was standing near the wheelchair as resident began to take a few steps with her walker towards the wheelchair when resident appeared to have fallen backwards onto the floor. CNA immediately responded and then notified the nurse. Nurse completed a full body assessment, checking range of motion in all extremities and checking for pain, bumps, bruises, etc. No apparent injuries were noted at that time. Staff then assisted resident up in her wheelchair and to the dining room to eat breakfast. Resident had no complaints noted.A final report sent to the Illinois Department of Public Health documents R1 had a fall on 5/6/26 at 5:15AM. The report documents upon IDT investigation it was found on 05/06/26 at approximately 5:11AM CNA entered resident's room to assist her to get up in preparation to go to the dining room for breakfast. CNA placed the walker in front of the resident's recliner and resident stood up from the recliner and ambulated to the bathroom with her walker independently with the CNA walking with her as a standby assist which is her baseline status for ambulation for short distances. When resident finished using the bathroom the CNA placed her wheelchair near the bathroom door as resident uses a wheelchair for long distances and was getting ready to go to the dining room for breakfast. CNA was standing near wheelchair as resident began to take a few steps with her walker towards the wheelchair when resident appeared to have fallen backwards onto the floor. CNA immediately responded and then notified the nurse. Nurse completed a full body assessment, checking range of motion in all extremities and checking for pain, bumps, bruises, etc. No apparent injuries were noted at that time. Staff then assisted (R1) up in her wheelchair and to the dining room to eat breakfast. (R1) had no complaints noted. MD (Medical Doctor) and POA (Power of Attorney) notified of the incident. This report further documents that on 05/10/26 (R1) went on a family outing with her daughter/POA and during that outing resident began complaining of shortness of breath and no quite acting herself, so daughter decided to take her to be seen at the ER (Emergency room). While at the ER (R1) was diagnosed with bronchitis and non-displaced rib fractures. (R1) was treated with antibiotics, nebulizer treatments, and oral steroids at the hospital and was discharged back to the facility on [DATE].R1's hospital records dated 05/10/26 documents in part under CT (Computed tomography) angiogram pulmonary embolism with contrast bony thorax right posterior 9th, 8th, 7th nondisplaced rib fractures, left posterior 11th, 10th nondisplaced rib fractures. Under clinical impression 1. Bronchitis, 2. Multiple rib Fractures, 3. Fall at Nursing home. On 05/19/26 at 1:21PM, R1 stated that she did have a fall recently. R1 said that she was in the bathroom and went to leave the bathroom and fell on the floor. R1 said that she did have staff there in the room with her. R1 said that she hurt everywhere when she fell. R1 said that she went to the hospital on Mother's Day because she was having some problems breathing and they found out she had rib fractures from her fall. R1 said that she doesn't remember if staff had a gait belt on her or not when she fell. On 05/18/26 at 4:44PM, V20 (Family Member) stated that they took R1 to the hospital on [DATE] because she wasn't breathing really well and she was kind of out of it. V20 said that while they were at the hospital they did a CT scan and found out that R1 had multiple rib fractures from her fall on 05/06/26. V20 said that the hospital did keep R1 overnight. V20 said they did have a care plan meeting with V1 (Director of Operations) and V3 (Owner/Director of Operations) along with another regional nurse. V20 said that they have a video camera in R1's room and they reviewed the fall on 05/06/26 with V1 and V3. V20 said that you can hear R1 falling. On 05/20/26 at 11:12AM, V6 (Licensed Practical Nurse/LPN) stated that she did not observe R1 fall it wasn't until V17 (CNA) said that R1 fell that she knew about the fall. V6 said that she walked in and that R1 was sitting on the floor next to the toilet. V6 said that she yelled for the other CNA as well. V6 said that she checked R1's legs for shortening and rotation. V6 said she checked R1' s head for any bumps she said that R1 told her that she did not hit her head. V6 said that the only thing that R1 was complaining about was her back hurt. V6 said that she did a skin assessment and there was no bruising or skin tears noted. V6 said that she did neuro checks on R1 and they were all within normal limits. V6 said she did a good assessment on R1 then she had the other CNA go get a gait belt and then the 2 CNA's used the gait belt and assisted R1 off the floor. V6 said that R1 missed hitting the toilet and the sink in the bathroom. V6 said that she thought maybe R1's house shoes could have caused her to fall because she thought they looked a little too big.On 05/20/26 at 11:48AM, V13 (CNA) stated that they use a gait belt on R1 along with her walker to get her up.On 05/20/26 at 11:48AM, V9 (CNA) stated that R1 used to be on her hall but they moved her a little after the fall. V9 said that R1 would transfer with a gait belt and a standby assist and a walker for transfers and ambulation. V9 said that sometimes R1 would request privacy when using the restroom and she would crack the door and be right outside the door in case R1 tried to get up so she could keep and eye on her.On 05/20/26 at 11:55AM, V16 (CNA) stated that he has taken care of R1 and that she transfers with a gait belt and 1 assist with a walker. V16 said that R1 does pretty good with ambulating with the wheeled walker. V16 said that he would assist R1 to the bathroom to the toilet with a gait belt and walker then he would get R1's stuff that she needed while he could still visibility see R1.On 05/20/26 at 12:53PM, V5 (Registered Nurse) said that she has cared for R1. V5 said that R1 transfers with a gait belt walker and 1 assist. V5 said that she never heard R1 complain of any pain to her ribs after the fall on 05/06/26.On 05/20/26 at 1:38PM, V4 (Medical Doctor) stated that R1's rib fractures are probably from when R1 fell.On 05/20/26 at 1:58PM, V2 (Director of Nursing) stated that she was told about R1's fall in the bathroom. V2 said that R1 did not have any injuries that they was aware of from the fall. V2 said that the CNA was outside of the bathroom door getting R1's wheelchair and R1 was coming out of the bathroom and fell. V2 said that the CNA ran into the bathroom when R1 fell. V2 stated that she was not the DON at the time of the fall. V2 said that she was doing MDS and Care plans prior.On 05/20/26 at 2:45PM, V17 (CNA) stated that she was taking R1 to the restroom on 05/06/26. V17 said that R1 stood up from the toilet and then she tripped over her shoes when she was walking out of the bathroom. V17 said that R1 is able to stand up on her own. V17 said that she uses a gait belt on R1 and she is a stand by assist with ambulation. V17 said that R1 gets ready in the bathroom and she was getting dressed and ready in the bathroom she then took a few steps and fell. V17 said that she thinks it was the house slippers that made her fall they are too big. V17 said that R1 did not hit anything when she fell. V17 said that R1 was screaming when she fell. V17 said that they went to put a gait belt around R1 to get her up off the floor and R1 was complaining that the gait belt was to tight and hurting her. V17 said that they got R1 up off the floor after the nurse assessed her. V17 said that she does not remember R1 complaining of any rib pain.On 05/20/26 at 3:13PM, V11 (CNA) stated that when she takes care of R1 that she uses a gait belt and the walker when she assists her. V11 said that when she takes R1 to the bathroom she always stays in the bathroom with R1. V11 said that R1 is a standby by assist with ambulation with a gait belt.On 05/20/26 at 3:15PM, V15 (CNA) stated that R1 transfers with 1-2 assist with a gait belt and walker for transfers and ambulation. V15 said that it just depends on the day, sometimes R1 needs more assistance. V15 said that R1 will sometimes ask to have privacy in the bathroom. V15 said that she will stand outside of the bathroom door with the door cracked. V15 said that sometimes that R1 can be a standby assistant at time. V15 said that she doesn't remember R1 complaining of any rib pain after the fall.On 05/20/26 at 3:16PM, V10 (CNA) stated that when he gets R1 up to ambulate he uses a gait belt and 1-2 assist along with a walker.On 05/20/26 at 3:17PM, V12 (CNA) stated that R1 uses a gait belt and 1-2 assist with a walker for transfers and ambulation. V12 said that R1 told her that she fell by the sink in the bathroom.On 05/21/26 at 3:20PM the ring camera footage from R1's room dated 05/06/26 at 5:11AM was reviewed. On the video you can see V17 (CNA) going into R1's room then V17 slightly closes the door to R1's room. V17 then puts on gloves and goes over to R1's recliner that R1's was sleeping in. V17 then pulls R1's bedside table away from the side of R1's recliner and then grabs R1's call light from the top of R1 and puts it to the side. V17 then removes R1's blanket and places it to the side. Next V17 grabbed the remote to R1's recliner and raised up the back of the recliner to a sitting position which simultaneously lowered R1's foot rest. Once R1 was in the sitting position V17 then placed R1's walker in front of R1. V17 was holding on to the walker as R1 tried to get up out of the recliner. R1 pushed off of the recliner to get up. R1 had no gait belt on. After R1 was up with the walker V17 walked away from R1 with her back to R1 at a distance of approximately 3 feet away from R1. V17 then started to watch R1's television. V17 continued to watch TV as R1 walked to the bathroom with her walker with no gait belt on or assistance from V17. V17 did look at R1 when she finally got close to the bathroom doorway. R1 appeared to be taking higher steps with her right foot when she was ambulating. Once R1 got into the bathroom you can see V17 walking into the bathroom behind R1.On 05/21/26 at 3:25PM a second video from the ring camera in R1's room dated 05/06/26 at 5:19AM was reviewed. On the video you can hear a toilet flush then V17 came out of the bathroom and got R1's wheelchair. V17 was standing outside of R1's bathroom with a wheelchair which appeared not to be in the locked position, the wheelchair did have foot pedals to the side and appeared not to be able to fit inside the bathroom door. V17 looked over to the television every now and then. V17 then backed away from the bathroom with the wheelchair still watching the TV every now and then. V17 was approximately 3-4 feet away from R1 at that time. Next R1 was noted coming out of the bathroom with the wheeled walker while V17 was standing back behind the wheelchair inside the room. As R1 was coming out of the bathroom you can see R1's right hand grab the door frame and then it looked as if R1 was falling. You can then hear R1 screaming and see V17 go running into the bathroom. You can continue to hear R1 screaming, then see V17 leave the room and go out into the hallway. On 05/21/26 at 9:10AM, V7 (Therapy Director) watched the video footage of R1 from 05/06/26 at 5:11AM and 05/06/26 at 5:19AM that was taken in R1's room. V7 said she doesn't know if she would consider what V17 was doing as standby assistance but was maybe more like supervision instead since V17 was at times watching the television. V7 said that the way section GG of the MDS is worded what V17 was doing in the video before and during R1's fall was more supervision than set-up help or stand by assistance. V7 said that staff should always have a gait belt on the residents because you never know what is going to happen. V7 confirmed that R1 did not have a gait belt on when V17 was standing by her, when she got out of the recliner or when R1 was walking to the bathroom with the walker and or when R1 fell. V7 said that V17 should have parked the wheelchair outside of the bathroom door locked the wheels then went into the bathroom and assisted R1 outside of the bathroom door while having a gait belt on R1 the whole time. V7 said that what V17 was doing was not considered assisting R1 with transfers or ambulation at all. V7 said that she has not been told to educate the CNA' s on transfers or gait belt usage with R1 or any other residents. V7 said that they did pick R1 up on therapy for PT (Physical Therapy), OT (occupational Therapy), and ST (Speech therapy).On 05/21/26 at 9:26AM, V13 (CNA) stated that they have to help R1 with ambulation and transfers and when they do assist R1 or any resident they have to have a gait belt on unless they are completely independent with transfers and ambulation and we don't' have to be in there to help them. V13 said that they have been educated on making sure that we use gait belts on residents who require assistance of 1-2 and not to leave a resident in the bathroom unattended, along with fall preventions.On 05/21/26 at 9:30AM, V9 (CNA) stated that a resident who requires assistance with transfer and ambulation should be assisted with standing up and helped with transfers and ambulation. V9 said that they should always have a gait belt on a resident at all times when transferring and with ambulation. V9 said that the only time that a resident would not have a gait belt on with transfers and ambulation is if the resident is completely independent with transfers and ambulation. V9 said that they were just in-serviced on fall prevention, transfer, and gait belt use and about R1's fall. V9 said that they were in-service about R1 and all residents about making sure to use a gait belt on all residents you assist with ambulation and transfers and not to leave a resident unattended in the bathroom. V9 said R1 before the fall was a 1 assist with a walker and gait belt. V9 said R1 was still a 1-2 assist with walker and gait belt after the fall. V9 said if you see a resident fall you make sure the resident is safe.On 05/21/26 at 9:36AM, V14 (CNA) stated that she doesn't take care of R1. V14 said that if a resident's care plan documents that they are to be assisted with transfers and ambulation that means that they are 100% assist with transfers and ambulation. V14 said that anytime you have a resident who needs assistance in any way that you make sure that they have a gait belt on at all times during the transfer and ambulation. V14 said that she was just in-serviced about a week to two weeks ago on fall prevention, transfers, using a gait belt and making sure you don't leave any resident unattended in the bathroom unsupervised.On 05/21/26 at 10:16AM, V3 (Owner/Director of Operations) stated that the V17 in the video with R1 had the call light on when R1 fell but V17 left the room to go get the nurse. V3 said that V17 was only gone out of R1's room when R1 fell for 30 seconds or less to get help from the nurse.On 05/21/26 at 11:32AM, V2 (Director of Nursing/DON) said around 2 weeks ago that all staff were in-serviced on fall preventions, transfers, using a gait belt and not leaving a resident unattended in the bathroom or shower rooms. V2 said that if staff assist a resident to the toilet or shower the resident should always be within arm's reach of staff at all times. V2 said that staff can't leave the bathroom or shower room. V2 said that a resident who is partial to moderate assistance is a resident who must have staff walk with them with a gait belt. V2 stated that if it says on the care plan to assist with transfers and ambulation then the staff should assist the resident with transfer and ambulation with a gait belt.The Facility's Gait Belt Policy with a revision date of 4/2014 documents under purpose to aid in resident ambulation and transfers and to promote optimal balance and safety.The Facility's undated Falls Prevention Strategies & Interventions Policy documents under Staff Actions information gathering: read history of ambulation and transfers and review investigation and implementation of interventions and evaluations-look at what the surveyor reviews, staff education and supervision specify what supervision is needed; do not just write provide supervision, assist with ambulation, Ambulation Care plan. Prior to the survey date of 5/26/26, the facility had taken the following actions to correct the non-compliance: 1. A Quality Assurance and Performance Improvement meeting was held on 05/06/26 to discuss identifying hazards and risks, evaluating them, implementing interventions to reduce them and to monitor for effectiveness and to modify interventions when necessary. In attendance - V1 (Director of Operations), V2 (Director of Nursing/Former MDS/Care plan Nurse), V8 (Registered Nurse), V4 (Medical Doctor), V21 (Regional Nurse), V22 (Business Office Manager), and V7 (Director of Therapy). 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents have the potential to be affected. 3. Measures put into place/systematic changes to ensure the deficient practice does not recur: In-services were provided to nursing staff on ADL (Activities of Daily Living) care, transfers, proper supervision during adl care, focus on transfers and ambulation, fall prevention, proper supervision during adl's, focus on transfers and ambulation, falls, and fall management and prevention. All in-services were completed on 05/06/26. 4. Plan to monitor that the resident environment remains as free of accidents as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Review all new risk management reports daily 5 days per week x 4 weeks to ensure that all fall managements protocol is followed and proper supervision during ADL's was maintained. The first audit completed on 05/07/26.

Based on observation, interview, and record review the facility failed to ensure personal protective equipment was worn per current standards of practice for 5 of 9 (R5, R34, R44, R57, R76) residents reviewed for transmission-based precautions in the sample of 33. Findings Include:1. R34's admission Record with a print date of 09/25/2025 documents R34 was admitted to the facility on [DATE] with diagnoses that include heart failure and hypertension. R34's MDS (Minimum Data Set) dated 7/4/2025 documents R34 has a BIMS (Brief Interview for Mental Status) score of 07, indicating R34 has a severe cognitive deficit. R34's Order Summary Report dated 09/25/2025 documents a physician order dated 9/22/25 of, Isolation, due to covid positive, per facility protocol. R34's current Care Plan did not document a Focus area related to Covid 19 and/or transmission-based precautions. 2. R57's admission Record with a print date of 9/25/2025 documents R57 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Disease, muscle weakness, and dysphagia. R57's MDS dated [DATE] documents R57 has a BIMS score of 05 indicating R57 has a severe cognitive deficit. R57's Order Summary Report dated 9/25/2025 documents a physician order with a start date of 9/22/25 of, Contact Isolation per Facility Protocol Related To (+/positive) for covid. R57's current Care Plan did not document a Focus area related to Covid 19 and/or transmission-based precautions. On 09/22/2025 at 12:46 PM, R34 and R57's room door was observed to be open and V16 (Certified Nursing Assistant/CNA) entered the room wearing a surgical mask and carrying a meal tray. There was a green sign on R34 and R57's room door indicating the residents were on airborne contact droplet precautions. This sign indicated anyone entering the room should wear gloves, gown, a N95 mask, and eye protection. V16 did not don a gown, gloves, N95 or eye protection. As V16 exited the room this surveyor asked if the surgical mask was the only PPE required in that room. V16 looked at the green sign on the door and stated she just missed the sign. V16 stated the door was open and that was probably how she missed it. On 09/22/2025 at 2:13 PM, V15 (Director of Clinical Operations) stated eye protection is supposed to be worn when entering a room where a resident has tested positive for Covid. When asked if V16 should have worn eye protection, a gown, and an N95 when she entered R34 and R57's room, V15 stated she would have to check on that. 3. R44's admission Record with a print date of 09/25/2025 documents R44 was admitted to the facility on [DATE] with diagnoses that include atrial fibrillation, heart failure, chronic kidney disease, and vascular dementia. R44's MDS dated [DATE] documents R44 has a BIMS score of 05, indicating a severe cognitive deficit. R44's Order Summary Report dated 9/25/25 documents a physician order of, Contact Isolation Per Facility Protocol Related To (+) for Covid. R44's current Care Plan does not document a Focus area related to Covid and/or Transmission Based Precautions. On 09/22/2025 at 12:58 PM, V17 (Environmental Services) entered R44's room after donning a gown, gloves, and an N95. V17 did not don eye protection prior to entering R44's room. When asked why she didn't don eye protection prior to entering the room, V17 stated they didn't have any available on the unit for her to don so she didn't put eye protection on. This surveyor observed face shields (eye protection) in bins/door storage on the same unit throughout this same time frame. On 9/25/25 at 9:00 AM, V1 (Administrator) stated staff should wear full PPE, including gown, gloves, eye protection, and N95 when entering a room where a resident has tested positive for Covid and is on droplet precautions. The facility Isolation Policy-Categories of Transmission-Based Precautions dated January 2023 documents, Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Droplet Precautions: 1. Droplet Precautions may be implemented for an individual documented or suspected to be infected with microorganism transmitted by droplets (large-particle droplets).that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). 2. Residents on droplet precautions will be placed in a private room if possible. a. When a private room is not available, residents may share a room with a resident infected with the same microorganism or with limited risk factors.3. Masks will be worn when entering the room. 4. Gloves, gown, and goggles should be worn if there is a risk of spraying respiratory secretions. Airborne Precautions: 1. Airborne precautions are indicated when an individual is infected with a pathogen that is very small.and can be transmitted long distances through the air. 2. Preventing the spread of airborne pathogens requires a room with special air handling and ventilation called an airborne infection isolation room (AIIR). 3. If an AIIR is not available, a resident suspected of having an airborne infectious disease shall be masked and transported to a facility with an AIIR. The facility Coronavirus Prevention and Control policy dated 7/9/2022 documents, . Residents with Confirmed Covid-19.Staff wear full PPE (N95, respirator, gown, gloves, eye protection. 4. R76's admission Record documents an admission date of 3/21/25 with diagnoses including but are not limited to type II diabetes mellitus with diabetic neuropathy, peripheral vascular disease, peripheral vascular angioplasty, and long term use of anticoagulants. R76's most recent care plan documents R76 has a focus area dated 4/1/25 of being at risk for impaired skin integrity. Interventions for this focus area include but aren't limited to float heels while in bed dated 4/1/25, observe for signs and symptoms of breakdown/infection dated 4/1/25, and skin assessment on admission and weekly dated 4/1/25. Another focus area dated 6/13/25 documents R76 has an actual alteration in skin integrity. Interventions for this focus area include but are not limited to pressure relief surface to bed dated 9/23/25 and to see treatment orders on physician's order sheet and skin and wound tabs. R76's Physician's Order Summary Report includes but are not limited to Enhanced Barrier Precautions due to organism in urine dated 7/28/25, cleanse bilateral lower extremity wounds with wound cleanser, pat dry and apply mupirocin 2% ointment to wound of left proximal leg, then cover with gauze and wrap lower left extremity from toes to knee daily to prevent picking /scratching dated 9/23/25, and to clean right mid leg wound with wound cleanser pat dry and apply mupirocin 2% ointment and cover with gauze daily dated 9/23/25. R76's MDS dated [DATE] in section I documents a diagnosis of peripheral vascular disease and diabetes mellitus. R76's Skin and Wound Evaluation's dated 9/24/25 document a venous stasis ulcer to right dorsum of 3rd toe that was present on admission that measured 0.2 centimeters (cm) by 0.5cm by 0.6cm with granulation tissue, a venous ulcer to right medial malleolus that measures 1.1cm by 1.7cm by 0.9cm covered with 10% of epithelial tissue and 90% granulation tissue, a wound labeled as other that are caused from R76 scratching at her skin located on the right shin, and a wound of left lateral lower leg caused from scratching self. On 9/24/25 at 3:52 PM, R76's dressing changes and treatments to multiple wounds of bilateral lower extremities performed by V4 (Registered Nurse/RN) and V3 (Assistant Director of Nurses) was observed. Upon entering the room there was EBP signage observed on R76's door and supplies located outside of the room including disposable gloves and disposable gowns. V4 donned and doffed gloves and performed hand hygiene between dressings and from cleaning to applying the dressing of each wound. V4 was not observed wearing a disposable gown while providing care and treatment of R76's wounds. On 9/25/25 at 7:57 AM, V4 stated EBP is followed for when providing high contact care like dressing and treatment of wounds, if the resident is infected with a multidrug resistant organism or has any implanted medical devices such as a urinary catheter or intravenous catheter. V4 stated before providing wound care on 9/24/25 to R76 she should have donned a disposable gown. V4 agreed EBP was not fully followed since she did not don a disposable gown before providing care to R76's wounds. 5. R5's admission Record documents an admission date of 6/10/22 and diagnoses including but are not limited to type II diabetes mellitus with diabetic neuropathy, repeated falls, and unspecified dementia. R5's most recent Care Plan documents a focus area of R5 is at risk for actual alteration in skin integrity dated 9/21/25. Interventions related to this focus area include but are not limited to float heels while in bed dated 10/16/24, incontinence care and apply barrier cream dated 10/16/24, pressure relieving mattress dated 10/16/24, and treatments as ordered dated 10/16/24. R5's Physician's Order Summary Report documents the following orders including Enhanced Barrier Precautions due to wound dated 9/25/25, apply equal parts of nystatin cream and zinc to surrounding area and apply a small dressing to coccyx laceration and scratches on buttocks every shift, and to apply zinc oxide ointment 10% apply to coccyx buttocks dated 9/12/25. R5's MDS dated [DATE] documents in section I diagnoses of multi drug resistant organism pneumonia and diabetes mellitus. Section M of same MDS documents R5 has a pressure ulcer injury/a scar over a bony prominence, or a non-removable dressing/device. R5's Skin/Wound Evaluation dated 9/18/25 documents R5 has a pressure wound, stage 2 located on medial coccyx. Wound measurements on that date were 0.4 centimeters (cm) by 1.5cm by 0.3cm. Same skin evaluation documents 100% of wound bed was granulation tissue. Same skin evaluation documents scratch marks as well to buttocks. Progress for wound was documented as improving. On 9/24/25 at 3:44 PM, dressing change on R5's coccyx and buttocks performed by V4 and assisted by V14 (Certified Nurse's Aide /CNA) was observed. V4 donned gloves and performed the dressing changes to R5's coccyx and buttocks according to physician's orders. V4 donned and doffed gloves and performed hand hygiene between wounds and between cleansing and applying new dressings according to current standards of practice. V4 and V14 were not observed wearing disposable gowns while providing wound care. There was no EBP signage on R5's door or any EBP or PPE supplies on or near the entryway to R5's room. On 9/25/2025 at 7:57 AM, V4 stated EBP is used when treating wounds, a resident has an infection caused by a multidrug resistant organism or had implanted medical devices. V4 stated she as well as V14 should have donned a disposable gown along with disposable gloves before providing wound care to R5. V4 agreed EBP was not completely followed while providing wound care because gowns were not donned for the dressing changes. V4 also agreed there was no signage on the door of R5's room or any EBP supplies located at or near the door of R5's room. On 9/25/25 at 12:44 PM V2 (Director of Nurses/DON) stated EBP should be employed when providing wound care, if a resident is infected with a multidrug resistant organism, or if a resident has some sort of implanted medical device that extends from the body. V2 stated EBP includes but isn't limited to the wearing of disposable gowns, gloves and sometimes face shields depending upon the care being provided. V2 stated she would expect EBP precautions to be followed and personal protective equipment be worn including disposable gowns and gloves for providing wound care to residents. V2 agreed V4 and V14 should have donned disposable gowns along with their disposable gloves before providing wound care to R5 and R76. The facility's Enhanced Barrier Precaution (EBP) policy dated 3/28/24 documents that EBP expands the use of personal protective equipment and refer to an infection control intervention designed to reduce transmission of multidrug resistant organisms that employs targeted gown and glove use during high contact resident care activities. Facility's EBP policy also states EBP will be instituted for those residents deemed to be at high risk for multi drug resistant organisms with any of the following: wounds and or indwelling medical devices even if the resident is not known to be infected or colonized with a multidrug resistant organism. Examples of high contact resident care activities requiring gown and glove use for EBP include wound care meaning any skin opening requiring a dressing.

Based on interview, record review and observation, the facility failed to implement planned fall interventions for 2 (R7 and R52) of 7 residents reviewed for falls in a sample of 36. Findings included: 1. R7's Admission Record documented admission to the facility on [DATE] and included diagnoses of muscle weakness, abnormal gait, Parkinson's disease and extra-pyramidal/movement disorder among others. R7's Minimum Data Set (MDS) dated [DATE] documented R7 needs supervision from staff for toileting. This same MDS documented R7's had a Brief Interview for Mental Status (BIMS) score of 14, which indicates R7 was cognitively intact. A nursing note in R7's Electronic Health Record (EHR) dated 9/21/24 at 6:00 AM, documented the following in part: Resident observed lying on floor on back in doorway of room with overturned walker beside him. When asked what happened resident stated that he fell trying to go to bathroom. Resident is alert and verbal per norm. A form titled Illinois Department of Public Health Report with incident date of 9/21/24 at 6:00 AM documented the following in part: IDT (Interdisciplinary Team) reviewed this incident and found on 9/21/24 at 6:00 AM, (R7) got up from his chair in his room un-assisted and attempted to walk to the bathroom and fell . Upon IDT reviewing and investigating this incident, it was determined that (R7) exhibited poor safety awareness .Non-skid strips have been placed in (R7's) room. A bedside commode was placed in (R7's) room near his chair for easier and closer access. Resident's care plan has been updated accordingly. R7's Care Plan documented a focus area of: I am at risk for falls with initiation date of 11/8/2021. This same care plan under the Risk for Falls focus area, listed the following interventions: Bedside commode in resident's room near his recliner for easy access to use the restroom with initiation date of 9/21/2024. On 10/28/2024 at approximately 10:00 AM, R7's room was observed without a bedside commode present. On 10/29/2024 at approximately 10:00 AM and again at 1:45 PM, R7's room was observed without a bedside commode. On 10/30/2024 at 9:15 AM, R7's room was observed without a bedside commode present. On 10/29/2024 at 1:45 PM, R7 said he fell (9/21/24) trying to walk to the bathroom from his recliner. R7 said after his fall, the facility staff did not bring him a bedside commode and never even offered one for his use. R7 denied having any further falls since falling on 9/21/2024. On 10/30/2024 at 9:50 AM, V5 (Certified Nursing Assistant/CNA) stated R7 was not supposed to have a bedside commode as far as she knew. 2. R52's Admission Record documented admission to the facility on [DATE] and included diagnoses of dementia, chronic obstructive pulmonary disease and over active bladder. R52's MDS, dated [DATE], documented R52 has a BIMS score of 5, indicating R52 has severe cognitive impairment. A facility incident report dated 7/8/2024 documented R52 was observed on the floor next to his bed with his pillow and blanket. Full body assessment done and no injuries. R52 unable to explain if he fell or intended to lie in the floor. R52 unable to explain what happened. IDT reviewed and decided to implement a concave mattress as a safety measure. R52's Care Plan documented the following focus area of At Risk for Falls, initiated 1/23/2023. This same care plan under the Risk for Falls focus area, listed the following interventions: Scoop mattress (concaved mattress) to be applied to R52's bed with initiated date of 7/8/2024. On 10/29/2024 at approximately 10:45 AM, R52's bed was observed with a non-concaved regular mattress on it. On 10/30/2024 at 9:20 AM, R52's bed was observed with the same non-concaved mattress on it. On 10/30/2024 at 9:30 AM, V2 (Director of Nursing) said a scoop mattress (concaved mattress) has higher edges with a lower middle section. V2 said these types of mattresses help prevent a person from rolling out of bed. V2 said she did not know R52 was supposed to have a concaved mattress and she had never applied one to his bed. On 10/30/2024 at 9:50 AM, V5 (Certified Nursing Assistant) said R52 has not had a concaved mattress on his bed that she can remember. A facility policy titled Fall and Fall Risk, Managing, with revision date of March 2018, documented the following in part: When a resident is found on the floor, a fall is considered to have occurred. Staff will identify interventions related to the resident's specific risks to try to prevent the resident from falling and try to minimize complications from falling. Staff will implement a resident centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling.

Based on interview and record review, the facility failed to develop and implement a plan of care for a resident with Dementia that included appropriate treatment and services to attain or maintain the highest practicable well being for 1 (R77) of 3 residents reviewed for dementia care in a sample of 36. Findings included: According to his Admission Record, R77 was admitted to this facility on 10/10/2024 with diagnoses of dementia, bipolar and anxiety among others. R77's MDS (Minimum Data Set) dated 10/17/2024 documented R77 is never understood, has short and long term memory problems, and due to this R77 could not participate in a BIMS (Brief Interview for Mental Status) assessment. R77's Care Plan, with initiation date of 10/11/2024 included focus areas with interventions for the following problems and risks: urinary tract complications, weakness, self care deficit, risk for falls, risk for pain, risk for skin injury, risk for Covid 19, risk for constipation, black box medication warning and anticoagulant therapy. R77's Care Plan did not include a focus area with planned interventions to address R77's cognitive deficit or dementia. On 10/30/2024 at 9:30 AM, V2 (Director of Nursing) said it was her expectation for dementia care to be included in a resident's care plan if they had a diagnosis of dementia. On 10/30/2024 at 12:55 PM, V7 (Care Plan Coordinator) said R77's Care Plan did not address R77's cognitive deficits or diagnosis of dementia, but should have. V7 said it must have gotten missed.

Based on interview and record review, the facility failed to provide showers or bathing alternative, twice per week for 2 (R7 and R56) of 3 residents reviewed for showers in a sample of 36. Findings included: 1. R7's Admission Record documents admission to the facility on [DATE] and included diagnoses of muscle weakness, abnormal gait, Parkinson's disease and extra-pyramidal/movement disorder. R7's Minimum Data Set (MDS) dated [DATE] documented R7 needs partial moderate assistance from staff for showering/bathing and does not exhibit the behavior of rejecting care. This same MDS documented R7 had a Brief Interview for Mental Status (BIMS) score of 14, indicating he was cognitively intact. On 10/28/2024 at approximately 10:00 AM, R7 said he does not receive his showers as scheduled and at times goes long periods without a bath. R7 said he was supposed to get two showers per week but sometimes the staff do not come and get him for his shower. R7 said he needs a lot of assistance from the staff to get his showers. R7 said he is supposed to get his shower on Tuesday and Friday. The facility's shower schedule for R7's hall documented R7 was scheduled for showers on Tuesdays and Fridays every week. Shower documentation for R7 revealed over the past three months, staff failed to provide documented evidence of showers for R7 on 8/6/24, 8/9/24, 8/16/24, 9/13/24 and 10/22/24. 2. R56's Admission Sheet documented admission to the facility on [DATE] and included diagnoses of heart failure, epilepsy, muscle weakness and adult failure to thrive. R56's MDS (dated 8/9/24) documented R56 needs substantial maximum assistance from staff for showering/bathing and does not exhibit the behavior of rejecting care. This same MDS documented R56 had a BIMS score of 10, indicating moderate cognitive impairment. On 10/30/2024 at 9:34 AM, R56 said she is supposed to get her bath on Wednesday and Saturday. R56 said she has not been getting showers as scheduled. R56 said frequently gets only one shower per week. The facility's shower schedule for R56's hall documented R56 was scheduled for a shower on Wednesdays and Sundays each week. R56's shower documentation for the past three months revealed the facility failed to provide documented evidence of showers for R56 on 8/10/24, 8/17/24, 8/31/24, 10/16/24 and 10/19/24. On 10/30/24 at 9:50 AM, V5 (Certified Nursing Assistant/CNA) said residents are scheduled for two showers per week and the CNAs do the best they can at getting them done, but sometimes showers get missed. V5 said showers are to be documented and turned in to the nurse. V5 said if a resident refused the shower then it is supposed to be documented and turned in to the nurse as well. On 10/30/24 at 9:30 AM, V2 (Director of Nursing) said showers are to be given twice per week and shower refusals are to documented. V2 said no further shower documentation was available for R56 or R7. A facility policy titled Bath, Bed/Shower/Tub, with revision date of February 2018, documented the following in part: The purpose of this procedure is to promote cleanliness and provide comfort to the resident, (staff are to document) The date and time the shower/tub bath was performed and if the resident refused the shower, the reason why and the intervention taken.

Based on observation, interview, and record review the facility failed to ensure restorative programs were implemented to prevent a decline in condition for one of one residents (R35) reviewed for position/mobility in the sample of 36. Findings Include: R35's Admission Record with a print date of 10/31/24 documents R35 was admitted to the facility on [DATE] with diagnoses that included heart failure, heart disease, insomnia, and obstructive and reflux uropathy. R35's Minimum Data Set (MDS) dated [DATE] documents R35 had a BIMS (Brief Interview for Mental Status) score of 04, which indicates R35 has a severe cognitive deficit. This same MDS does not document any restorative programs or physical therapy. On 10/29/24 at 11:27 AM, V9 (Licensed Practical Nurse/LPN) was observed administering medication to R35. R35 was tearful. V9 questioned R35 why he was tearful and R35 stated that his family wants him to walk but they cannot find a tank (oxygen tank) for him to use. R35 stated he has not walked in he does not know how long and was not sure if he was able. V9 stated she would locate a tank and have someone walk him after lunch. V2 (Director of Nursing/DON) was also present during this interaction and stated she would locate a tank. When V2 returned, she stated she was going to have to have a conversation with (R35) because physical therapy did not have him on their list. On 10/29/24 at 3:20 PM, R35 was sitting in a wheelchair in his room. R35 stated he hadn't walked in a few weeks. R35 stated he did use his walker in his room to ambulate to the bathroom with assist of staff. R35's Order Summary Report dated 10/29/2024 did not document an order for restorative programs. R35's current Care Plan did not document a Focus Area for restorative programs or therapy. On 10/31/24 at 1:00 PM, when asked if she could verify R35 did not have a restorative program on the care plan, V1 (Administrator) stated R35's care plan did document the following interventions under the Covid 19 Focus areas, Encourage doorway exercise activities for modified socialization and Encourage the resident to participate in the facility therapeutic recreation/activity program. R35's PT (Physical Therapy) Discharge Summary dated 9/25/24 documents under Discharge Recommendations and Status, Discharge Recommendations: Shower chair with back, Assistive device for safe functional mobility and Assistance with IADL's (Instrumental Activities of Daily Living). Restorative Programs- Restorative Program Established/Trained=Restorative Ambulation Program. Ambulation Program Established/Trained: Patient is currently able to walk in corridor, walk to dining room, and walk in room, balance is steady, and tier is functional and with Restorative Nursing Program, patient will be able to walk in room with assist of one, and walk in corridor with assist of one, and balance will require the physical support of one, by performing the following Restorative Nursing interventions: allow patient to take his or her time, provide assistance of one and use gait belt. R35's Nursing Restorative Care Program documents R35 has approaches of BUE (bilateral upper extremities) with 2 # (pound) fw (free weights) x (times) 25 reps (repetitions) in all available planes and BLE (bilateral lower extremity) exercises with 2 # ankle weights x 25 reps in all available planes. This same Program documents neither approach was signed off as administered prior to 10/22/24. This indicates R35 had restorative program recommendations made during the physical therapy discharge assessment on 9/25/24 and restorative programs were not started until 10/22/24 and the walking program was not included in the restorative programs. On 10/29/24 at 1:55 PM, V8 (Director of Rehabilitation) stated they fill out a care plan form after someone finishes therapy and the care plan form documents what restorative programs a resident should be receiving and then it is given to the Restorative Aid, (V10). On 10/29/24 at 2:04 PM, V10 (Restorative Aid) showed this surveyor the restorative programs for R35 that documents his restorative programs with the date of 10/2024 and documents restorative programs began on 10/22/24. V10 stated to her knowledge there were no restoratives in place prior to 10/22/24 and if there would have been she would have known about them. V10 stated she got the care plan order from therapy and started it the same day on 10/22/24. V10 stated there were no restorative programs in place for R35 prior to 10/22/24. On 10/29/24 at 3:05 PM, V8 (Director of Rehab) stated R35's physical therapy evaluation documents an initial evaluation on 9/21/24, treatment on 9/24/24, and a discharge assessment on 9/25/24. This surveyor reviewed the discharge assessment and asked if the section labeled Discharge Recommendations and Status meant R35 should be walking with his restorative programs, V8 stated, Yes. When asked why the restorative program didn't start until 10/22/24, V8 stated she turned in the initial restorative programs before 10/22/24. When asked why it wasn't started before 10/22/24 she stated she didn't know and would have to check. On 10/30/24 at 2:23 PM, V8 (Director of Rehabilitation) stated she wasn't able to find any programs for R35 prior to 10/22/24 and no information on why there was no walking program. On 10/31/24 at 12:34 PM, when asked if she would expect restorative programs to start once the recommendations were made by physical therapy, V1 (Administrator) stated she would expect it to start as soon as they got everything together for them. This surveyor reviewed with V1, R35's therapy discharge summary was completed 9/25/24 with a recommendation for restorative programs and they were not started until 10/22/24. When asked if that was an acceptable time frame, V1 stated she would give them thirty days to start the restorative programs once the recommendation was made. On 10/31/24 at 2:00 PM, V8 (Director of Rehabilitation) stated someone could theoretically have a decline in their condition and abilities in thirty days. V8 stated they have now started meeting weekly so residents can get started on restoratives as soon as they are finished with therapy. The facility Restorative Nursing Services policy dated 7/2017 documents, Residents will receive restorative nursing care as needed to help promote optimal safety and independence

Based on observation, interview, and record review the facility failed to ensure timely physician notification of a change in a pressure wound, clarify changes in wound treatment orders, and administer treatments as ordered for a pressure wound for 1 (R1) of 3 residents reviewed for wound care in the sample of 3. Findings include: 1. R1's face sheet documented an admitted [DATE] and diagnoses including: other reduced mobility, obstructive sleep apnea, unsteadiness on feet, morbid obesity, type 2 diabetes mellitus, pressure ulcer of sacral region stage 4, bacteremia, osteomyelitis. R1's 1/16/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. On 1/16/24 at 9:50 AM, V5 (R1's Power of Attorney/ POA) said she was speaking with R1 on the phone about a month prior to this investigation when R1 complained of pain to R1's bottom. V5 said she called the facility and spoke with V2 (Director of Nursing/ DON) about assessing R1's bottom due to R1's complaints of pain. V5 said she was told by V2 at that time that R1 did have a small area on R1's bottom that looked like a paper cut. V5 said R1 had this chronic area on R1's bottom that would cycle through healing and opening. V5 said R1 was sent to the hospital on 12/21/23 and was told by the hospital R1 had a wound on R1's bottom that was large enough to put your fist in. V5 said this was a surprise because the facility had not reported any new or worsening wounds to R1's bottom. V5 said the hospital had told her that this wound would need to be surgically drained and debrided. V5 said after R1's surgery it was found R1's wound was infected, and osteomyelitis was present. R1's 9/25/23 care plan for Actual Alteration in Skin Integrity Pressure Ulcer to Sacrum documented the following interventions with corresponding dates: 9/25/23 observe for signs and symptoms of breakdown/ infections, 12/15/23 keep off sacrum as much as possible, 12/15/23 cleanse area with soap and water dry well, apply collagen, calcium alginate, and border dressing, 12/21/23 Treatment: Dakins soak (gauze) with flagyl to wound bed cover with calcium (alginate) and boarder (dressing), 1/10/24 to see wound doctor every Thursday, 1/10/24 wound vac at 125 mmHG (millimeters of mercury) continuous medium intensity monitor (amount) of (drainage every shift). On 1/16/24 at 1:13 PM, V3 (Licensed Practical Nurse/ LPN) said R1 had a pressure area on her bottom that would cycle through opening and closing. V3 said R1 had covid in September 2023 and had refused to be assisted to turn and the area had reopened and was being treated. V3 said R1 was not always compliant with care. V3 said she was caring for R1 on 12/19/23 and that she observed a change to the wound on R1's bottom that day. V3 said the wound had a black center and a small open area on that date. V3 said she then reported the change in R1's wound to V2 (DON) on 12/19/23 and was told that R1 would be seen in the facility by V9 (Wound Physician) on 12/21/23. V3 said that on 12/19/23, R1's wound did not have any odor or drainage. V3 said the afternoon of 12/19/23, R1 was transferred to the hospital for altered mental status and returned later on 12/19/23 with a diagnosis of Urinary Tract Infection (UTI) and was prescribed oral antibiotics. R1's 12/19/23 hospital records documented in part . Sent from (facility) with possible UTI and increased confusion . Report of more confusion, history of UTI . Clinical Impression: Acute cystitis without hematuria . R1's progress notes documented R1 was sent to the hospital on 12/19/23 at 12:47 PM and returned to the facility on [DATE] at 5:40 PM. R1's hospital records documented a 12/21/23 at 2:13 PM note documented in part . Spoke with (Hospital Physician) regarding positive blood culture. (R1) given (intravenous antibiotics) in (Emergency Department) and prescribed (oral antibiotic) at discharge. (Hospital Physician) states treatment appropriate . On 1/16/24 at 1:42 PM, V2 (DON) said the last time she saw R1's wound it was just a small split at top of R1's gluteal fold. V2 initially stated she did not recall being notified by V3 that R1's wound had changed. On 1/18/24 at 3:24 PM, V2 (DON) clarified that she was notified of R1's wound change by V3 (LPN) over the phone on either 12/19/23 or 12/20/23. V2 said she was off work due to illness during that time. R1's Wound Healing Progress Report completed by V2 (Director of Nursing) documented a sacral wound with measurements (length x width x depth) as follows: 11/24/23 1 x 0.1 x 0.1 cm (centimeters), 11/30/23 1 x 0.1 x 0.1 cm, 12/7/23 1 x 0.1 x 0.1 cm, 12/14/23 1 x 0.1 x 0.1 cm. R1's Treatment Administration Record (TAR) documented the following orders: 9/25/23 through 12/15/23 cleanse area to sacrum with soap and water, pat dry, apply a thin layer of medihoney 100% paste, cover with calcium alginate and border dressing every shift; a 12/15/23 through 12/23/23 order to cleanse area to sacrum with soap and water, dry well, apply collagen and cover with calcium alginate and border dressing every shift, keep resident off sacrum as much as possible. On 1/16/24 at 3:00 PM, V9 (Wound Physician) said he was notified of R1's wound when he arrived at the facility on 12/21/23. V9 said R1's sacral wound prior to debridement was very large and open with black necrotic tissue and had a very strong odor. V9 said he debrided R1's sacral wound in the facility and changed the wound care treatment. V9 said he suspected R1 to have gas forming gangrene and was going to treat it with flagyl, dankins, and hydrogen peroxide. V9 said there was a second wound to R1's left buttock that did not appear to be infected. V9 said the second wound to R1's left buttock appeared to be a shear wound and could have happened just prior to V9 entering the facility. V9 said R1 was sent to the hospital on 12/21/23 after he had seen R1 in the facility where R1's wound was further debrided, and the sacral and buttock wounds became one. R1's 12/21/23 Wound Evaluation & Management Summary completed by V9 (Wound Physician) documented in part .Wound Sacrum Full Thickness .Etiology infection .Wound Size (Length x Width x Depth) 6 x 4 x 3 cm (centimeters) .Undermining 3 cm at 12 o'clock .Dressing Treatment Plan .Alginate calcium apply twice daily for 30 days; Sodium hypochlorite solution (dakins) apply twice daily for 30 days: 1/2; Hydrogen peroxide apply twice daily for 30 days; Metronidazole sprinkle apply daily for 30 days .Wound of the Left Buttock Full Thickness .Etiology infection .Wound Size (Length x Width x Depth) 2 x 3 0.2 cm .Dressing Treatment Plan .Alginate calcium apply twice daily for 30 days; Sodium hypochlorite solution (dakins) apply twice daily for 30 days: 1/2 . On 1/18/24 at 10:46 AM, V9 said he expected the facility to follow his orders. V9 said if the facility would have notified him on 12/19/23 with a picture of R1's wound, he would probably have changed R1's wound treatment orders to include dankins solution twice a day. V9 also stated however, if the facility would have notified him prior to 12/21/23, he did not think it would have changed R1's outcome. V9 said he had treated R1 for several years and R1 was very noncompliant with off loading pressure and the wound to R1's sacrum was unavoidable. R1's 1/14/24 Assessment for Clinically Unavoidable Pressure Sores documented in part . Clinical conditions that are the primary risk factors for developing pressure sores included, but are not limited to, resident immobility and: severe chronic pulmonary obstructive disease, chronic bowel incontinence, continuous urinary incontinence or chronic voiding dysfunction, sepsis, head of bed elevated the majority of the day due to medical necessity, serum albumin below 3.4 g/dl (grams per deciliter), weight loss of more than 10% during last month. On 1/18/24 at 1:09 PM, V14 (Attending Physician) said he could not recall if the facility had notified him of any changes to R1's wound on 12/19/23 or 12/20/23. V14 said if the facility had notified him, he would have ordered to continue the current wound treatment orders and to follow up with V9 on V9's next weekly visit. R1's December 2023 Electronic Medication Administration Record (EMAR) documented a 12/21/23 order for dakins wound solution to buttocks to be administered at 2:00 AM and 2:00 PM and was marked administered by V7 (Registered Nurse/ RN) on 12/21/23 at 2:00 PM. R1's Electronic Medical Record (EMR) documented the order for dakins wound solution to buttocks was entered on 12/21/23 at 1:29 PM by V7 (RN). R1's December 2023 Electronic Treatment Administration Record (ETAR) documented a 12/15/23 order for cleanse area to sacrum with soap and water dry well apply collagen and cover with calcium alginate and border dressing every shift. Keep resident off sacrum as much as possible at 2:00 AM and 2:00 PM and was marked administered by V7 on 12/21/23 at 2:00 PM. R1's December 2023 ETAR also documented a 12/21/23 order for apply dakins soak gauze with flagyl 250 mg (milligram) to wound bed cover with calcium alginate and border dressing at 2:00 AM and 2:00 PM, and was marked as administered by V7 on 12/21/23 at 2:00 PM. On 1/18/24 at 9:12 AM, V7 (RN) was asked which treatment he had completed for R1's wound care on 12/21/23 since there were three different wound care orders documented on the MAR and TAR, and V7 replied he did not know how to look up past charting on dressing changes. V2 (DON) assisted V7 with finding R1's December 2023 EMAR and ETAR. V7 said he did not recall which of R1's treatment orders he had completed on 12/21/23. V7 said he completed R1's wound treatments on 12/21/23 at 2:00 PM as they were charted. V7 was asked what R1's wound looked like on 12/21/23 and V7 replied he could not recall. V7 was asked if R1's wound was open on 12/21/23 and V7 replied he could not recall. V7 was asked who had given him the order to change R1's wound treatment on 12/21/23 and V7 replied he could not recall. On 1/18/23 at 9:21 AM, V2 (DON) said she expected staff would accurately chart any treatment they complete. On 1/18/23 at 9:58 AM, V11 (Certified Nursing Assistant/CNA) said R1's wound had gotten dark a few days prior to R1 being sent out to the hospital. V11 said R1's wound was open prior to V9 (Wound Physician) arriving on 12/21/23. During this interview, V7 (RN) interrupted V11 and told V11 she did not recall and instructed that she did not have to answer any of the surveyors' questions. R1's EMR progress notes from 12/8/23 through 12/21/23 did not document any change or new wounds to R1 or any complaints of pain to sacrum or buttocks. R1's 12/21/23 at 6:15 PM hospital record documented in part . arrived from (facility) with reports of altered mental status . (R1) has known UTI. (R1) was seen in the emergency department on 12/19/23 and diagnosed with UTI. (R1) was sent into the Emergency Department (ED) for worsening altered mental status today. Blood cultures review from ED stay on 12/19/23 revealed a positive culture in the aerobic bottle of Streptococcus dysgalactiae . (R1) does have history of frequent UTIs Differential Diagnosis: Cerebral Vascular Accident (CVA), Transient Ischemic Attack (TIA), UTI, encephalopathy, pneumonia . R1's hospital record documented a 1/5/24 Infections Disease Consultation in part .History of Present Illness: . patient is bed-bound, stage IV pressure ulcer sacral. Patient transferred from outside hospital earlier today for further treatment of suspected osteomyelitis of sacral area and recent bacteremia .patient recently admitted to (outside hospital) on 12/22/23 and found to have E. coli UTI (Urinary Tract Infection) and Streptococcus bacteremia. Patient had sacral wound culture on 12/22 which grew Proteus. Patient underwent debridement of the sacral ulcer on 12/28 and bone culture grew Enterococcus, Enterobacter, E. Coli. Tissue grew Enterococcus and Pseudomonas. Patient started on wound vac .Recommendations: Unfortunately there was not much benefit of long-term treatment of sacral osteomyelitis in bed-bound patient as soon as we stop antibiotics the infection will come back and progress. To assure success in treatment, patient has to be motivated, repositioned frequently with hospital bed, evaluated for nutritional status, and potential diverting colostomy .continue empiric antibiotics but I would recommend 14 days of treatment for soft skin tissue infection rather than full 6 weeks of treatment of osteomyelitis . The facility's revised April 2018 Pressure Ulcers/ Skin Breakdown - Clinical Protocol documented in part . the nurse shall describe and document/ report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue .The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents .During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds .The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions . The facility's revised April 2019 Administering Medications policy documented in part .4. Medications are administered in accordance with prescriber orders, including any required time frame .22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration; .g. The signature and title of the person administering the drug. 24. Topical medications used in treatments are reordered on the resident's treatment record (TAR) . The facility's revised May 2017 Change in a Resident's Condition or Status policy documented in part .Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status .The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): d. significant change in the resident's physical/ emotional/ mental condition; e. need to alter the resident's medical treatment significantly; .A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff .c. Requires interdisciplinary review and/ or revision to the care plan .Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/ mental condition or status .The nurse will record in the resident's medical record information related to changes in the resident's medical/mental condition or status .

Based on observation, interview, and record review the facility failed to ensure a resident was free from physical restraints for 1 of 6 residents (R1) reviewed for restraint use in the sample of 6. Findings include: On 4/7/23 at 5:45pm, V2 (Director of Nursing/DON) stated the facility is restraint free, with no residents currently having restraints being utilized. On 4/7/23 at 6:10pm, V1 (Administrator) stated the facility is restraint free and that restraints are not used at the facility. On 4/7/23 at 6:25pm, R1 was observed in the North Hall common area watching TV with other residents. R1 was noted to stand up out of her wheelchair and attempt to ambulate, requiring redirection from staff. R1 was alert and oriented only to herself. R1 was noted to be utilizing no restraint devices. R1's Resident Face Sheet documented an admitted [DATE], and diagnoses including Unspecified Dementia with Behavior Disturbance, Macular Degeneration, Legal Blindness, Bipolar Disorder, and Cognitive Communication Deficit. R1's Minimum Data Set (MDS) dated [DATE] documented a BIMS (Brief Interview for Mental Status) Score of 0, indicating R1 has severe deficits in cognition. The same MDS documented that R1 requires extensive assistance from at least two staff members for transfers, and R1's balance moving from a sitting to standing position is unsteady and is only stable with staff assistance. The MDS Section P, Restraints, documented there are no restraints used for R1. R1's April 2023 Physicians Orders had no orders for restraint devices to be used. R1's Care Plan with a review date of 4/7/23 documents, I have episodes of aggression and agitation which has the potential for injury or negative outcomes to my peers, with the corresponding intervention, Provide increased supervision to assure safety during these episodes til I have calmed. There were no interventions related to the use of restraint devices. A Resident Incident Report in R1's medical record documented, Date/Time of Incident: 04/05/23 at 6:00pm. (V14/Licensed Practical Nurse/LPN) reported when she came in for her shift, (R1) was sitting in a dining room chair on North Hall at the nurses' station. (R1) had a sheet around her midsection and it was loosely tied around the back behind the chair. It was loose to where the sheet was not touching her body and (V15/Registered Nurse/RN) was sitting next to her at the desk while (R1) was playing with the sheet and an activity blanket. The resident's arms were free and the resident was content and making no attempts to stand but was calm. No injuries were assessed. The Physician was notified on 04/06/23 at 8:00am, The POA (Power of Attorney) was notified on 04/06/23 at 8:10am. Additional follow up: (R1's Physician) has been notified and the facility has received a verbal temporary order for a restraint if the resident's behaviors are causing harm to herself or others. After review of all statements, (V1/Administrator) believes, and according to (V15's) statement, she did willfully (she acted based on situation at the time to help protect (R1) from falling or attacking other peer, not that (V15) intended to use as a restraint), she did drape a sheet across the dining room chair, flowing to (R1) midsection a loosely tied the sheet around the back of the chair .Although the resident would have been able to remove the sheet .by definition it would still be considered a restraint. Restraint Policy: Restraints shall only be used for the safety and well-being of the resident(s), and only after other alternatives have been tried successfully. Restraint Assessment completed, order received from PCP (Primary Care Provider) for temporary use of restraint when all interventions have been exhausted, and she is presenting a danger to herself or others. Reassess in ten days for planned D/C (Discontinuation) of order. On 4/11/23 at 3:10pm V15 (RN) was interviewed by phone. V15 stated on 4/5/23 she worked from 6:00am to 6:00pm on the North Hall. V15 stated about ten minutes before her shift ended at 6:00pm, V15 saw R1 ambulating up the hall. V15 stated R1 is not to ambulate unassisted as R1 is, confused, a huge fall risk, and blind. V15 stated she went to R1, who was very wobbly, and R1 almost fell twice but V15 kept her from falling. V15 stated she sat R1 down at a table by the nurses' station in a chair by a peer. V15 stated she got R1 a snack, a drink, and an activity book, but R1 kept trying to get up. V15 stated R1 then started picking up the peer's activity book and pencils and started throwing them, and then started shaking the table. V15 stated she ambulated R1 to a dining room chair right by the nurses' station and sat her in it. V15 stated she tried distracting R1 by talking softly and holding her hand, but R1 was still trying to get up. V15 stated she then got a sheet from the linen closet and placed it across R1's lap and tied it loosely behind the chair. V15 stated the sheet was so loosely fastened R1 could have easily gotten up had she tried. V15 stated she placed an activity blanket in R1's lap. V15 stated R1 calmed right down and there were no further issues. V15 stated V14 (LPN) relieved V15 at 6:00pm, and V14 and V15 removed the sheet from R1, got her wheelchair, which had been in her room, they transferred R1 into it, and V15 went home. V15 stated the next morning, on 4/6/23 at about 4:30am, V15 was called by V1 who stated V15 failed to follow the restraint policy and was being written up and suspended until V15 could be in serviced, which was to be 4/12/23. V15 stated, I wasn't even thinking about the sheet being a restraint. And I was not trying to abuse R1, I love all my residents and would never do that. On 4/18/23 at 9:30am, the Surveyor asked V15 (RN) to recreate the sheet restraint with V8 (Certified Nursing Assistant/CNA) taking the place of R1. V15 demonstrated moving a dining room chair from around the table and moving it closer to the North Hall nurses' station, about six feet away from the nurses seat at the computer. V15 went to the linen closet and came back with a flat sheet, placing the sheet loosely on V8's lap and tying the back once over, not knotted, very loosely, leaving V8's hands and arms free. V15 stated there were no staff who witnessed her place the sheet around R1. V15 stated she did not contact R1's Physician or POA, did not check the chart for a Physician's Order or a Restraint Consent signed by the POA, or a Restraint Assessment. V15 stated she did not contact V2 (DON) stating V2 was already gone for the day. On 4/18/22 at 10:10am, R1 was observed in the facility dining room. R1 had no restraint devices in use. On 4/18/23 at 1:00pm, V2 (DON) stated per the facility policy V2 could temporarily authorize a restraint in emergency situations with a physician's order but acknowledged V15 on 4/5/23 did not contact V2 nor obtain a physician's order. V2 stated when she arrived at the facility about 7:00am on 4/6/23, she immediately assessed R1 for injuries from the restraint and there were none. V2 stated on that day she completed a Restraint Assessment, obtained verbal consent from R1's POA and a physician's order for a least restrictive soft restraint. V2 was unable to explain what that meant exactly but acknowledged it wouldn't include tying R1 with a sheet to a chair. V2 stated she would need to contact V16 (R1's Physician) to clarify the order. An undated Restraint Consent Form listed R1's name at the top, and the Resident Representative Signature and Date line were blank. There was no documentation in the April 2023 Nursing Progress Notes to indicate V2 had obtained verbal consent from R1's POA for any restraint. A Physicians Telephone Order Sheet dated 4/8/23 documented, May use less resistant restraint for resident when behaviors could cause harm to self or others when other interventions exhausted. There was no medical diagnosis on this order to indicate what it was being used to treat or the specific type of restraint to be used. On 4/18/23 at 1:40pm, V14 (LPN) stated she entered the North Hall at about 5:55pm on 4/5/23 to begin her shift. V14 stated she saw R1 sitting in a dining room chair with a flat sheet around her middle, which was tied loosely behind the chair. V14 stated V15 said R1 had been having a lot of behaviors that day and V15 had been trying to calm her down. V14 stated she was Flabbergasted to see R1 restrained in this manner. V14 stated, I knew right then it was wrong, and I should have said something to her (V15) about it, but she is a good nurse and a good person, and I didn't want to get her into trouble. I think she was just frustrated and made a bad choice. V14 stated they removed the sheet, transferred R1 into her wheelchair, and R1 didn't have further behaviors. V14 stated she did not physically assess R1 as the sheet had not been tight enough to injure R1. V14 stated between 11:00pm to 12:00am that evening, V14 decided she needed to report the incident, so she called V2 (DON), who instructed her to notify V1 (Administrator). V14 stated she was told by V1 she should have immediately reported it, and V14 stated she was written up by administration Because they said I violated the abuse policy by not immediately reporting it. On 4/18/23 at 2:10pm, V1 (Administrator) stated she was called at about midnight on 4/6/23 to report R1 having been restrained as referenced above. V1 stated she asked V14 why she had not reported it earlier. V1 stated she began an immediate investigation, calling other staff who had been present on both the 6am to 6pm and 6pm to 6am shifts, and then called V15 (RN) and left V15 a voicemail. V1 stated V15 returned her call at about 4:20am on 4/6/23. V1 stated she told V15 about V14's report. V15 stated she had tried snacks, drinks, coloring books and pencils for redirection, which were not effective. V1 stated V15 told V1 she laid a sheet over R1's lap and loosely tied it behind the chair, placing an activity blanket in R1's lap, which was effective in calming R1 down. V1 stated V15 was written up for violating the facility's restraint policy due to not having a physician's order and the method of the restraint used. On 4/19/23 at 9:24am, V1 provided what she stated was an updated Physicians Telephone Order, undated, which stated, Least restrictive restraint possible when other interventions have been exhausted (soft fabric, loosely tied) in chair no more than one hour at a time. There was no diagnosis on this order. On 4/19/23 at 10:05am, V16 (R1's Physician) stated he was not contacted about R1 being restrained until V17 (Regional Director of Operations) called him on 4/7/23 in the late afternoon or early evening. V16 stated tying a resident to a chair using a sheet is not an appropriate form of restraint. V16 stated one to one supervision should have been utilized if other interventions were not working. V16 stated R1 has had several falls and gait instability. V16 stated going forward, if R1 requires a restraint he will probably order a weighted lap cushion. A Use of Restraints Policy with a revision date of April 2017 documented, The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove the device in the same manner in which the staff applied it .and this restricts his/her typical ability to change positions or place, that device is considered a restraint. Restraints shall only be used to treat the residents medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls .Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including Tucking sheets so tightly that a bed bound resident cannot move .(and) placing the resident in a chair that prevents the resident from rising .Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention and a restraint is required to: A) Treat the medical symptom. B) Protect the resident's safety, and C) Help the resident attain the highest level of his/her physical or psychological well-being .Prior to placing a resident in restraints, there shall be a pre restraining assessment and review to determine the need for restraints. Emergency use of restraints is permitted if their use is immediately necessary to prevent the resident from injuring himself/herself or others and/or to prevent the resident from interfering with life-sustaining treatment, and no other less restrictive interventions are feasible .The Director of Nurses has the authority to order the use of emergency restraints. The attending Physician must be notified of such and the reason for the order .Restraints shall be used upon written order of the physician and after obtaining consent from the resident and/or representative.

Based on observation, interview, and record review the facility failed to implement interventions for pressure injuries for 1 (R3) of 3 residents reviewed for wounds in a sample of 9. The Findings Include: R3's Face Sheet documents admission to this facility on 05/18/22. R3's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's admission baseline care plan dated 05/18/22 includes - Category: Skin integrity. Goal: Will not develop skin breakdown. Intervention: Educate resident and family on skin condition and prevention of skin breakdown; Float heels while in bed . R3's most recent MDS (Minimum Data Set) dated 08/09/22 documents a brief interview for mental status score a 2, indicating R3 is severely cognitively impaired. He is totally dependent and requires 1-2+ person physical assist for all ADLs other than eating for which he requires supervision and one person assist. R3 is triggered for the following care areas - [CONDITION(S)], cognitive loss/dementia, communication, urinary incontinence and indwelling catheter, behavioral symptoms, falls, nutritional status, pressure ulcers, and [CONDITION(S)] drug use. R3's progress note dated 09/07/2022 at 3:38 PM by V1 (Administrator) documents in part - .Admin and QA (quality assurance) nurse (V27 - Licensed Practical Nurse - LPN) updated (V16 - Family Member) on the decub on the residents bottom and the blisters that has opened on the residents heels .(V16) asked about (R3) seeing (V25 - general surgeon) on Monday still. Admin explained that since the resident is a hoyer lift (V25) will not be able to see him per (V25) office. However the QA nurse will be asking V24 (PCP - primary care physician) on Friday who does he recommend to see about a possible abscess . R3's care plan updated on 09/07/22 includes - Focus: Alterations in skin integrity - blisters to bilateral heels. Goal: Wound will decrease. Interventions include: Float heels while in bed .Cleanse wounds to right heel, right medial foot, right medial ankle, left heel, and left lateral ankle daily with soap and water, pat dry, paint with [MEDICATION(S)] and wrap with kerlix, float heels at all times and use heel lift boots bilaterally. R3's facility wound assessments dated 09/09/22 include - 1) Wound type: Diabetic foot ulcer. Wound location: Left heel. Date wound identified: 09/09/22. Present upon admission: No. Assessment occasion: New wound. Stage: Blank. Drainage: Serous, scant. Infection. No. Pain with wound/treatment: No. [CONDITION(S)]: None. Wound bed: 100% eschar. Measurements: Length 6.30cm. Width 3.30cm. Depth 0.00cm. Wound edges: Border definition - indistinct, diffuse, not clearly visible. Description: Normal, healthy skin. Surrounding skin: Pink, slight [CONDITION(S)]. Dorsalis Pedis: Palpable/strong. Posterior tibial: Palpable/strong. Capillary refill: less than 3 seconds. Affected extremity: Normal skin color. Temperature: Normal/warm to touch. Skin: Normal elasticity. Date physician notified 09/09/22 . Treatments: Air mattress with full rail left side. 2) Wound type: Diabetic foot ulcer. Wound location: Right heel. Date wound identified: 09/09/22. Present upon admission: No. Assessment occasion: New wound. Stage: Blank. Drainage: None. Infection. No. Pain with wound/treatment: No. [CONDITION(S)]: None. Wound bed: 100% eschar. Measurements: Length 7.20cm. Width 5.40cm. Depth 0.00cm. Wound edges: Border definition - indistinct, diffuse, not clearly visible. Description: Normal, healthy skin. Surrounding skin: Pink, slight [CONDITION(S)]. Dorsalis Pedis: Palpable/strong. Posterior tibial: Palpable/strong. Capillary refill: less than 3 seconds. Affected extremity: Normal skin color. Temperature: Normal/warm to touch. Skin: Normal elasticity. Date physician notified 09/09/22 . Treatments: Air mattress with full rail left side. R3's progress note dated 09/09/22 at 1:33 PM by V29 documents, V24 here for rounds this am. Recommends sending to another general surgeon since V25 unable to see him for abscess rectal area . R3's progress note dated 09/09/22 at 2:16 PM documents in part - .let patient's family know about appointment with (local hospital) wound clinic in (town) on Monday (09/12/22) at 2:30 PM with V21 (Wound Specialist). R3's progress note dated 09/12/22 at 5:24 PM documents R3 has returned from his appointment with the wound clinic. The hospital wound clinic physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse wounds 1-5 daily with soap and water, pat dry, paint with [MEDICATION(S)], and wrap with Kerlix. Float heels AT ALL TIMES. D/C heel protectors and use heel lift boots bilaterally. R3's September 2022 POS (physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Turn and reposition every 2 hours and as needed, order/start date 09/12/22. R3's September TAR includes - Float heels at all times and use heel lift boots bilaterally, order/start date 9/12/22, d/c 09/14/22; float heels at all times and use heel lift boots bilaterally, order/start date 09/19/22. On 09/14/22, R3's progress notes document at 11:24 AM he was non-responsive to verbal or painful stimuli. No response to sternal rub .R3 was transported by ambulance to the local emergency room for evaluation and treatment at this time. R3's hospital Discharge Summary includes - admitted : 09/14/22. discharge date [DATE]. Admission Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Summary of History and Physical: [AGE] year-old Caucasian male with past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . As per family at bedside, he started having worsening decub ulcers for the last 4-5 weeks, following with wound clinic as an outpatient . family okay with returning to nursing home today . R3's Braden Risk Assessment Report dated 09/19/22 by V28 (RN) documents a score of 14 indicating R3 is at moderate risk for developing pressure injuries. R3's care plan is updated to include - 09/19/22 - Float heels at all times and use heel lift boots bilaterally. R3's facility wound assessments dated 09/19/22 are as follows - 1) Wound type: Diabetic foot ulcer. Wound location: Right heel. Wound status: Unchanged. Date wound identified: 09/12/22. Present upon admission: No. Assessment occasion: Weekly update. Stage: Blank. Drainage: None. Infection. No. Pain with wound/treatment: No. [CONDITION(S)]: None. Wound bed: Epithelial tissue: 40%. Granulation tissue: 40%. Slough: 20%. Eschar: 0%. Measurements: Length 9.50cm. Width 9.00cm. Depth 0.10cm. Wound edges: Border definition - Well defined. Description: Normal, healthy skin. Surrounding skin: Normal. Dorsalis Pedis: Palpable/weak. Posterior tibial: Palpable/weak. Capillary refill: less than 3 seconds. Affected extremity: Normal skin color. Temperature: Normal/warm to touch. Skin: Normal elasticity. Date physician notified 09/20/22 . Treatments include Float heels at all times and use heel lift boots bilaterally. 2) Wound type: Diabetic foot ulcer. Wound location: Left heel. Wound status: Improved. Date wound identified: 09/12/22. Present upon admission: No. Assessment occasion: Weekly update. Stage: Blank. Drainage: None. Infection. No. Pain with wound/treatment: No. [CONDITION(S)]: None. Wound bed: Epithelial tissue: 40%. Granulation tissue: 40%. Slough: 20%. Eschar: 0%. Measurements: Length 3.20cm. Width 5.50cm. Depth 0.10cm. Wound edges: Border definition - Well defined. Description: Normal, healthy skin. Surrounding skin: Normal. Dorsalis Pedis: Palpable/weak. Posterior tibial: Palpable/weak. Capillary refill: less than 3 seconds. Affected extremity: Normal skin color. Temperature: Normal/warm to touch. Skin: Normal elasticity. Date physician notified 09/20/22. Treatments include Float heels at all times and use heel lift boots bilaterally. On 09/20/22 at 8:45 AM, R3 was observed in his room seated in his wheelchair at this time. R3 was dressed, bilateral feet/heels were bandaged with toes and upper part of foot open to air. R3's right and left foot were positioned and resting on the foot pedals of his wheelchair. R3's legs, feet, or heels were not being floated, and R3 had no heel protectors or cushion on either foot at this time. On 09/20/22 at 8:50 AM, V9 (Certified Nursing Assistant - CNA) and V11 (CNA) stated R3 gets laid down after meals due to his bed sores and per family request. When asked what is done for pressure relief/wound prevention interventions, V9 and V11 stated they turn and reposition residents every 2 hours for wound prevention and every hour if they have existing wounds for prevention and healing. When asked what other interventions were used for offloading they stated if a resident is chair or bedfast they will move the resident from side to side and place pillows for comfort when up in chair or in bed. When ask about pressure relieving interventions for feet/heels, V9 and V11 stated they would float a resident's heels to relieve pressure if necessary. On 09/20/22 at 9:10 AM, R3 had been placed back in bed after breakfast. He was lying flat on his back on a low air loss mattress, bed in low position with fall mat in place, bed against the wall on the right side. Feet toward window, head towards doorway to room. R3 was not able to be interviewed, mumbled words, and fell asleep mid conversation. R3's heels were not being floated and were observed to be directly on the mattress. No pillow under legs or heel float interventions in place. On 09/20/22 at 11:33 AM, R3 was up in his wheelchair seated at the dining room table for the noon meal. R3's legs were hanging dependent from his wheelchair and both feet were positioned flat on the floor. R3 has no cover over his toes and there were no heel float boots or pressure relieving interventions being implemented. R3 had a visitor sitting with him (V15 - Family Member) who stated after R3 went to the hospital in May 2022, he admitted here because she could not handle him at home anymore. At that point, he needed more assistance than she could provide. V15 commented about how red his feet were and stated he had been to the wound doctor once and is scheduled to go again. R3 would close his eyes during the meal observation when V15 asked if he was hungry. V15 made the comment that he slept all the time prior to admission here. At that time, R3 mumbled that they are making a mountain out of it . On 09/20/22 at 12:52 PM, R3 was still seated in wheelchair in dining room after lunch with a few other residents remaining. R3 stated, I can't get started. R3's feet were hanging dependent and resting on floor, toes exposed, heels not being floated or protected. On 09/20/22 at 1:21 PM, V17 (Activity Director) stated R3 said he wanted to lay down at this time. V17 stated sometimes he stays for activities. R3's right foot dressing had blood soaked through at the ankle. R3's feet remain unelevated or in a protected position on the dining room floor. At this time, V10 (CNA) and V9 transferred R3 from the dining room back to his room via Hoyer lift from his wheelchair to bed. After R3 was placed in bed and staff left the room, R3's feet were lying directly on his mattress without heel lift boots or floating provided. On 09/20/22 at 3:00 PM, R3 was observed in bed, feet not elevated, no heel protection or floating provided, feet lying flat on mattress. On 09/20/22 at 4:06 PM, R3 was observed in bed, Feet not elevated, no heel protection or floating provided, feet lying flat on mattress. On 09/21/22 at 7:27 AM, R3 was in bed asleep. Feet not elevated, no heel protection or floating provided, feet lying flat on mattress. On 09/21/22 at 8:00 AM, during med pass observation R3 was seated in his wheelchair at a dining room table. R3's right foot was on floor his left foot was on wheelchair foot pedal. R3 did not have on any type of heel protector or pressure relieving intervention or covering on his feet midway down to toes. Basic interventions for pressure relief had not been observed being utilized to this point of the survey. On 09/21/22 at 8:17 AM, V2 (Director of Nursing - DON) was in the dining room for the breakfast meal. When asked what was expected as far as wound prevention/intervention specifically for R3's heels, V2 stated R3 did have some green quilted heel protectors but could not locate them in his room at this time. V2 stated they were possibly in the laundry. At this time, V2 went to R3's room and brought back socks to cover his exposed toes. This surveyor relayed the observations of R3's feet not being floated or protected when he is up in the wheelchair or when he is in bed, but instead have been observed to be directly on his mattress or hanging dependently with feet on the floor or on the foot pedals of his wheelchair. At 8:52 AM, V2 came back into the dining room with a pair of light blue padded heel protectors with heel cut out and placed on R3's feet. V2 stated R3's new heel float boots that V21 (Wound Specialist) recommended on 09/12/22 have been ordered and are on the way - they should be here today. When asked if there should have pressure relieving measures in place while they waited for R3's new heel float boots to arrive, V2 stated, Yes, there should have been interventions in place. On 09/21/22 at 11:20 AM, R3 is back in the dining room for lunch. R3 is now seated in a newly implemented geriatric chair with a high back that can recline, he has socks covering his toes, padded lift boots with the heel cut out on each foot, quilt under legs, and is currently sleeping. On 09/27/22 at 2:13 PM, V21 stated the following regarding R3's wounds - V21 stated, My initial consultation with R3 was on 09/12/22. When I saw the patient, (V16 - Family Member) came with R3 and gave the history that he had recent hip surgery. When V16 saw the wounds were getting worse, the patient was brought to me. Since the surgeon was not available, I saw the patient on consult. He was afebrile, vital signs were normal, sats were normal. He had an intact blister on the right heel and the left heel. There was no infection, no drainage. I did not debride any of his wounds on 09/12/22. I cleaned all the wounds with saline, [MEDICATION(S)], and foam to both heels, Santyl and alginate to the sacral wounds. I provided treatment orders for the facility. He was to return to my clinic in one week. This surveyor relayed that R3 returned to the hospital on 09/14/22 to 09/19/22, with the facility record documenting he would return to the wound clinic on 09/28/22 at 1:30 PM. V21 was asked if R3 would be able to develop the 9 wounds treated on 09/12/22 in the time frame since 08/22/22. V21 stated if the facility wasn't trying all measures, the answer would be yes. V21 stated they noted wounds getting worse in spite of management. V21 added, When I start treatment on someone, if it does not get better in one week, I do something different. I feel treatment was appropriate at the time and they did refer to me timely. When asked about the timeframe R3's bilateral heels could have developed the deep tissue injuries (DTI) first identified by the facility on 09/09/22, V21 stated, Depending on the patient, DTI's would be just a matter of days to develop. For instance, if they were poorly nourished, had [CONDITION(S)] (chronic obstructive pulmonary disease), diabetes, or other pertinent diagnoses. He has many things working against him. V21 stated his clinic works closely with the local primary care clinics to collaborate care. V21 continued, Once they keep him coming to me, I have a certified wound nurse and we do our treatments together. When asked if V21 thought R3's wounds were avoidable or unavoidable, V21 stated, In this situation, his wounds were unavoidable. Relayed to V21 that my observation while in the facility on 09/20/22 and the morning of 09/21/22, was that R3 had no pressure relieving interventions in place when in bed or up in a chair, and the reason the facility gave was they were waiting on special order heel float boots to be delivered. V21 stated he did write an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . I would emphasize to work as hard as they can. A facility policy titled, Prevention of Pressure Ulcers/Injuries dated Revised 2017 included - Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Preparation: Review the resident's care plan and identify risk factors as well as the interventions designed to reduce or eliminate those considered modifiable .Prevention: . Mobility/Repositioning: 1. Choose a frequency for repositioning based on the resident's mobility, the support surface in use, skin condition and tolerance . Support Surfaces and Pressure Redistribution: Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. Monitoring: . 2. Review the interventions and strategies for effectiveness on an ongoing basis.

Based on observation, interview, and record review the facility failed to maintain a pest free environment. This has the potential to affect all 72 residents living in the facility. Findings include: R9's face sheet documented diagnoses including: nontraumatic subacute subdural hemorrhage, neuralgia and neuritis, major depressive disorder, and [CONDITION(S)]. R9's 5/20/22 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 11, meaning R9 was interviewable. On 8/23/22 at 10:17 AM, R9 said there had been bugs in his room for the past couple months. R9 said he had reported to facility management his concerns with bugs in his room and nothing had been done about it. At that time a cockroach was observed running across the floor under R9's bed and another cockroach was observed running across the floor under R9's refrigerator in R9's room. On 8/23/22 at 1:10 PM, V9 Certified Nurse's Assistant (CNA) was observed standing in the 200 hallway and a cockroach was observed crawling up a resident's door frame. V9 donned gloves and tried to kill the cockroach. V9 was unsuccessful in killing the cockroach due to it crawling behind the hallway handrail. V9 said the facility did have a cockroach problem. On 8/23/22 at 11:23 AM, V10 Licensed Practical Nurse (LPN) said the facility has been infested with cockroaches for several months. V10 said management is aware of the cockroach infestation. V10 stated the cockroach infestation was so bad we can't keep food in the facility because cockroaches will get in our food. On 8/24/22 at 11:23 AM, V4 (CNA) said she had seen cockroaches in the facility hallways and in resident's rooms. V4 said the cockroaches were small so V4 did not report them to facility management. On 8/24/22 at 11:35 AM a cockroach was observed in the day room bathroom running across the floor and up the door frame. The facility's August 2015 Pest, Preventing and Managing Infestations of policy documented in part . Staff should be trained to recognize insect and pest infestation, and know what their specific roles will be should an infestation occur General Guidelines . [outside pest control company] will be used and contracted to do preventative management for pest . will complete monthly inspections . will also be used as needed bases and when the monthly prevention is not sufficient . The Resident Census and Conditions of Residents Form (CMS-672) dated 8/23/2022, documents there are 72 residents living in the facility.

Based on observation, interview, and record review the facility failed to provide an accessible call light for 1 of 5 residents (R58) reviewed for environment in a sample of 39. Findings include: R58's face sheet documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R58's 8/9/22 Minimum Data Set (MDS) documented R58 was not interviewable. R58's Electronic Medical Record (EMR) showed R58 returned to the facility from a hospital stay on 8/2/22. R58's care plans did not show any accommodation for a call light or alternate form for reaching out to staff. On 8/23/22 at 9:56 AM, R58 was lying in bed and no call light was observed in R58's room. The call light outlet in R58's room did not have a call light cord connected to it. No physical bell was observed in R58's room. On 8/24/22 at 10:05 AM, R58 was lying in bed and no call light was observed in R58's room. No physical bell was observed in R58's room. V4 Certified Nurse's Assistant (CNA) said when R58 returned from the hospital he was pulling the call light out of the wall and staff did not replace it. On 8/24/22 at 10:36 AM, V2 Director of Nursing (DON) said when R58 returned from the hospital on 8/2/22 he was found by staff to have the call light cord wrapped around his neck and the call light was removed from his room for his safety. V2 said R58 should have a physical bell in his room. On 8/24/22 at 10:50 AM, V1 (Administrator) said R58 did not have the call light cord wrapped around R58's neck. V1 said R58 was flinging the call light around when R58 returned from the hospital on 8/2/22. On 8/26/22 at 11:19 AM, V1 said when R58 returned from the hospital on 8/2/22 R58 was combative and was flinging the call light around and facility staff had removed it for R58's safety and a physical bell was placed in R58's room. V1 said she expected staff to ensure R58's physical bell was within reach while R58 was in bed. The facility's September 2003 Answering the Call Light policy documented in part . General Guidelines . 4. Be sure that the call light is plugged in at all times. 5. When the resident is in bed . be sure the call light is within easy reach of the resident .

Based on observation, interview, and record review the facility failed to ensure resident rooms were maintained in a clean and sanitary condition for 2 out 5 residents (R17 and R29) reviewed for environment in a sample of 39 residents. Findings include: 1. R17's Face Sheet documents admission to this facility on 05/12/22. R17's Diagnosis Sheet includes [CONDITION(S)] with [CONDITION(S)], adjustment disorder with depressed mood, major depressive disorder, heart failure, and [CONDITION(S)]. R17's most recent admission minimum data set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 12, indicated she is moderately cognitively impaired. On 8/23/22 at 10:13 AM brown dried matter was observed on R17's privacy curtain. R17 said she was unsure how long the brown matter had been there but R17 thought about a month. R17 said she thought it was gross it had been there that long. On 8/24/22 at 10:05 AM brown dried matter was observed to be on R17's privacy curtain. On 8/24/22 at 10:51 AM, V12 (Housekeeping Supervisor) said the brown matter dried on R17's privacy curtain was feces. V12 said R17's privacy curtain needed to be taken down and washed. 2. R29's Face Sheet documents admission to this facility on 06/01/22. R29's Diagnosis Sheet includes [CONDITION(S)] with behavior disturbance, [CONDITION(S)] disorder, major depressive disorder, and cerebral infarction. R29's most recent admission MDS dated [DATE] documents a BIMS score of 8, indicating she is moderately cognitively impaired. On 8/23/22 at 1:02 PM, R29 stated they don't do a very good job cleaning around here and the place is filthy. R29's room was noted to have a privacy curtain with multiple unknown stains on it, bedsheets with dark brown/ black matter, and the floor was unswept and had other unknown substances dried on it. On 8/26/22 at 11:19 AM, V1 (Administrator) said she expected staff to report to V1 or any housekeeping staff if dried feces was observed on a resident's privacy curtain so the privacy curtain can be taken down and cleaned. V1 said she expected the resident's room to be cleaned, swept, and mopped daily. The facility's June 2009 Cleaning and Disinfection of Environmental Surfaces policy documented in part . Environmental surfaces will be cleaned and disinfected according to current CDC (Center for Disease Control) recommendations for disinfection of healthcare facilities . 9. Housekeeping surfaces . will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled . 11 . curtains in resident areas sill be cleaned with there surfaces are visibly contaminated or soiled .

Based on observation, interview and record review, the facility failed to ensure that residents received the required assistance in showering and nail care for 3 of 6 residents (R12, R72, R32) reviewed for ADL's (Activities of Daily Living) in a sample of 39 residents The Findings Include: 1. R12's Facesheet documents R12 was admitted to the facility on [DATE]. The same facesheet documents R12 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's MDS (Minimum Data Set) dated 8/12/22 note that R12 has a BIMS (Brief Interview of Mental Status) of 03, which indicates severe cognitive impairment. Section G of the same MDS note that R12's self performance for bathing is total dependence and support provided is two+ persons physical assist. R12's personal hygiene self performance is extensive assistance-resident involved in activity, staff provide weight bearing support and support provided is one person physical assist. R12 was observed on 8/23/22 at 11:10am and 8/24/22 at 10:56am. His hair was not combed and was sticking up all around his head. R12's fingernails on both hands had moderate amount of brown material underneath them. On 8/24/22 at 1:00pm, R12 said that his fingernails had not been done in a while. Document labeled Bath Care Roster note that R12 received a sponge bath on 8/7/22. Document labeled facility completed care details document that R12 received a shower on 8/15/22. No other documentation was could be provided from 8/7/22 to 8/15/22 of R12 receiving any other showers indicating R12 went 8 days without receiving a shower. 2. R72's Facesheet documents R72 was admitted to the facility on [DATE]. The same document note that R72 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R72's MDS dated [DATE] note under section C that R72 has a BIMS should not be conducted due to resident rarely/never understood. The same MDS note under section G that self performance of bathing is total dependence and bathing support provided is two+ person physical assist. Self performance for self hygiene is total dependence-full staff performance every time during entire 7 day period and support provided is two+ person physical assist. On 8/23/22 at 11:15 am, R72 was observed sitting in her wheelchair. R72's hair had not been brushed and was all over her head. R72's fingernails were noted to have a moderate amount of brown material underneath them. On 8/24/22 at 10:15am, R72's hair had been brushed and her fingernails remained to have a moderate amount of brown material underneath them. On 8/24/22 at 10:15am, V17 (family member) said that he had brushed his wife's hair, not staff. V17 said he has to brush it most all of time. Document labeled Bath Care Roster from 5/18/22 thru 8/24/22 note that R72 received a shower on 8/8/22 and document labeled Completed Care Details note R72 had a shower on 8/22/22. No other documentation could be provided from 8/8/22 thru 8/22/22 of R72 receiving any other showers indicating R72 went 14 days without receiving a shower. 3. R32's Facesheet documents that R32 was admitted to the facility on [DATE]. The same facesheet note R32 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R32's MDS dated [DATE] note that R32 has a BIMS of 5 which indicates severe cognitive impairment. The same MDS section G note that R32 self performance for personal hygiene is extensive assistance-resident involved in activity, staff support for personal hygiene is limited assistance. Section G also note under bathing that the support provided is limited assistance and self performance is extensive assistance. Review of document labeled Bath Care Roster dated 5/24/22 thru 8/24/22 note that R32 received a shower on 8/1/22. Document labeled Completed Care details note that R32 received a complete bed bath on 8/12/22 and no other showers/baths documented to 8/24/22. These documents indicate that R32 went 11 days and then 12 days without a shower. On 8/26/22 at 11:30am, V1 (Administrator) said that it is their policy that residents receive a shower or bath twice weekly. V1 said there is no written policy for baths/showers. V1 said if a resident requests more, they will provide a shower more often. On 8/26/22 at 1:30pm, V14 (LPN/Licensed Practical Nurse) said that the residents are on a bathing schedule and receive a shower or bath twice weekly. V14 also said that if a a resident is heavily soiled, they will usually provide a bath then also. V14 said that the nails are checked and scraped daily by V15 (Activity Director). V14 said that Activities do all except the diabetics and the nurses do them. On 8/26/22 at 1:40pm, V15 said that she checks residents fingernails 2 days a week on Mondays and Fridays. V15 said if they need cleaned or trimmed, she will do them. V15 said she does not do the diabetics, the nurses do them.

Based on interview and record review, the facility failed to communicate a change in a residents advance directive code status for one of 18 residents reviewed for advanced directives (R65) in a sample of 38. The findings include: R65's electronic medical record documents that he is [AGE] years old and readmitted on [DATE]. R65's Significant Change MDS dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. R65's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 09:36AM, R65's Electronic Record (Echart) lists Attempt CPR (Cardiopulmonary Resuscitation) on the Basic information screen and lists CPR to the left of his name and under Advance Directives. R65's Practitioner Orders for Life -Sustaining Treatment (POLST) form with completion dates of [DATE] and [DATE] has 'Do Not Resuscitate' checked on both. On [DATE] at 03:55 PM, V15 (Licensed Practical Nurse/LPN) stated there was a list at the nurses station that listed the code status of resident's on her hall. When asked what R65's code status was on the list, V15 said R65 was not on the list. When asked how V15 would determine if CPR should be initiated for R65 if entering his room and he was not breathing or had a pulse, V15 said she thought it was listed in R65's chart. V15 then found a document titled Advanced Directives that had R65 listed as Do Not Resuscitate. When asked to compare the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This surveyor then asked V15 if she would initiate CPR if she found R65 not breathing or without a pulse, and V15 replied that she did not know. On [DATE] at 09:40 AM, V2 (Director of Nursing/DON) said R65 was sent to the hospital and upon his return on [DATE], R65 told her he wanted to have CPR initiated and that is why R65's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . When questioned about the POLST documents listing R65 as a Do Not Resuscitate, V2 did not know why the POLST had not been changed. V2 also said R65 has changed his mind a few times, and although he has been admitted to hospice, he still wants to have CPR initiated. V2 was asked how the staff were to know that R65 changed his mind and wanted to receive CPR, and V2 said the staff knowing this could be a problem for him, and said the facility would need to initiate a protocol specific for R65 due to him changing his mind.

Based on interview, observations and record review, the facility failed to provide services/treatment to prevent reduction in Range of Motion for 1 (R38) of 5 residents reviewed for Range of Motion in the sample of 38. The findings include: R38's Facesheet indicates that R38 was admitted to the facility on [DATE]. The same document notes that R38 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R38's OT (Occupational Therapy) Discharge Instructions dated 10/05/20 note Discharge Plans and Instructions of Pt (patient) to remain LTC (Long Term Care) with patient to wear B splints as tolerated. There was no Physicians Order for R38 to wear B splints found in the record to correspond with the OT recommendations. On 5/23/21 at 10:00am, when questioned about her hands, R38 stated that the facility does not do anything with her hands. On 5/23/21 at 2:15PM, R38 was noted to be sitting in her recliner, and her left and right hands were noted to be contracted, with the left being in a tight closed fist. No brace/splint was noted on either upper extremity at this time. In addition, on 5/24/21 at 9:00am, 11:00am, and 2:00pm, R38 did not have any splint or brace on, and there was no brace/splint observed at the bedside on either day. On 5/25/21 at 2:56pm, staff was observed applying the splint/brace to R38's upper extremities. At this same time, R38 stated They don't ever put 'these things' on, when referring to the brace/splint. On 5/25/21 at 3:00pm, V8 (CNA/Certified Nurse Assistant/Restorative Aide) said that R38 will not leave the brace/splint on. V8 further stated that therapy has changed the orders to applying the brace/splint for 2 hours and removing for 2 hours, however V8 said she could not find any orders that document this change. On 5/27/21at 10:20am, V7 (CEO/Owner) said that V8 used her own judgement regarding the 2 hours on, 2 hours off, thinking it would be more comfortable for R38 since she frequently refuses. A new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On during day and Pt to wear B Resting Hand Splint. Off at night.

Based on observation, interview and record review the facility failed to maintain a sanitary environment and follow proper food handling processes to prevent foodborne illness. These failures have the potential to affect all 80 residents living in the facility. Findings Include: During the initial tour in the kitchen on 8/20/19 at 9:30 AM, it was observed that the countertop slicer was covered with a plastic bag to indicate that it was ready for use. When the covering was removed it was found to have dried food debris on the base and under it, causing it to stick to the counter. Behind and under the blade was found to have food crumbs and dried food. V3 (Dietary Manager) at this time stated that they would get it cleaned up, and it hasn't been used in a little while. On 8/20/19 at 10:11 AM, R62 stated generally my food is cold. My husband brings me food. Their scrambled eggs are brown and will not melt butter. She went on to state that the hot food is not hot and the cold food is not cold. On 8/21/19 at 11:45AM, a test tray was received to determine if food was served at proper temperatures. Food items on the tray that were not within acceptable temperature range were the pasta salad at 90 degrees Fahrenheit. V3 at this time stated that it is a cold pasta salad and that the temperature was 42 degrees Fahrenheit. When V3 checked the temperature at the surveyors request it was 80 degrees Fahrenheit. V3 removed the pasta salad from the serving line and took the salad away from residents of whom had already been served. The pasta salad recipe provided by V3 documented the pasta salad should be served at 41 degrees Fahrenheit or lower. The Resident Census and Conditions of Residents dated 8/20/19, reports 80 residents reside in the facility.

Based on observation and interview, the facility failed to ensure call lights were in reach for 3 of 18 residents (R48, R59, R52) reviewed for call lights in a sample of 39. Findings include: 1. R48's Face Sheet indicates she was admitted to the facility on [DATE]. Section C of the MDS(Minimum Data Set) lists R48 has a BIMS(Brief Interview of Mental Status) of 00 which indicates that R48 is unable to complete cognitive interview. On 08/20/19 at 09:51 AM, R48 was lying in her bed upon entry in her room. No call light was noted to be in her reach or on her bed. When asked about her call light R48 was unable to answer. V5(Certified Nurse Assistant/Restorative Aide) came in the room and found the call light under the mattress at the head of bed. On 08/21/19 at 09:17 AM, R48's call light was noted to be to the residents left and hanging over the side of the bed on the floor. During that time, V5 came to residents room and placed it in R48's reach. V5 stated she didn't know why the call light was under the mattress and that she usually doesn't work this floor. 2. R52's face sheet indicates that she was admitted to the facility on [DATE]. Review of the MDS indicates that R52 has a BIMS of 12 which indicates that R52 has moderate cognitive impairment. On 8/20/19 at 10:00am, during interview with R52 it was noted that she did not have a call light. During that time V5 walked by R52's room. V5 was then asked for assistance to get call light for R52. V5 found the call light at the foot of R52's bed. On 8/20/19 at 10:00am, R52 stated that staff do sometimes forget to put her call light within her reach. V5 shook her head and said she didn't know why the call light was not within reach. 3. Review of the MDS indicates that R59 has a BIMS of 00 which indicates that he is unable to complete cognitive interview. Review of the Physicians Orders document that R59 was admitted to a local hospice on 6/27/19. On 8/20/19 at 10:15am, R59 was up in a reclining chair sitting at the foot of his bed on the left side. No call light was noted to be in his reach or around his chair. V5 found R59's call light on the floor on the right side of the head of bed. V5 then placed call light within R59's reach.

Based on record review and interview the facility failed do a significant change comprehensive assessment for 1 of 18 residents (R59) reviewed for assessment in the sample of 39. The findings include: Review of R59's Physicians orders indicate that R59 was admitted into hospice on 6/27/19. R59's MDS (Minimum Data Set) indicate that an annual was submitted was on 7/26/19 and a readmission MDS was submitted on 6/2/19 for an readmission from the hospital to the facility. Review of the electronic medical record list MDS assessments being completed on 7/26/19 as open and 6/2/19 as Accepted. No significant change MDS for R59's admission to hospice was found in R59 medical record. On 8/21/19 at 2:30pm V10 (MDS Coordinator) stated that No she did not complete a significant change in status for R59's admission into hospice. V10 also said that she is new and still learning and is not sure why one wasn't done.